1

WELCOME

2012 TRILLIUM

PRIMARY HEALTH CARE

RESEARCH DAY

This program is funded by the Ministry of Health and Long-Term Care

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Acknowledgements

Learning Objectives:

To provide a forum for presentation of innovative activity or original research in primary care, either in progress or completed.

To bring together a variety of health care providers, including academic and practicing clinicians, residents, graduate students, researchers and administrators working in pri-mary health care.

To provide an opportunity for the enhancement of research skills through workshops, oral and poster presentations and through the informal exchange of information among peers.

This program meets the accreditation criteria of The College of Family Physicians of Canada and has been

accredited for up to 6.25 Mainpro-M1 credits.

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Contents

Acknowledgements & Learning Objectives 2

Program 4-5

Presentation Schedule 6-9

Distinguished Paper Presentation 10

Keynote - Martin Bass Lecture 10-11

Workshop Presentations 12-13

Concurrent Oral Paper Session I 14-21

Concurrent Oral Paper Session II 21-28

Poster Presentations Session I 29-35

Poster Presentations Session II 36-41

Index by Presenter 42

Notes 43

Declaration of potential conflict of interest:

Speakers will be requested to disclose to the audience, any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of this program.

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Program

8:15 am - 9:00 am Registration, Session I Poster Set-up (Dockside 9) and Continental Breakfast (Regatta Ballroom)

9:00 am - 9:10 am Opening Remarks - Regatta Ballroom · Moira Stewart - Lead, Primary Health Care System (PHCS) Program and SIIReN

9:10 am - 9:55 am Concurrent Paper Session I - Dockside 4,5,6,7,8 (15 min each: 10 min presentation and 5 min Q&A)

9:55 am - 10:30 am

Distinguished Lecture Presentation - Regatta Ballroom

Lecturer: Dr. Jeannie Haggerty, McGill University

“Instruments Evaluating Primary Healthcare Experience: What Patients Tell Us about Response

Formats, Bad Questions and Missing Pieces"

Instruments have been developed to elicit patient assessments of different attributes of primary healthcare

using different approaches, formats and questions. We administered six validated instruments to 110

adults in 13 groups and explored how well the instruments allowed them to express their healthcare experi-

ence and what they thought about questions and formats. We analyzed results qualitatively and used quali-

tative insight to understand quantitative observations using item response theory analysis. Patients want to

give feedback, try to be ‘good responders’ and want their evaluations to improve services, and we can help

them with this task. Insights from both qualitative and quantitative results point to best practice in question-

naire design, suggest how results might be better be reported, and suggest the need for more comprehen-

siveness evaluation tools.

10:30 am - 11:30 am Poster Presentations - Session I and Break - Regatta Ballroom

Each poster presenter will provide a 90 second overview to the conference audience followed by poster

viewings in Dockside 9 where you will have free time to review the posters you are most interested in

11:30 am - 12:15 pm Concurrent Paper Session II - Dockside 4,5,6,7,8

(15 min each: 10 min presentation and 5 min Q&A)

12:15 pm Buffet Lunch - Regatta Ballroom

1:00 pm - 1:50 pm

Martin Bass Lecture - Regatta Ballroom Introduction: Moira Stewart

"Primary Healthcare Planning Group (PHPG): Implications for PHC Policy and Research in Ontario" Keynote Speakers:

Susan Fitzpatrick, Assistant Deputy Minister, Negotiations and Accountability Management Division,

Ministry of Health and Long-Term Care

Dr. Brian Hutchison, Scientific Advisor for Primary Healthcare, Canadian Health Services Research

Foundation; Senior Advisor, Health Quality Ontario; Co-Chair, Canadian Working Group for Primary

Healthcare Improvement and Professor Emeritus, Department of Family Medicine, McMaster University;

The Primary Healthcare Planning Group (PHPG) was established in the fall of 2010 with a mandate to: ·

Draft and build consensus on a strategy for strengthening primary care in Ontario; and have the plan de-

bated by a broad-based group of stakeholders Five working groups were established in the areas of: Quali-

ty in Primary Care; Strengthening Primary Care Access; Increasing Efficiency in Family Practice Settings;

Improving Accountability in Primary Care; and Strengthening Primary Care Organization and Governance.

These working groups have contributed to the report: Strategic Directions for Strengthening Primary Care

in Ontario: Overview of Process and Recommendations of the Primary Healthcare Planning Group which

was recently released to the public.

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Program

1:50 pm - 2:40 pm

Poster Presentations - Session II and Break - Regatta Ballroom Each poster presenter will provide a 90 second overview to the conference audience followed by poster viewings in Dockside 9 where you will have free time to review the posters you are most interested in

4:00 pm Research Day Adjourns

2:40 pm - 4:00 pm

Workshops - Regatta Ballroom & Dockside 5

1. Ontario Primary Health Care System Models and Their Impact on Research, Dr. Richard

Glazier, Institute for Clinical Evaluative Sciences (ICES) , Regatta Ballroom

Ontario’s primary care models now include three-quarters of both the population and of primary

care physicians. These models were developed at different times, under different circumstanc-

es, with somewhat different purposes and have become distributed across the province and in

the population in a non-random way. The purpose of this workshop is to help participants con-

sider and more deeply understand the ways that primary care models may affect their research,

whether it is about processes and outcomes of clinical care, delivery of health services or popu-

lation health. This workshop will provide an overview of the nature and distribution of primary

care models including their geographic distribution and their demographics and case-

mix. Workshop participants will be asked to consider in small groups and report back on how

they feel inter-disciplinary teams, physician payments, and organizational factors (governance,

use of guidelines, after-hours coverage) affect their research and what they need to know about

these issues to inform their work. The workshop will conclude with information on what is

known about performance in different models of care, with a large group discussion of the im-

pact of the different models on primary care and population health.

