Development of comparable algorithms to measure primary care indicators using administrative health data across three Canadian provinces.

INTRODUCTION: Performance measurement has been recognized as key to transforming primary care (PC). Yet, performance reporting in PC lags behind even though high-performing PC is foundational to an effective and efficient health care system. OBJECTIVES: We used administrative data from three Canadian provinces, British Columbia, Ontario and Nova Scotia, to: 1) identify and develop a core set of PC performance indicators using administrative data and 2) examine their ability to capture PC performance. METHODS: Administrative data used included Physician Billings, Discharge Abstract Database, the National Ambulatory Care and Reporting System database, Census and Vital Statistics. Indicators were compiled based on a literature review of PC indicators previously developed with administrative data available in Canada (n=158). We engaged in iterative discussions to assess data conformity, completeness, and plausibility of results in all jurisdictions. Challenges to creating comparable algorithms were examined through content analysis and research team discussions, which included clinicians, analysts, and health services researchers familiar with PC. RESULTS: Our final list included 21 PC performance indicators pertaining to 1) technical care (n=4), 2) continuity of care (n=6), and 3) health services utilization (n=11). Establishing comparable algorithms across provinces was possible though time intensive. A major challenge was inconsistent data elements. Ease of data access, and a deep understanding of the data and practice context, was essential for selecting the most appropriate data elements. CONCLUSIONS: This project is unique in creating algorithms to measure PC performance across provinces. It was essential to balance internal validity of the indicators within a province and external validity across provinces. The intuitive desire of having the exact same coding across provinces was infeasible due to lack of standardized PC data. Rather, a context-tailored definition was developed for each jurisdiction. This work serves as an example for developing comparable PC performance indicators across different provincial/territorial jurisdictions.

Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada.

BACKGROUND: Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed. METHODS: This will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER's processes. CONCLUSION: We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement. TRIAL REGISTRATION: Clinicaltrials.gov NCT03689049 ; registered September 28, 2018.

Temporal association between home nursing and hospital costs at end of life in three provinces.

BACKGROUND: Research has demonstrated that increases in palliative homecare nursing are associated with a reduction in the rate of subsequent hospitalizations. However, little evidence is available about the cost-savings potential of palliative nursing when accounting for both increased nursing costs and potentially reduced hospital costs. METHODS: Our retrospective cohort study included cancer decedents from British Columbia, Ontario, and Nova Scotia who received any palliative nursing in the last 6 months of life. A Poisson regression analysis was used to determine the association of increased nursing costs (in 2-week blocks) on the relative average hospital costs in the subsequent 2-week block and on the overall total cost (hospital costs plus nursing costs in the preceding 2-week block). RESULTS: The cohort included 58,022 cancer decedents. Results of the analysis for the last month of life showed an association between increased nursing costs and decreased relative hospital costs in comparisons with a reference group (>0 to 1 hour nursing in the block): the maximum decrease was 55% for Ontario, 31% for British Columbia, and 38% for Nova Scotia. Also, increased nursing costs in the last month were almost always associated with lower total costs in comparison with the reference. For example, cost savings per person-block ranged from $376 (>10 nursing hours) to $1,124 (>4 to 6 nursing hours) in British Columbia. CONCLUSIONS: In the last month of life, increased palliative nursing costs (compared with costs for >0 to 1 hour of nursing in the block) were associated with lower relative hospital costs and a lower total cost in a subsequent block. Our research suggests a cost-savings potential associated with increased community-based palliative nursing.

Quality of end-of-life cancer care in Canada: a retrospective four-province study using administrative health care data.

