Walter Rosser

Chronic Constipation: An Evidence-Based Review

Background: Chronic constipation is a common condition seen in family practice among the elderly and women. There is no consensus regarding its exact definition, and it may be interpreted differently by physicians and patients. Physicians prescribe various treatments, and patients often adopt different over-the-counter remedies. Chronic constipation is either caused by slow colonic transit or pelvic floor dysfunction, and treatment differs accordingly. Methods: To update our knowledge of chronic constipation and its etiology and best-evidence treatment, information was synthesized from articles published in PubMed, EMBASE, and Cochrane Database of Systematic Reviews. Levels of evidence and recommendations were made according to the Strength of Recommendation taxonomy. Results: The standard advice of increasing dietary fibers, fluids, and exercise for relieving chronic constipation will only benefit patients with true deficiency. Biofeedback works best for constipation caused by pelvic floor dysfunction. Pharmacological agents increase bulk or water content in the bowel lumen or aim to stimulate bowel movements. Novel classes of compounds have emerged for treating chronic constipation, with promising clinical trial data. Finally, the link between senna abuse and colon cancer remains unsupported. Conclusions: Chronic constipation should be managed according to its etiology and guided by the best evidence-based treatment.

Improving health care globally: a critical review of the necessity of family medicine research and recommendations to build research capacity.

An invitational conference led by the World Organization of Family Doctors (Wonca) involving selected delegates from 34 countries was held in Kingston, Ontario, Canada, March 8 to12, 2003. The conference theme was “Improving Health Globally: The Necessity of Family Medicine Research.” Guiding conference discussions was the value that to improve health care worldwide, strong, evidence-based primary care is indispensable. Eight papers reviewed before the meeting formed the basic material from which the conference developed 9 recommendations. Wonca, as an international body of family medicine, was regarded as particularly suited to pursue these conference recommendations: Research achievements in family medicine should be displayed to policy makers, health (insurance) authorities, and academic leaders in a systematic way. In all countries, sentinel practice systems should be developed to provide surveillance reports on illness and diseases that have the greatest impact on the population’s health and wellness in the community. A clearinghouse should be organized to provide a central repository of knowledge about family medicine research expertise, training, and mentoring. National research institutes and university departments of family medicine with a research mission should be developed. Practice-based research networks should be developed around the world. Family medicine research journals, conferences, and Web sites should be strengthened to disseminate research findings internationally, and their use coordinated. Improved representation of family medicine research journals in databases, such as Index Medicus, should be pursued. Funding of international collaborative research in family medicine should be facilitated. International ethical guidelines, with an international ethical review process, should be developed in particular for participatory (action) research, where researchers work in partnership with communities. When implementing these recommendations, the specific needs and implications for developing countries should be addressed. The Wonca executive committee has reviewed these recommendations and the supporting rationale for each. They plan to follow the recommendations, but to do so will require the support and cooperation of many individuals, organizations, and national governments around the world.

Progress of Ontario's Family Health Team model: a patient-centered medical home.

Ontario’s Family Health Team (FHT) model, implemented in 2005, may be North America’s largest example of a patient-centered medical home. The model, based on multidisciplinary teams and an innovative incentive-based funding system, has been developed primarily from fee-for-service primary care practices. Nearly 2 million Ontarians are served by 170 FHTs. Preliminary observations suggest high satisfaction among patients, higher income and more gratification for family physicians, and trends for more medical students to select careers in family medicine. Popular demand is resulting in expansion to 200 FHTs. We describe the development, implementation, reimbursement plan, and current status of this multidisciplinary model, relating it to the principles of the patient-centered medical home. We also identify its potential to provide an understanding of many aspects of primary care.

Global Health and Primary Care Research

A strong primary health care system is essential to provide effective and efficient health care in both resource-rich and resource-poor countries. Although a direct link has not been proven, we can reasonably expect better economic status when the health of the population is improved. Research in primary care is essential to inform practice and to develop better health systems and health policies. Among the challenges for primary care, especially in countries with limited resources, is the need to enhance the research capacity and to engage primary care clinicians in the research enterprise. These caregivers need to be an integral part of the research enterprise so the right questions will be asked, the results from research will be used in practice, and a scholarly and evidence-based approach to primary care will become the norm. The challenge of developing research in primary care can be met only by creating a strong infrastructure. This will include strengthening academic departments, enhancing links to researchers in other fields, improving training programs for future primary care researchers, developing more practice-based primary care research networks, and increasing funding for research in primary care. A greatly increased commitment on the part of international organizations both within and outside of primary care is needed, in particular those organizations involved with funding research. We provide suggestions to improve the global primary care research enterprise for the benefit of the worlds population.

The Canadian contribution to the US physician workforce

Background: A physician shortage has been declared in both Canada and the United States. We sought to examine the migration pattern of Canadian-trained physicians to the United States, the contribution of this migration to the Canadian physician shortage and policy options in light of competing shortages in both countries. Methods: We performed a cross-sectional analysis of the 2004 and 2006 American Medical Association Physician Masterfiles, the 2002 Area Resource File and data from the Canadian Institute for Health Information, the Canadian Medical Association and the Association of Faculties of Medicine of Canada. We describe the migration pattern of Canadian medical school graduates to the United States, the number of Canadian-trained physicians in the United States in 2006, the proportion who were in active practice, the proportion who were practising in rural or underserved areas and the annual contribution of Canadian-trained physicians to the US physician workforce. Results: Two-thirds of the 12 040 Canadian-educated physicians living in the United States in 2006 were practising in direct patient care, 1023 in rural areas. About 186, or 1 in 9, Canadian-educated physicians from each graduating class joined the US physician workforce providing direct patient care. Canadian-educated physicians are more likely than US-educated physicians to practise in rural areas. Interpretation: Minimizing emigration, and perhaps recruiting physicians to return to Canada, could reduce physician shortages, particularly in subspecialties and rural areas. In light of competing physician shortages, it will be important to consider policy options that reduce emigration, improve access to care and reduce reliance on physicians from developing countries.