2. An Introduction to Item Response Theory Analysis and Its Use In Enhancing Reliability

of Instruments, Dr. Jeannie Haggerty, Department of Family Medicine, McGill University,

Dockside 5

Item response theory (IRT) analysis is an important adjunct to factor analysis and reliability

measures in developing reliable and valid instruments. It evaluates how well individual ques-

tions and response options perform relative to an underlying construct. This workshop will pro-

vide a brief introduction to both non-parametric and parametric IRT and use examples from our

research to show how we have used it to identify high and low performing items, to improve

response options and evaluate bias in instruments. After the introduction, workshop partici-

pants will be presented with various IRT graphs and invited to interpret dimensions such as

discriminating capacity and response function. We will then show how we have used IRT re-

sults to drop questions from a subscale and improve response options. We will specifically

demonstrate how we have used IRT to evaluate the equivalency of French and English ver-

sions of instruments.

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CONCURRENT PAPER SESSION I

Rooms Dockside 4 Dockside 5 Dockside 6

9:10-9:25

What shapes family physicians patterns of care for community

patients at end-of-life? A grounded theory study

Joshua Shadd

Patient poverty and panel size in primary care

Laura Muldoon

The burden of chronic conditions in primary care

Patricia Sullivan-Taylor Michelle Martin-Rhee

Shaheena Mukhi

9:25-9:40

Psychotherapy in Family Medicine

Saadia Hameed

Understanding health inequities and access to primary health care in

southeastern Ontario

Amrit Sehdev

Computerized clinical decision support systems role in diabetes management: A

systematic review and meta analysis

Rebecca Jeffery

9:40-9:55

Nutritional profile and preventable illness among children in urban slums

of Lahore, Pakistan

Saleem M. Rana & Asma A Latif

Research opportunities for studying equity of primary health care access

for mental health care in Canada

Heather Maddocks

The prescribing trends by nurse practitioners to older adults in Ontario:

2000-2010

Joan Tranmer

Room Regatta Ballroom

9:55-10:30

Distinguished Lecture Presentation Dr. Jeannie Haggerty, McGill University

Instruments Evaluating Primary Healthcare Experience: What Patients Tell Us about Response Formats, Bad Questions and Missing Pieces

10:30-11:30 POSTER PPRESENTATIONS- SESSION I AND BREAK – Dockside 9

Prioritizing measures of hospice palliative care: Stakeholder input into a

regional overview document

Joshua Shadd

Predictors of up-to-date colorectal cancer screening and patient-centred care in Family Health Team primary

care practices

Michelle Dimitris

Resident-led geriatric outreach pilot program needs assessment report:

Bridging community and specialized care to improve elderly care

Liliana MacKenzie

Clinical audit of patient attainment of key chronic disease management

metrics

Steven Lipari

The symptom of fatigue in primary care: Assessing health care utilization

in the Canadian context

Kathryn Nicholson

“Working the system”: The influence of beliefs, attitudes and experience on patient

behaviour

Michelle Nelson

Poster 1 Poster 2 Poster 3

Poster 7 Poster 8 Poster 9

Presentation Schedule

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CONCURRENT PAPER SESSION I

Dockside 7 Dockside 8 Rooms

Truckers Research for Innovative Health Promotion Programs: A knowledge

translation experience from a health survey to on-going action

Michelle Howard

How does the organization of community based networks foster

improvements in health and system outcomes?

Beatrice McDonough

9:10-9:25

Power in clinical learning environments: Expanding our understanding of how social

power influences learner empowerment

Keyna Bracken & Judy Baird

The impact of panel size on quality of care – A population based study

Simone Dahrouge

9:25-9:40

How did Ontario primary healthcare teams benefit from a learning collaborative

program? A qualitative study

Han Han & Jyoti Kotecha

Toward seamless patient care

Roberta Heale

9:40-9:55

Regatta Ballroom Room

Distinguished Lecture Presentation Dr. Jeannie Haggerty, McGill University

Instruments Evaluating Primary Healthcare Experience: What Patients Tell Us about Response Formats, Bad Questions and Missing Pieces

9:55-10:30

10:30-11:30

Poster 4 Poster 5 Poster 6 Poster 25

What guideline attributes can affect uptake in clinical practice? Results of a realist review on guideline implementability

Ananda Chatterjee

Fostering a culture of interdisciplinary collaboration in Ontario's Family Health

Teams

Rachelle Ashcroft

Evaluating the impact of open

access on utilization of outside medical services in an academic

Family Health Team

Todd Greenspoon

Determinants of

emergency department use by

non-urgent cases in a community

hospital

Kristina Lyte

Pilot feasibility study of a personal health record (MyOSCAR) linked with a clinic

electronic medical record

Michelle Howard

Improving data quality in EMRs for quality improvement efforts: A

qualitative comparison of two data quality improvement approaches

Karim Vassanji & Karim Keshavjee

Learners experience in an

interprofessional diabetes clinic in family practice

Inge Schabort &

Michele MacDonald Westruck

BHIP: Be health in pregnancy–

nutritional and physical activity interventions to

improve gestational weight gain

management

Rishma Walji

POSTER PPRESENTATIONS- SESSION I AND BREAK - Dockside 9

Poster 10 Poster 11 Poster 12 Poster 26

Presentation Schedule

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Presentation Schedule

11:30-12:15 CONCURRENT PAPER SESSION II

Rooms Dockside 4 Dockside 5 Dockside 6

11:30-11:45

The nurse practitioner tracking study: Monitoring the integration of NPs into

Ontario’s healthcare system

Irene Koren & Ellen Rukholm

The validation of practice-based survey tools for use in primary health

care performance measurement in Canada

Ali Moses McKeag

Effectiveness of providing free nicotine replacement therapy through Ontario

Family Health Teams: Preliminary findings

Peter Selby

11:45-12:00

A pilot feasibility RCT evaluating the addition of an onsite obstetrician to a collaborative primary care maternity

centre

Keyna Bracken

Estimating the prevalence of neuropathic pain in a primary care electronic medical record database