BACKGROUND: The quality of data comparing care at the end of life (eol) in cancer patients across Canada is poor. This project used identical cohorts and definitions to evaluate quality indicators for eol care in British Columbia, Alberta, Ontario, and Nova Scotia. METHODS: This retrospective cohort study of cancer decedents during fiscal years 2004-2009 used administrative health care data to examine health service quality indicators commonly used and previously identified as important to quality eol care: emergency department use, hospitalizations, intensive care unit admissions, chemotherapy, physician house calls, and home care visits near the eol, as well as death in hospital. Crude and standardized rates were calculated. In each province, two separate multivariable logistic regression models examined factors associated with receiving aggressive or supportive care. RESULTS: Overall, among the identified 200,285 cancer patients who died of their disease, 54% died in a hospital, with British Columbia having the lowest standardized rate of such deaths (50.2%). Emergency department use at eol ranged from 30.7% in Nova Scotia to 47.9% in Ontario. Of all patients, 8.7% received aggressive care (similar across all provinces), and 46.3% received supportive care (range: 41.2% in Nova Scotia to 61.8% in British Columbia). Lower neighbourhood income was consistently associated with a decreased likelihood of supportive care receipt. INTERPRETATION: We successfully used administrative health care data from four Canadian provinces to create identical cohorts with commonly defined indicators. This work is an important step toward maturing the field of eol care in Canada. Future work in this arena would be facilitated by national-level data-sharing arrangements.

Palliative care by family physicians in the 1990s. Resilience amid reform.

OBJECTIVE: To explore issues family physicians face in providing community-based palliative care to their patients in the context of a changing health care system. DESIGN: Focus groups. SETTING: Small (< 10,000 population), medium-sized (10,000 to 50,000), and large (> 50,000) communities in Nova Scotia. PARTICIPANTS: Twenty-five men and women physicians with varying years of practice experience in both solo and group practices. METHOD: A semistructured approach was used, asking physicians to reflect on recent palliative care experiences in order to explore issues of care. MAIN FINDINGS: Five themes emerged from the discussions: resources needed, availability of family support, time and money supporting physicians' activities, symptom control for patients, and physicians' emotional reactions to caring for dying patients. CONCLUSION: With downsizing of hospitals and greater emphasis on community-based care, the issues identified in this study will need attention, particularly in designing an integrated service delivery model for palliative care.

Physician characteristics in relation to cardiovascular drugs commonly prescribed for hypertension in Nova Scotia.

BACKGROUND: Cardiovascular drugs are the most frequently prescribed class of drugs in Canada. Among them, drugs used to treat hypertension are the single largest component. Variability in how these drugs are prescribed should be based on the specific characteristics of patients. However, some evidence shows that physician characteristics can also play a substantial role in prescribing trends. Such variation is also associated with varying beneficial and adverse patient outcomes. PURPOSE: To determine whether prescribing patterns of drugs used to treat hypertension in elderly patients in Nova Scotia varied by physician characteristics. METHODS: A retrospective, population-based descriptive study was done using the Nova Scotia Pharmacare program data for the fiscal year 1995/96. The unit of analysis was the individual physician. All drugs indicated in the management of hypertension were included for the analysis. RESULTS: Of 1466 physicians included in the analysis, 1004 were family physicians (FPs) and/or general practitioners (GPs), 155 were internal medicine specialists and 307 were other specialists. Fifty-eight per cent of 103,193 eligible senior citizens received at least one of the study medications. FPs and/or GPs prescribed 95.9% of all the study drugs. Internists prescribed proportionately fewer angiotensin-converting enzyme inhibitors, thiazides and other diuretics compared with the FPs and/or GPs but more beta-blockers and calcium channel blockers. A large proportion of the FPs and/or GPs (55.3%) prescribed less than 10% of the total day's supply of drugs, whereas a small proportion of FPs and/or GPs (16.3%) prescribed 52.6% of all the study drugs. There was no variation in the distribution of the types of antihypertensives prescribed based on physician age, sex or volume of prescribing. A slight variation in prescribing was seen with location of practice. CONCLUSIONS: Patterns of prescribing cardiovascular drugs used to treat hypertension were remarkably unaffected by physician characteristics. This finding counters other evidence in the literature that has raised concerns over prescribing patterns of certain types of physicians. Prescribing patterns may vary for other drug classes, but for this group of antihypertensives, little variability was found.

Asthma in primary care: making guidelines work.

