Natalie Kennie

A Systematic Review of Interventions to Improve Diabetes Care in Socially Disadvantaged Populations

OBJECTIVE—To identify and synthesize evidence about the effectiveness of patient, provider, and health system interventions to improve diabetes care among socially disadvantaged populations. RESEARCH DESIGN AND METHODS—Studies that were included targeted interventions toward socially disadvantaged adults with type 1 or type 2 diabetes; were conducted in industrialized countries; were measured outcomes of self-management, provider management, or clinical outcomes; and were randomized controlled trials, controlled trials, or before-and-after studies with a contemporaneous control group. Seven databases were searched for articles published in any language between January 1986 and December 2004. Twenty-six intervention features were identified and analyzed in terms of their association with successful or unsuccessful interventions. RESULTS—Eleven of 17 studies that met inclusion criteria had positive results. Features that appeared to have the most consistent positive effects included cultural tailoring of the intervention, community educators or lay people leading the intervention, one-on-one interventions with individualized assessment and reassessment, incorporating treatment algorithms, focusing on behavior-related tasks, providing feedback, and high-intensity interventions (>10 contact times) delivered over a long duration (≥6 months). Interventions that were consistently associated with the largest negative outcomes included those that used mainly didactic teaching or that focused only on diabetes knowledge. CONCLUSIONS—This systematic review provides evidence for the effectiveness of interventions to improve diabetes care among socially disadvantaged populations and identifies key intervention features that may predict success. These types of interventions would require additional resources for needs assessment, leader training, community and family outreach, and follow-up.

The impact of space and time on interprofessional teamwork in Canadian primary health care settings: implications for health care reform

Aim This paper explores the impact of space and time on interprofessional teamwork in three primary health care centres and the implications for Canadian and other primary health care reform. Background Primary health care reform in Canada has emphasized the creation of interprofessional teams for the delivery of collaborative patient-centred care. This involves the expansion and transformation of existing primary health care centres into interprofessional family health teams (FHT) promising to provide patients better access, more comprehensive care, and improved utilization of individual health professionals. Benefits for providers include improved workplace satisfaction and organizational efficiencies. Currently, there is little evidence for how effective interprofessional teamwork happens and little is known about how to create high-functioning teams in the primary health care setting. Methods We used ethnographic observations and interviews to gain a deep understanding of the nature of interprofessional teamwork. Three academic family health centres participated in a total of 139 h of observation and 37 interviews. Team members in all three centres from the disciplines of medicine, nursing, physiotherapy, occupational therapy, social work, dietetics, pharmacy, and office administration participated in this study. Findings We found that both the quantity and quality of interprofessional communication and collaboration in primary health care is significantly impacted by space and time. Across our research sites, the physical layout of clinical space and the temporal organization of clinical practice led to different approaches to, and degrees of success with, interprofessional teamwork. Varied models of interprofessional collaboration resulted when these factors came together in different ways. These findings have important implications for the transition to interprofessional family health teams in Canada and beyond.

Integrating into family practice: the experiences of pharmacists in Ontario, Canada

Aims and objectives This research examines the experiences of pharmacists as they integrated and adapted to meet the drug‐related needs of family practice settings.

Developing a tool to measure contributions to medication-related processes in family practice.

Successful team care requires a shared understanding of roles and expertise. This paper describes the development and preliminary exploration of the psychometric properties of a tool designed to measure contributions to family practice medication-related processes. Our team identified medication-related processes commonly occurring in family practice. We assessed clinical appropriateness using a sensibility questionnaire and pilot-tested with 11 pharmacists, nurses and physicians. We performed a simulated exercise to group the processes and assessed the internal consistency of the groupings using Cronbachs alpha coefficient. We examined test-retest reliability using intra-class coefficient (ICC). Following three revisions, the final Medication Use Processes Matrix (MUPM) included 22 medication-related processes and scale descriptors reflecting contribution to each process. Mean sensibility ratings were high for each component. We developed five theoretical groupings (diagnosis & prescribing, monitoring, administrative/documentation, education, medication review) and found their overall internal consistency was good (α > 0.80). The test-retest reliability was strong (ICC > 0.80). Preliminary validation showed significant differences in how health professionals view interprofessional contributions toward medication-related processes. Interprofessional care requires a negotiated understanding of processes and contributions. The MUPM provides an explicit description of medication-related processes in primary care, measures perceived contributions and emerges as a new tool to measure collaborative care in family practices.

Reliability testing of a case-leveling framework for assigning level of difficulty of pharmacist's initial patient medication assessments

OBJECTIVE To develop and test the reliability of a case-leveling framework for assigning level of difficulty of the pharmacists task for initial medication assessments conducted by pharmacists integrated into family physician offices. DESIGN Descriptive study. SETTING Seven family practice sites in Ontario from June 2004 to July 2006. PATIENTS Patients referred by their family physician for pharmacist assessment. INTERVENTION Individual medication assessments, monitoring, and follow-up by pharmacists. A case-leveling framework was developed with three levels of complexity (graded as I, II, or III) including specific descriptors and practice-based examples. Reliability was assessed between two standardized assessors and between one assessor and project pharmacists. Project pharmacist feedback was elicited through an e-mail survey. Reliability is reported using the kappa statistic. MAIN OUTCOME MEASURES Reliability of a case-leveling framework and helpfulness of the framework as reported by pharmacists. RESULTS 53 patient cases were evaluated for interrater reliability between standardized assessors. The mean (+/- SD) case level assigned was 1.8 +/- 0.68, and the kappa was 0.62 (95% CI 0.44-0.79), indicating a substantial strength of agreement between raters. For the second reliability test, 52 cases were rated, with a level of agreement between project pharmacists and the external assessor of 0.46 (95% CI 0.27-0.65), indicating moderate agreement. Feedback resulted in slight revisions to the original framework. CONCLUSION The case-leveling framework was a reliable method and can be used to determine the level of difficulty of patient cases in primary care.

Demonstrating Value, Documenting Care: Lessons Learned about Writing Comprehensive Patient Medication Assessments in the IMPACT Project: Part II: Practical Suggestions for Documentation That Makes an Impact

Summary of recommendations1. Suggest decrease dose of XX [name of drug] to 150 mg once daily given low creatinineclear ance of 40 mL/min.2. Suggest tapering XX [name of drug] to X mg[dose] at bedtime for 1 week, then stoppingalt ogether (have discussed with patient; sheis willing to start today if you agree).3. Mrs. Y has agreed to stop XX [name of drug](which may have been contributing to recenthigh BP) and will monitor BP daily at hometo make sure it decreases to <130/80 mm HgBOX 1 The IMPACT experience The IMPACT project was a large-scale demonstration project funded by the Ontario Primary Health Care Transition FundProject in which 7 nondispensing pharmacists were integrated into 7 different family physician group practices between June2004 and July 2006. The IMPACT pharmacists worked approximately 2.5 days per week over the 2-year period conductingcomprehensive medication assessments for patients, providing drug information and education for health care providers,and implementing approaches to optimize drug prescribing and use within the practice.

Examining physicians' perspectives during the integration of a pharmacist into family practice: Qualitative results from the IMPACT study

Rationale:Physicians may have concerns about medical-legal issues, scope of practice, continuity of care, workload, and satisfaction as other health disciplines integrate into primary care. This st...