Bridget Ryan

Increasing cancer screening for Ontario’s South Asians: Lessons from a

multidisciplinary knowledge exchange workshop

Andrew Pinto

12:00-12:15

The effect of post-discharge outpatient care on unplanned readmissions: The

EPOC readmission study

Lise Bjerre

A validation study of EMR based diagnostic algorithms for five chronic conditions: Enhancing osteoarthritis

and hypertension diagnostic algorithms

Amjed Kadhim-Saleh

The impact of Family Health Teams (FHTs) on colorectal cancer screening

Gladys Honein

12:15 Lunch Buffet - Regatta Ballroom

1:00-1:50 Martin Bass Lecture - Introduction: Moira Stewart

Dr. Brian Hutchison & Susan Fitzpatrick Primary Healthcare Planning Group (PHPG): Implications for PHC Policy and Research in Ontario

1:50-2:40 POSTER PPRESENTATIONS - SESSION II AND BREAK - Dockside 9

Diabetes group medical visits: A win-win for patients and providers

Inge Schabort

Diabetes management – Quality assessment of care at Stonechurch

Family Health Centre

Jo Jo Leung & Ramin Haider

What is the patient’s perspective of the self-management of multiple chronic

conditions? A qualitative synthesis of the literature

Valerie Blazhko

Leveling the Playing Field – Making Primary Care Accessible for Spinal

Cord Injury Consumers

Colleen McMillan & Craig Bauman

Studying context in complex chronic disease interventions

Priya Vasa

Socio-demographic factors influencing the rates of alcohol cessation and relapse in

lung cancer survivors

Ehab Fadhel

Poster 13 Poster 14 Poster 15

Poster 19 Poster 20 Poster 21

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CONCURRENT PAPER SESSION II 11:30-12:15

Dockside 7 Dockside 8 Rooms

Dietary assessment practices and use of electronic assessment tools in FHTs in

Ontario

Carolina Bonilla

Pan-Canadian primary health care(PHC) indicators: Updated for use by policy-

makers and PHC providers

Michael Terner

11:30-11:45

Improved weight management in primary care

Paula Brauer

Laying the foundation for performance measurement in primary care in Ontario

Brian Hutchison &Greg Webster

11:45-12:00

An innovative model of care for enhancing the management of cognitive

impairment in primary care

Linda Lee

Becoming a family medicine resident teacher: A qualitative study

Britta Laslo & Manjot Grewal

12:00-12:15

12:15

Martin Bass Lecture - Introduction: Moira Stewart Dr. Brian Hutchison & Susan Fitzpatrick

Primary Healthcare Planning Group (PHPG): Implications for PHC Policy and Research in Ontario 1:00-1:50

POSTER PPRESENTATIONS - SESSION II AND BREAK - Dockside 9 1:50-2:40

Optimizing, translating and mentoring our way to better pain management

Arun Radhakrishnan

Creating a roadmap for improving electronic medical record implementation

& use in Canadian primary health care

Amanda L. Terry

Foundations for a patient-centred primary care model for vulnerable

older adults

Susan Hum

The Canadian Primary Health Care Research Network: A patient-oriented research, training and policy network

William E. Hogg

Socioeconomic and gender-based disparities in rates of hospitalization

among human immunodeficiency virus infected patients in Ontario: A population-

based study

Tony Antoniou

Smoking cessation at Stonechurch Family Health Centre: A retrospective

cohort

Steven V. Zizzo

Lunch Buffet - Regatta Ballroom

Poster 16 Poster 17 Poster 18

Poster 22 Poster 23 Poster 24

Presentation Schedule

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Distinguished Paper Presentation

9:55 am - 10:30 am - Regatta Ballroom “Instruments Evaluating Primary Healthcare Experience: What Patients Tell Us about Response Formats, Bad Questions and Missing Pieces"

Lecturer: Dr. Jeannie Haggerty, McGill University

Jeannie Haggerty received her PhD in Epidemiology from McGill University in 1998. She was recruited to the McGill Department of Family Medicine in 2010 and holds the McGill Research Chair in Family and Community Medicine Research, based at St. Mary’s Hospital Centre. Her domain of research is the factors related to accessibility and quality of primary care in Canada and in developing countries, particularly the im-pact of health system policies and reforms. In recent years she has focused on the development and validation of measures of patient and provider experience health care. She has established a cohort to follow the health and healthcare changes over time in four healthcare network

Abstract:

Instruments have been developed to elicit patient assessments of different attributes of primary healthcare using different approaches, formats and questions. We adminis-tered six validated instruments to 110 adults in 13 groups and explored how well the instruments allowed them to express their healthcare experience and what they thought about questions and formats. We analyzed results qualitatively and used quali-tative insight to understand quantitative observations using item response theory anal-ysis. Patients want to give feedback, try to be ‘good responders’ and want their evalua-tions to improve services, and we can help them with this task. Insights from both qual-itative and quantitative results point to best practice in questionnaire design, suggest how results might be better be reported, and suggest the need for more comprehen-siveness evaluation tools.