OBJECTIVE: To determine the views of family physicians regarding selected asthma recommendations from a Canadian practice guideline and the supporting evidence, and to identify issues needing further development if family physicians are to find guideline recommendations to be truly useful clinical tools. SETTING: Four urban communities in Nova Scotia, Prince Edward Island and New Brunswick. PARTICIPANTS: Twenty community family physicians representing different practice settings, and varying according to age and sex, were recruited to participate. DATA COLLECTION: Four focus groups were held, each lasting 2 h, at which recommendations from a published asthma guideline were presented for discussion on the applicability to their practices. The data were analyzed using a grounded theory method. RESULTS: Physicians rely on clinical judgment in lieu of objective measures in diagnosing asthma and resist treating every exacerbation with steroids. They thought that the recommendations on smoking and patient education should have been stronger or more prominent. Patient noncompliance limits the usefulness of home peak flow measures. Topics such as allergy assessment and most pharmacological therapies triggered little discussion. DISCUSSION: Asthma guideline developers and those interested in enhancing compliance with recommendations will need to attend to factors such as physician attitudes and beliefs on a variety of issues, including the use of objective measures and the availability of adequate resources to conduct the tests. Similarly, negative patient attitudes toward an increased use of corticosteroids suggest that a public education program would be most helpful regarding that group of recommendations.

Community family medicine teachers' perceptions of their teaching role.

OBJECTIVES: Our study explored community preceptors' perceptions of their teaching role, to better understand effective ambulatory and community-based teaching. METHODS: Bandura's social cognitive theory and Schön's notion of reflective practice guided conceptual development of an interview exploring preceptors' views of their role, teaching goals, teaching techniques, student assessment practices, factors affecting teaching and learning, and balance of patient and student needs. Preceptors reflected also on a significant personal teaching experience. A total of 17 highly student-rated preceptors participated. A trained interviewer conducted each interview; all were transcribed and subjected to content analysis. RESULTS: Preceptors (male, 14; female, 3) described learner-centred approaches, setting goals jointly with the student. Demonstration, guided practice, observation and feedback were integral to the experience. Preceptors saw student comfort in the environment as key to effective learning; they attempted to maximize students' learning and breadth of experience. They wanted students to understand content, "know-how" and "being a family physician". Patients remained the primary responsibility, but learners' needs were viewed as compatible with that responsibility. Many preceptors perceived a professional responsibility as "role models". CONCLUSIONS: Preceptors recognized the dynamic environment in which they taught students, and they described strategies which demonstrated how they adapted their teaching to meet the needs of the learner in that environment. These teachers combined learner-centred approaches with sound educational practices, broad learning experiences, attention to student learning and concern for development of professional expertise and judgement. These findings may assist faculty development in family medicine, and other disciplines, in providing effective ambulatory care teaching.

Family Medicine residents' knowledge and attitudes about end-of-life care.

The medical management of end-of-life symptoms, and the psychosocial care of the dying and their families have not been a specific part of the curriculum for undergraduate medical students or residency training programs. The purpose of our research was to assess family medicine residents' knowledge of and attitudes toward care of the dying. All entering (PGY1) and exiting (PGY2) residents of the Dalhousie University Family Medicine Residency Program were given a 50-item survey on end-of-life care. They survey contains two 25-item subscales concerning attitudes/opinions toward end-of-life care, and knowledge about care. Thirty-one of the 33 entering PGY1s 94%) and 26 of the 30 exiting PGY2s (86%) completed the surveys. Overall attitude scores were felt to be high among both groups, with little difference between them. Areas of concern regarding the adequacy of knowledge were found in relation to managing opioid drugs and the symptom of dyspnea. Interventions are now in development to address these issues in the residency program. In an era of subspecialties, the challenge of integrating these areas into the curriculum without creating rotations in specialist palliative care is an issue faced by most family medicine residency programs.

Pod people. Response of family physicians and family practice nurses to Kosovar refugees in Greenwood, NS.