Influences on breast cancer screening behaviors in Tamil immigrant women 50 years old and over.

Objective To investigate, using the Health Belief Model as a theoretical framework, the incentives and barriers to breast cancer screening in a recent immigrant group, older Tamil women from Sri Lanka. Method Tamil women who had had a mammogram and Tamil women who had never had a mammogram were compared on the following variables: socio-demographics, personal risk estimates for breast cancer, risk-reduction expectancies, beliefs and knowledge about breast cancer and screening recommendations, and acculturation. Results Groups differed significantly in terms of education, years living in North America, acculturation, and beliefs/knowledge about breast cancer. When education and acculturation were controlled, perceived barriers to mammography were most predictive of mammography utilization. Discussion Results are discussed with a view to developing culture-appropriate educational campaigns.

Older immigrant Tamil women and their doctors: attitudes toward breast cancer screening.

Cultural beliefs have been hypothesized to be powerful barriers to breast cancer screening in minority women and physician recommendation is consistently reported to be the strongest incentive. This study investigated (1) beliefs regarding breast cancer and (2) the perception of barriers to mammography and clinical breast examination in a sample of immigrant Tamil women, as well as in a sample of primary care physicians. Three focus groups, each consisting of 10 immigrant Tamil women from Sri Lanka aged 50 years or over were conducted and 52 primary care physicians who serve this population completed mailed surveys. The most common barriers to screening reported by the women were (1) lack of understanding of the role of early detection in medical care, (2) religious beliefs and, (3) fear of social stigmatization. Physicians reported the most common barriers to their screening recommendations for this group of women to be (1) womens episodic care, (2) unrelated presenting problems and, (3) women refusing to be screened. Interventions to increase screening in this and other minority groups requires an elaborated understanding of utilization barriers for both women and their doctors.

Gastrointestinal adverse effects of varenicline at maintenance dose: a meta-analysis

BackgroundTobacco smoking remains the leading modifiable health hazard and varenicline is amongst the most popular pharmacological options for smoking cessation. The purpose of this study is to critically evaluate the extent of gastrointestinal adverse effects of varenicline when used at maintenance dose (1 mg twice a day) for smoking cessation.MethodsWe conducted a meta-analysis of randomised controlled trials published in PUBMED and EMBASE according to the PRISMA guidelines. Selected studies satisfied the following criteria: (i) duration of at least 6 weeks, (ii) titrated dose of varenicline for 7 days then a maintenance dose of 1 mg twice-per-day, (iii) randomized placebo-controlled design, (iv) extractable data on adverse event - nausea, constipation or flatulence. Data was synthesized into pooled odd ratios (OR) basing on random effects model. Quality of studies was also rated as per Cochrane risk-of-bias assessment. Number need to harm (NNH) was calculated for each adverse effect.Results98 potentially relevant studies were identified, 12 of which met the final inclusion criteria (n = 5114). All 12 studies reported adverse events on nausea, which led to an OR of 4.45 (95% CI = 3.79-5.23, p < 0.001; I2 = 0.06%, CI = 0%-58.34%) and a NNH of 5. Eight studies (n = 3539) contain data on constipation pooled into an OR of 2.45 (95% CI = 1.61-3.72, p < 0.001; I2 = 34.09%, CI = 0%-70.81%) with a NNH of 24. Finally, five studies (n = 2516) reported adverse events of flatulence, which pooled an OR of 1.74 (95% CI = 1.23-2.48, p = 0.002; I2 = 0%, CI = 0%- 79.2%) with a NNH of 35.ConclusionsUse of varenicline at maintenance dose of 1 mg twice a day for longer than 6 weeks is associated with adverse gastrointestinal effects. In realistic terms, for every 5 treated subjects, there will be an event of nausea, and for every 24 and 35 treated subjects, we will expect an event of constipation and flatulence respectively. Family physicians should counsel patients of such risks accordingly during their maintenance therapy with varenicline.

Access and Quality of Primary Care for People With Disabilities: A Comparison of Practice Factors:

This study shows how practice factors, particularly payment type, affect quality and accessibility of primary care for adults with disabilities. The study consisted of: (a) a survey of practice characteristics, including accessibility, accommodations for disabled patients, and payment type; and, (b) a retrospective chart audit for quality of care indicators. The sample consisted of 513 patients within 73 doctors within 47 practices. The study show that there are significant differences between payment types on location, number of physicians and other health professionals, caseloads and patient contacts. Salaried practices scored significantly higher on accessibility and willingness to make accommodations for patients with disabilities. Salary practices scored significantly higher than FFS or capitation for the treatment of diabetes, hypertension and urinary tract infections. Capitation practices scored significantly lower than the other two payment types on preventive care. These findings raise questions regarding the mix of salary to other models of practice, and incentives for ensuring that those with the greatest need receive the best possible primary care.

Promoting continuity of care should be integral to any health care system.

Many physicians and patients believe that a long-term doctor–patient relationship built on trust and mutual respect is a central tenet of effective and efficient health care.[1][1] However, are such pronouncements, frequently made by colleges representing primary-care disciplines, based on more