Martin Bass Lecture 1:00 pm - 1:50 pm - Regatta Ballroom Primary Healthcare Planning Group (PHPG): Implications for PHC Policy and Re-search in Ontario"

Susan Fitzpatrick, Assistant Deputy Minister, Negotiations and Accountability Man-agement Division, Ministry of Health and Long-Term Care

Susan Fitzpatrick is the Assistant Deputy Minister, Negotiations and Accountability Management Division, Ministry of Health and Long-Term Care. Susan has worked for the Ontario Public Service since 1982. She has progressed through a number of jobs including Manager, Director of Provider Services Branch and Executive Director, Negotiations and Accountability Management. Susan is responsible for a large health care programs portfolio including health services, primary care and provincial pro-grams with transfer payments of more than $12.5 billion and 326 staff. Susan was a key member of the core group leading the 2008 OMA physician negotiations. She was responsible for developing a negotiating strategy and mandate to address key govern-ment priorities and negotiating innovative performance-based funding arrangements, restructuring relationships, and transforming the way business is conducted.

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Dr. Brian Hutchison, Scientific Advisor for Primary Healthcare, Canadian Health Ser-vices Research Foundation; Senior Advisor, Health Quality Ontario; Co-Chair, Canadi-an Working Group for Primary Healthcare Improvement and Professor Emeritus, De-partment of Family Medicine, McMaster University; Brian Hutchison is a Professor Emeritus in the Departments of Family Medicine and Clinical Epidemiology and Biostatistics at McMaster University, Co-Chair of the Cana-dian Working Group for Primary Healthcare Improvement and Senior Advisor for Pri-mary Care to Health Quality Ontario He is a past Director (2002-2005) of the McMaster University Centre for Health Economics and Policy Analysis (CHEPA) and served as founding Editor-in-Chief of Healthcare Policy (2004-2009) and President of the Canadi-an Association for Health Services and Policy Research (2010-2011). He practiced comprehensive family medicine for five years in a fee-for-service group practice, fol-lowed by 25 years in a McMaster University academic family practice. Brian held a Na-tional Health Research Scholar award from Health Canada from 1994 to 1999. He was the 2004 recipient of the Health Services Research Advancement Award presented by the Canadian Health Services Research Foundation. Brian received a Lifetime Achievement Award in Family Medicine Research from the College of Family Physi-cians of Canada in 2008. His areas of research and policy interest include organiza-tion, funding and delivery of primary and community care, needs-based health care re-source allocation and funding methods, provider payment methods, quality improve-ment and preventive care.

The Primary Healthcare Planning Group (PHPG) was established in the fall of 2010 with a mandate to: · Draft and build consensus on a strategy for strengthening primary care in Ontario; and have the plan debated by a broad-based group of stakeholders Five working groups were established in the areas of: Quality in Primary Care; Strengthening Primary Care Access; Increasing Efficiency in Family Practice Settings; Improving Accountability in Primary Care; and Strengthening Primary Care Organiza-tion and Governance. These working groups have contributed to the report: Strategic Directions for Strengthening Primary Care in Ontario: Overview of Process and Rec-ommendations of the Primary Healthcare Planning Group which was recently released to the public.

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Workshops

2:40 pm - 4:00 pm - Regatta Ballroom & Dockside 5 1. Ontario Primary Health Care System Models and Their Impact on Research, Dr.

Richard Glazier, Institute for Clinical Evaluative Sciences (ICES) Regatta Ballroom

Ontario’s primary care models now include three-quarters of both the population and of primary care physicians. These models were developed at different times, under different circumstances, with somewhat different purposes and have become distrib-uted across the province and in the population in a non-random way. The purpose of this workshop is to help participants consider and more deeply understand the ways that primary care models may affect their research, whether it is about pro-cesses and outcomes of clinical care, delivery of health services or population health. This workshop will provide an overview of the nature and distribution of pri-mary care models including their geographic distribution and their demographics and case-mix. Workshop participants will be asked to consider in small groups and re-port back on how they feel inter-disciplinary teams, physician payments, and organi-zational factors (governance, use of guidelines, after-hours coverage) affect their re-search and what they need to know about these issues to inform their work. The workshop will conclude with information on what is known about performance in dif-ferent models of care, with a large group discussion of the impact of the different models on primary care and population health.

Bio

Dr. Rick Glazier is a Senior Scientist and the Program Lead of Primary Care and Population Health at the Institute for Clinical Evaluative Sciences (ICES). He is also a Family Physician in the Department of Family and Community Medicine at St. Michael’s Hospital, and a Scientist in its Centre for Research on Inner City Health (CRICH). At the University of Toronto, Dr. Glazier is a Professor in the Department of Family and Community Medicine (DFCM), and cross-appointed at the Dalla Lana School of Public Health. He is an author of over 150 peer-reviewed publications, a co-editor of Neighbourhood Environments and Resources for Healthy Living – A Fo-cus on Diabetes in Toronto: An ICES Atlas (2007), and a contributor to Primary Care in Ontario: ICES Atlas (2006). Dr. Glazier’s honours include: “Family Medicine Re-searcher of the Year” (2005, College of Family Physicians of Canada), inaugural “Research Mentorship” award (2009, DFCM, University of Toronto), “President’s Award” for contributions to primary care research (2011, North American Primary Care Research Group), and the award for “Outstanding Contributions to Family Medicine Research” (2011/2012, Department of Family & Community Medicine, Uni-versity of Toronto). Dr. Glazier’s research interests include primary care health ser-vices delivery models, health of disadvantaged populations, management of chronic diseases, and population-based and geographic methods for improving equity in health.

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2. An Introduction to Item Response Theory Analysis and Its Use In Enhancing Reliability of Instruments, Dr. Jeannie Haggerty, Department of Family Medi-cine, McGill University Dockside 5

Item response theory (IRT) analysis is an important adjunct to factor analysis and reliability measures in developing reliable and valid instruments. It evaluates how well individual questions and response options perform relative to an underlying construct. This workshop will provide a brief introduction to both non-parametric and parametric IRT and use examples from our research to show how we have used it to identify high and low performing items, to improve response options and evaluate bias in instruments. After the introduction, workshop participants will be presented with various IRT graphs and invited to interpret dimensions such as dis-criminating capacity and response function. We will then show how we have used IRT results to drop questions from a subscale and improve response options. We will specifically demonstrate how we have used IRT to evaluate the equivalency of French and English versions of instruments.