OBJECTIVE: To explore roles of family physicians and family practice nurses who provided care to Kosovar refugees at Greenwood, NS. DESIGN: Qualitative study based on individual interviews with family physicians and family practice nurses. SETTING: Family practices in Halifax, NS. PARTICIPANTS: Six family practice nurses, four physician faculty members, four community-based family physicians, and two family medicine residents were interviewed. Participants were purposefully chosen from the roster of service providers. METHOD: All interviews were conducted by one of the researchers and were semistructured. Interviews lasted approximately 30 minutes and were immediately transcribed. Key words and phrases were identified and compared with subsequent interviews until saturation was achieved. MAIN FINDINGS: Data yielded four analytical categories: the clinical encounter, expectation and experience, role and team functioning, and response. Participants reported how providing care in the context of a refugee camp was both similar to and different from their daily activities in family practice, as were their working relationships with other health care professionals. CONCLUSION: Primary care for refugees during complex health emergencies is often underreported in the literature. Yet family practice physicians and nurses recounted that they had the requisite skills to provide care in such a context.

Identifying potential need for cancer palliation in Nova Scotia.

OBJECTIVE: To assess the degree to which Nova Scotia cancer patients who may need palliative care are being referred to the comprehensive Halifax-based Palliative Care Program (PCP). METHODS: The authors conducted a retrospective, population-based study using administrative health data for all adults in Nova Scotia who died of cancer from 1988 to 1994. Proportions and odds ratios (ORs) were used to determine where there were differences in age, sex, place of residence, cancer cause of death, year of death and use of palliative radiotherapy between those who were referred to the PCP at the Halifax Infirmary and those who were not, and between those who were referred late (within 14 days of death) and those who were referred earlier. RESULTS: Of the 14,494 adults who died of cancer during the study period, 2057 (14.2%) were registered in the PCP. Within Halifax County, 1582 (36.4%) of the 4340 patients with terminal cancer were seen in the PCP. Predictors of PCP registration were residence in Halifax County (OR 19.2, 95% confidence interval [CI] 15.4-23.9), younger age compared with those 85 years of age or older (for those 20-54 years of age, OR 4.9, 95% CI 3.2-7.6; 55-64 years, OR 3.4, 95% CI 2.2-5.1; 65-74 years, OR 3.1, 95% CI 2.1-4.5; 75-84 years, OR 2.1, 95% CI 1.4-3.1), and having received palliative radiation (OR 1.8, 95% CI 1.5-2.2). PCP referral was associated directly with head and neck cancer (OR 5.4, 95% CI 3.0-9.7) and inversely with hematopoietic (OR 0.2, 95% CI 0.4-0.9), lymph node (OR 0.3, 95% CI 0.1-0.4) and lung (OR 0.6, 95% CI 0.4-0.9) cancer. Predictors of late referral (being referred to the PCP within 14 days of death) were age 65-84 years (OR 1.4, 95% CI 1.1-1.8) and 85 years and over (OR 1.8, 95% CI 1.1-3.0), no palliative radiation (OR 2.0, 95% CI 1.4-3.1) and cancer cause of death. People dying within 6 months of diagnosis were somewhat less likely to have been referred to the PCP (OR 0.8, 95% CI 0.6-0.9), but those who were referred were more likely to have been referred late (OR 2.6, 95% CI 2.0-3.5). INTERPRETATION: Referral to the PCP and earlier rather than late referral were more likely for younger people with terminal cancer, those who received palliative radiation and those living closer to the PCP. Referral rates also varied by cancer cause of death and the time between diagnosis and death.

The family's perspective on issues of hydration in terminal care.