Bio

Jeannie Haggerty received her PhD in Epidemiology from McGill University in 1998. She was recruited to the McGill Department of Family Medicine in 2010 and holds the McGill Research Chair in Family and Community Medicine Research, based at St. Mary’s Hospital Centre. Her domain of research is the factors related to accessi-bility and quality of primary care in Canada and in developing countries, particularly the impact of health system policies and reforms. In recent years she has focused on the development and validation of measures of patient and provider experience health care. She has established a cohort to follow the health and healthcare changes over time in four healthcare network.

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Papers Concurrent Paper Session I

9:10 - 9:25 Dockside 4

WHAT SHAPES FAMILY PHYSICIANS’ PATTERNS OF CARE FOR COMMUNITY PATIENTS AT END-OF-LIFE? A GROUNDED THEORY STUDY Presenter: Joshua Shadd Affiliation: Western University, Centre for Studies in Family Medicine, London PURPOSE: Commentators note that family physicians (FPs) vary in their patterns of care (e.g. provision of home visits, after hours coverage) for community patients at end of life. The nature and causes of this variation have not been well-described. The goals of this study were to: 1) describe dimensions of care which vary between FPs, and 2) explore the process by which FPs adopt their particular patterns. METHODOLOGY: Grounded theory based on in-depth interviews with FPs in southwestern Ontario. FPs were recruited initially by a maximum-variation sampling strategy, and later by theoretical sampling. Saturation of the primary process theme was achieved after nine interviews. RESULTS: Regarding the study’s first goal, participants identified three dimensions of care which differ among FPs (availability, nature of needs met, relationships with other care providers). Regarding the second goal, participants described seeking alignment as the primary process shaping their patterns of practice. Furthermore, FPs adopt patterns of activity which are sensitive to context, and seek to balance the needs of multiple parties. Personal satisfaction in providing care to community patients at end of life is eroded if system design or contextual constraints hamper FPs’ ability to meet patients’ needs, or exact an unacceptable toll in the process. CONCLUSIONS: Educational, policy or administrative interventions to enhance family physicians’ engagement in the care of community patients at end of life are likely to be successful to the degree that FPs perceive the intervention to support the process of seeking alignment in the care of this patient population.

9:10 - 9:25 Dockside 5 PATIENT POVERTY AND PANEL SIZE IN PRIMARY CARE Presenter: Dr. Laura Muldoon Affiliation: Somerset West Community Health Centre Authors: Laura Muldoon, Jennifer Rayner, Simone Dahrouge Objective: Determine if poverty is associated with increased workload for primary care providers (PCPs) Background: Patient poverty is linked to poorer health. Weighting capitation rates and primary care (PC) panels by patient co-morbidity is well accepted, but there is doubt about whether poverty should also be considered. Methods: Data from Ontario’s 73 Community Health Centres (CHCs) was linked to health administrative databases at the Institute for Clinical Evaluative Sciences to establish the co-morbidity profile of patients and identify individuals living in poverty (social assistance recipients). Panel size was calculated as the number of patients per full time equivalent Primary Care Provider (PCP). Multiple linear regressions were used to assess the association between panel size and poverty. Results: Higher proportions of social assistance recipients in a panel were associated with a smaller panel size. Controlling for co-morbidity removed the association. Conclusions: Social assistance recipients likely generate a higher workload for PCPs in CHCs; however, this is largely because they are sicker. Further information is required about the spectrum of services used by poor patients in CHCs.

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9:10 - 9:25 Dockside 6

THE BURDEN OF CHRONIC CONDITIONS IN PRIMARY CARE Presenter: Ms. Patricia Sullivan Taylor, MPA Affiliation: CIHI, Primary Health Care Information, Toronto Co-presenters: Ms. Michelle Martin-Rhee, PhD; Ms. Shaheena Mukhi, MHA Authors: Ms. Patricia Sullivan Taylor, MPA Ms; Michelle Martin-Rhee, PhD; Ms. Shaheena Mukhi, MHA Purpose: 1) To showcase and highlight the use of Electronic Medical Record (EMR) data to better understand primary health care (PHC) patient profiles. 2) To examine the impact of multiple chronic conditions on various outcomes, including health service utilization, lab results, blood pressure values and medication usage. Methodology: Using EMR data from the Canadian Institute for Health Information’s (CIHI) Primary Health Care

Voluntary Reporting System (PHC VRS), we identified patients with various chronic diseases. Patient demographics such as age, gender and distance travelled to PHC clinic were investigated. Multivariate analyses were used to demonstrate the impact of multimorbidity on several factors, such as A1C levels, LDL levels and health service utilization.

Preliminary results indicate: 1) Patients with two or more comorbidities are

more likely to be older, female and high service users than patients with one or no chronic conditions.

2) Patients over 65 are 6 times more likely to have at least 3 chronic conditions and thus require more care coordination and interventions from a multidisciplinary team.

3) Age and comorbidity have a stronger association to patient outcomes including A1C levels and health service utilization than distance and estimated income.

Conclusions: 1) Distance from clinic and estimated income do not have the same impact as factors such as age and comorbidity. 2) Older patients with more chronic conditions have more complex care needs. 3) Better understanding of patient demographics can assist in targeting care and programs to patients with specific needs.

9:10 - 9:25 Dockside 7

TRUCKERS RESEARCH FOR INNOVATIVE HEALTH PROMOTION PROGRAMS: A KNOWLEDGE TRANSLATION EXPERIENCE FROM A HEALTH SURVEY TO ON-GOING ACTION

Presenter: Michelle Howard, PhD

Affiliation: McMaster University, Department of Family Medicine, Hamilton

Authors: Beatrice McDonough, BScN, MScN, MSc, PhD(c) ; Ricardo Angeles, MD, MPH, MHPEd; Lisa Dolovich, BScPhm, PharmD MSc; Michelle Howard, PhD; John Riva, BA, DC; Francine Marzanek, BSc, BEd; Helen Qian, BHSc, Kiska Colwill, BSc Pharm RPh

Statement of Purpose: Truck driving is a common occupation for men in Canada, Drivers experience higher than average health risks and poor lifestyle behaviours. There is a lack of detailed Canadian data on their health and wellness for planning and interventions, and fewer linkages between researchers and knowledge users to address the multi-faceted issues of workplace health and wellness in this industry.

The objective of this presentation is to describe the integrated knowledge translation activities of the Truckers Research for Innovative Health Promotion Programs (TRIHPP) group.

Methodology: A participatory approach to research and evaluation addressing the health challenges of truck drivers, in a knowledge-to-action framework is being used. Strategies include a series of sequential and parallel activities, including participant engagement in research and dissemination planning.

The multidisciplinary research team (public health, workplace health, primary care) is collaborating with truck drivers, trucking company managers, government, customers, and insurance and trucking advocacy organizations.

Results: Focus groups and a survey provided baseline data on health needs and risk factors. Creation of a ‘multi-stakeholder design team’ generated an action plan at individual, company, policy and regulatory levels, providing direction for research. Knowledge translation activities included stakeholder meetings, workshops, presentations, lay summaries, peer-reviewed publication, a healthy grab-and-go factsheet, and the TRIHPP website. Research derived from knowledge users includes a customer survey to understand industry challenges that contribute to barriers to healthy living.

Conclusions: Involvement of key stakeholders has fostered enthusiasm and collaboration, promoted uptake of findings, and generated opportunities for future research.

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9:10 - 9:25 Dockside 8

HOW DOES THE ORGANIZATION OF COMMUNITY BASED NETWORKS FOSTER IMPROVEMENTS IN HEALTH AND SYSTEM OUTCOMES?

Presenter: Beatrice McDonough, BScN, MScN, MSc, PhD(c)

Affiliation: McMaster University, Department of Family Medicine, Hamilton

Authors:Beatrice McDonough, BScN, MScN, MSc, PhD(c) ; Ricardo Angeles, MD, MPH, MHPEd; Lisa Dolovich, BScPhm, PharmD MSc; Francine Marzanek, BSc, BEd; Helen Qian, BHSc

Statement of Purpose: Hypertension is one of the most preventable causes of cardiovascular disease. The Cardiovascular Health Awareness Program (CHAP) is a community-based, primary care centered, peer-led, free of charge, cardiovascular disease risk assessment, blood pressure monitoring program for older adults, demonstrating effectiveness in lowering cardiovascular morbidity (BMJ, 2011). In each community, a local lead organization (LLO) leads CHAP in partnership with organizations as a mechanism for participants to become engaged in hypertension management including accessing local programs and resources.

Objective: To describe the effect of networks and partnership relationships within CHAP communities related to the primary prevention of high blood pressure.

Methodology: Cross-sectional analysis cohort study with 9 Ontario communities; representatives from CHAP LLO, CHAP participants and partner organizations.

Results: Using Butterfoss’s Community Coalition Action Theory, strength of partnership, stage of coalition development, structure and strength of social network and community profile were measured using the validated Partnership Self-Assessment Tool (PSAT), the validated Coalition Effectiveness Inventory (CEI), Social Network Mapping and a Community Profile to determine the effect on individual, community and system outcomes. Some individual (age, self-efficacy, gender), community (Rurality Index of Ontario Score, duration of CHAP), and partnership level (CEI and some domains of PSAT, proportion of pharmacies involved) factors were predictive of change in health behaviours and community resource utilization.

Conclusions: The application of this theory and measurement tools provide an unique visual approach to help researchers and community leaders better understand and improve partnerships, local networks and the overall collaborative process.

9:25 - 9:40 Dockside 4

PSYCHOTHERAPY IN FAMILY MEDICINE Presenter: Saadia Hameed, MBBS CFPC MClSc (candidate) Affiliation: Western University, Assistant Professor, Department of Family Medicine Schulich School of Medicine and Dentistry, London Authors: Saadia Hameed MBBS CFPC MClSc (candidate); Evelyn Vingilis Ph.D., C. Psych., Laura Lewis BSW, MSW, PhD (SW)

Purpose: To explore what psychotherapy means to Family Physicians, specifically how it is practiced and what are some of the factors that influence its practice. Participants: Purposive sampling of 18 family physicians for maximum variation. Methodology: A descriptive qualitative study with semi-structured interviews that were conducted, transcribed verbatim and analyzed by three independent reviewers. Consensus about thematic findings was reached after discussions. Results: The study showed significant variability in the definition of psychotherapy as defined by family physicians. Most family doctors felt that psychotherapy was inherent in the practice of family medicine, and was practiced frequently, yet they felt that the training they received was inadequate. Physicians said their patients presented with mood disorders, personality disorders, acute life stress, psychosis, post-traumatic stress disorder and addictions. Most physicians learned on the job and felt that knowing their patient over time made it possible for them to provide meaningful therapy and support to them despite the lack of training. Time, training, compensation, models of primary care where insured social worker/ psychologist services are present, presence or lack of community psychiatric resources are some of the factors cited by family doctors, which affected their practice of psychotherapy. Conclusion/Discussion: The strong physician patient relationship in family practice allows physicians to provide meaningful psychotherapy for patients despite inadequate training. However, this study raises some important questions; how much training should be adequate for family doctors to practice psychotherapy? Should there be some minimum standards? If shared care is being seen as a huge benefit to patient care and for provision of professional psychotherapy, should we be advocating for more insured services allowing family physicians to maintain a medical expert role?