We identified issues that are important to family caregivers when deciding whether or not artificial hydration should be provided to patients with advanced cancer. A qualitative study using semi-structured interviews was carried out in the home support and inpatient divisions of a palliative care program in Halifax, Nova Scotia. Participants included children and spouses of terminally ill patients who had dealt with or would soon deal with issues of hydration. Factors influencing caregivers included issues of symptom distress, ethical and emotional considerations, information exchange between health professionals and family, and culture. The perceived benefits of artificial hydration by the caregivers were central to the ethical, emotional, and cultural considerations involved in their decision making. Discussions with caregivers should attempt to (a) discover the patient's wishes and attitudes concerning the procedure; (b) provide as accurate information as is available about advantages and disadvantages; and (c) recognize and explore caregivers' concerns that may or may not have been expressed.

Dehydration and provision of fluids in palliative care. What is the evidence?

OBJECTIVE: To provide a clinical review of issues surrounding reduced fluid intake in palliative care patients and a practical approach to care for these patients. DATA SOURCES: Medline was searched from 1980 to 1995 for articles concerning dehydration in dying patients. In addition, the law databases QUICKLAW, WESTLAW, and MEDMAL were searched. STUDY SELECTION: Key papers were included for discussion in relation to the clinical evidence to treat or withhold treatment and to a representative sample of the social, ethical, and legal issues. SYNTHESIS: There is little clinical evidence to guide patients, families, or clinicians in treating with reduced fluid intake during the terminal phase of life. Assisting patients to take fluids as a social or symbolic act is recognized, as is the ethical and legal stance that assisting fluid intake should be thought of as a medical therapy. CONCLUSION: Without sound evidence upon which to base clinical decisions, patients, families, and clinicians are left to balance potential benefits and burdens against the goals of care.

Evaluating a palliative care program: methodology and limitations.

The article describes an evaluation of a palliative care service in a regional and tertiary care facility. The service components are described. The four outcomes chosen for evaluation were: (a) symptom relief; (b) satisfaction with care for patients/families; (c) utilization of community resources; (d) good nursing morale and low staff stress. Quality of life was measured using a symptom distress scale; satisfaction using an adapted Kristjanson FAMCARE scale; community resources with opinion and satisfaction surveys; and staff morale and stress with the Maslach Bumout Inventory and Latack's Coping Questionnaire. Results showed that overall symptom distress was reduced. Patients/families were generally satisfied, with some areas needing attention. Physicians were generally satisfied and believed patients/families benefited from the psychosocial support, respite, and education/information. Nurses felt they had the time, energy, resources and support to give quality care.

Pharmacy services in family medicine residencies. Survey of clinics associated with Canadian residency programs.

Surveys were mailed to 82 family medicine clinics associated with residency programs in Canada to ascertain the extent, if any, of pharmacy involvement in the programs. Eight of the 58 (13.8%) usable returns had pharmacists directly involved. They provided pharmacy-based services, offered clinical services, and participated in research.

Dehydration symptoms of palliative care cancer patients.

A cross-sectional survey of inpatient palliative care subjects (n = 52) was performed to determine the severity and distribution of symptoms thought to be associated with dehydration in terminally ill cancer patients and to clarify the association between the severity of these symptoms and commonly used objective measures of dehydration. Each patient rated the severity of seven symptoms using 100-mm visual analogue scales. The symptoms considered were thirst, dry mouth, bad taste, nausea, pleasure in drinking, fatigue, and pain. Associations were sought between these symptoms and predictor variables (fluid intake, plasma osmolality, sodium, and urea) and confounding variables (age, medications, oral disease, and mouth-care regimen). Mean symptom ratings were thirst 53.8 mm, dry mouth 60.0 mm, bad taste 46.6 mm, nausea 24.0 mm, pleasure in drinking 61.6 mm, fatigue 61.8 mm, and pain 33.5 mm. Using multiple-linear regression, no association could be demonstrated between thirst (the principal outcome of interest) and the predictor or confounding variables. Estimates of the study power performed after completion revealed a 76% chance of detecting a 20-mm difference between high and low fluid intake groups. This study provides the first quantitative estimate of the experience of dehydration symptoms in those with advanced cancer. The symptoms appear to be rated moderately severe, but there is no demonstrable association between severity and fluid intake. Further studies with greater statistical power and more accurate hydration assessment would strengthen our understanding of this association.