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9:25 - 9:40 Dockside 6

COMPUTERIZED CLINICAL DECISION SUPPORT SYSTEMS ROLE IN DIABETES MANAGEMENT: A SYSTEMATIC REVIEW AND META-ANALYSIS Presenter: Rebecca Jeffery, BSc(hon), MSc candidate Affiliation: McMaster University, Clinical Epidemiology and Biostatistics, Hamilton Authors: Rebecca Jeffery, BSc(hon), MSc candidate, Emma Iserman, MSc, R Brian Haynes, MD, PhD Purpose: Chronic diseases such as diabetes present unique challenges to health care providers due to the complexity of treatments. Computerized clinical decision support systems (CCDSS) may be able to improve patient care by supporting the decision making process for a clinician. There is limited evidence of the effectiveness of CCDSS in chronic disease management (CDM). However, a subset of studies on diabetes care in ambulatory settings appeared more positive in a recent review, possibly because most of these included information for patients as well as practitioners. Methods: We searched MEDLINE, EMBASE, INSPEC, EBM Reviews databases from inception to January 2012, using our published search strategy1 and reference lists of eligible studies. Only unconfounded RCTs that compare diabetes specific CCDSSs to usual care in ambulatory care settings, and include a measure of the process of care and patient outcomes, will be included. Results: In our recent review on CDM and CCDSSs, 55% of trials on diabetes centered CCDSSs found improvements in the process of care, while 63% reported improved patient outcomes. This update, which will include three additional RCTs, will provide more precise estimates of success, including a meta-analysis (which was previously not warranted because of heterogeneity), and will assess whether more recent studies continue the positive trend. Conclusions: CCDSSs may help clinicians improve the quality of care for diabetic patients, but this is not clearly established in the evidence available to early 2010. Roshanov PS et al. Implementation Sci 2011; 6:92

9:25 - 9:40 Dockside 5

UNDERSTANDING HEALTH INEQUITIES AND ACCESS TO PRIMARY HEALTH CARE IN SOUTHEASTERN ONTARIO Presenter: Amrit Sehdev Affiliation: Queens Public Health Informatics Team Authors: Dr. Paul Belanger, Dr. Kieran Moore, Suzanne Biro, Ron Shore, Amrit Sehdev Purpose: Identify needs of vulnerable populations in the SELHIN and creating a basis for planning an equitable primary health care system. Methodology: A deprivation index (DI) that represents levels of material and social deprivation was applied to the population. These variables are used to rank dissemination areas into quintiles, where each quintile represents ~20% of the underlying population. Postal codes, health indicators and outcomes from administrative health databases were scored according to the DI and applied geographically. Geographical spatial representation of the DI was used to inform a sampling strategy for key informant interviews and focus groups. Themes identified were used to develop a survey instrument to understand the primary health care experiences in the SELHIN. Approximately 1150 respondents were surveyed through a telephone format, and an additional 59 individuals from the most deprived quintile were completed through a face to face format. Results: Geographic accessibility to primary care physicians is characterized by an urban-rural cleavage, and the most materially deprived quintiles are also confronted with the least accessibility to primary care physicians. Discharge Abstract Database analysis showed that most deprived quintiles have greater hospital utilization rates and longer lengths of stay. Survey results show a strong correlation between DI and those who report overall quality of health care in the SELHIN is poor or very poor, experience food insecurity, and those who have not been to a dentist in the last three years. Conclusions: A mixed methods approach can provide the context and scope for primary health care needs.

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9:25 - 9:40 Dockside 7

POWER IN CLINICAL LEARNING ENVIRONMENTS: EXPANDING OUR UNDERSTANDING OF HOW SOCIAL POWER INFLUENCES LEARNER EMPOWERMENT

Presenter: Dr Keyna Bracken

Affiliation: McMaster University, Department of Family Medicine, Hamilton

Co-Presenter: Dr. Judy Baird

Authors: Dr. Keyna Bracken, Dr. Judy Baird, Dr. Lawrence Grierson Many factors at the structural and cultural levels of an educational organization, impact the values, attitudes and behaviours transmitted to learners. Learners perceive that good role models are valued both for their clinical care, cognition and also for their attention to social aspects of their relationship with the learner. The degree to which medical students feel empowered in their clinical environments influences how vulnerable they are to having their personal-professional values influenced negatively by the environments structural and cultural aspects. Objective: To determine if clerks’ perception of their individual empowerment correlates with the types of social power employed by their preceptor. Methodology: Pilot Cohort Study using 2 cohorts of medical students from Michael G. DeGroote School of Medicine that will receive modified versions of Teacher Power Use Scale (TPUS) and Leaner Empowerment Scale (LEM) by electronic survey. Outcomes: TPUS and LEM outcomes across each power /empowerment dimension will be analyzed by ANOVA. Significant results (p<.05) will be decomposed using Tukey’s HSD post hoc methodology. Correlational analysis will be performed to quantify any observed relationships with the amount of direct interaction with preceptors. Hypothesis: Rotations characterized by high preceptor power in dimensions of reward, referent and expert power will positively correlate with clerk personal empowerment. Conversely rotations characterized by high preceptor power in coercive and legitimate power will correlate negatively with clerk personal empowerment. The results of this study will increase our understanding of how social power both positively and negatively impacts learning in medical education.

9:25 - 9:40 Dockside 8

THE IMPACT OF PANEL SIZE ON QUALITY OF CARE - A POPULATION BASED STUDY Presenter: Simone Dahrouge Affiliation: Bruyère Research Institute, C.T. Lamont Primary Health Care Research Centre, Ottawa Authors: S Dahrouge, R Glazier, W Hogg, E Muggah, A Kopp, S Hawken, G Russell, M Hernandez, J Younger Rational: Existing data demonstrate that quality of care may be compromised when family physicians are responsible for managing large numbers of patients (panel size). We are conducting a population-based study to inform whether and where panel size benchmarks should be established. Approach: We use health administrative data housed at the Institute for Clinical Evaluative Sciences to examine the quality of care delivered (2008-2010) in relation to panel size (number of patients under the care of a full-time family physician) in Ontario’s patient enrolment primary care models. We limited the dataset to physicians with panel sizes >1200 for policy relevance and to eliminate those working part time. We included: 4,195 physicians, 8.3 million patients. Outcomes: Accessibility, continuity, comprehensiveness, prevention, and chronic disease management. Results: Preliminary unadjusted analyses indicate that there is no association between panel size and measures of accessibility. However, there is a negative relationship between increasing panel size and preventive care and to a lesser extent, comprehensiveness. Analyses for continuity and chronic disease management outcomes are underway. Regressions will be performed for all outcomes to account for the impact of case mix, rurality, provider age and sex, model of care, and patient age, sex, immigration, and income status. Conclusions: These preliminary analyses suggest that the ability to access primary care services is not affected in patients of providers with larger panel sizes. However, the technical quality of care may be compromised as a provider’s panel size increases. Further investigation into other outcome measures and possible interacting factors are underway.

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9:40 - 9:55 Dockside 4 NUTRITIONAL PROFILE AND PREVENTABLE ILLNESS AMONG CHILDREN IN URBAN SLUMS OF LAHORE, PAKISTAN

Presenter: Saleem M Rana, PhDa

Affiliation: Health Services Academy, Islamabad, Pakistan

Co-Presenter: Asma A Latif, PhDb

Authors: Saleem M Rana, PhDa , Asma A Latif, PhDb ,Noreen Zafar, FRCOGc, Aashifa Yaqoob, MSPHb, c, and Muhammad A Zafar, MBBSd

a. Health Services Academy, Islamabad, Pakistan b. Lahore College for Women University Lahore, Pakistan c. Consultant Gynecologist Girls and Women Health Initiative Lahore Pakistan d. Services Institute of Medical Sciences Lahore Pakistan

Preventable diseases among children are prevailing globally especially in developing countries. A major cause is assumed to be their nutritional profile. Nutritional status of children was determined in an urban slum of Aziz Bhatti town Farozepur road, opposite Lahore General Hospital, Lahore by Girls and Women Health Initiative (GWHI) Pakistan Lahore. Diagnosis and treatment was provided to all sick children on the spot. 1848 children of age between 1 to 5 years were attended from April 2009 to March 2011. Weight for age of children was compared by using WHO Anthro software and found below the WHO standards. In malaria and carries cases, average weight of male babies was significantly higher than females. Average weight was significantly higher in female babies in general weakness cases i.e. 9.01 + 3.15 (Mean + S.D) in male babies and 11.5 + 3.86 in female babies. Similar findings were observed in lower respiratory tract infection i.e. 6.5 + 0.51 (Mean + S.D) in male babies and 8.8 + 3.93 (Mean + S.D) in female babies. In the rest of the diseases (Skin infection, Upper Respiratory Tract Infection, Diarrheal Diseases, Worm Infestation and Urinary Tract Infections), non-significant results were found. The availability of diagnostic facilities and the awareness of the community regarding different diseases were very low. As these illnesses were nonspecific, especially during the early stages of onset, misdiagnosis and mistreatment can occur. Therefore, it was recommended that the necessary diagnostic materials, training of treating health providers and awareness should be in place for proper treatment in these areas. The major cause of infant mortality can be attributed to these preventable diseases.

Key words: prevalence, nutritional profile, preventable diseases, awareness, treatment, control

9:40 - 9:55 Dockside 5

RESEARCH OPPORTUNITIES FOR STUDYING EQUITY OF PRIMARY HEALTH CARE ACCESS FOR MENTAL HEALTH CARE IN CANADA Presenter: Heather Maddocks Affiliation: Centre for Studies in Family Medicine, Western University, London Authors: Heather Maddocks; Amanda Terry and Amardeep Thind The family practitioner (FP) is often the first point of access for mental health issues, and the provider of ongoing care. Equity of access in the use of FP services, and treatment involves a critical examination of how access varies by patient and area level factors, such as gender, age, and proxy measures for socio-economic status including area level data on median household income. This presentation will explore the research opportunities and potential data holdings that can be linked with electronic medical records (EMRs) to measure equity of access for mental health services. For example, a multilevel longitudinal analysis could examine how patient, practice, and area level variables create a context for differentiation in access to care by primary health care providers. Outcome measures may include number and type of referrals, prescriptions, and documentation of mental health issues in the EMR. Access to Canada-wide EMRs through the use of the CPCSSN (Canadian Primary Care Sentinel Surveillance Network) Database will allow a cross-national study of depression and other mental health issues, relating them to differences in provincial health care systems.

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9:40 - 9:55 Dockside 7

HOW DID ONTARIO PRIMARY HEALTHCARE TEAMS BENEFIT FROM LEARNING COLLABORATIVE PROGRAM? A QUALITATIVE STUDY

Presenter: Han Han, PhD

Affiliation: Queen's University, Centre for Studies in Primary Care, Department of Family, Kingston

Co-presenter: Jyoti Kotecha, PhD (candidate) Authors:Han Han, PhD; Jyoti Kotecha, PhD (candidate), MPA, CChem, MRSC; Judith Belle Brown, PhD; Jann Paquette-Warren, MSc; Jane Yealland, BA; Mike Green, MD, MSc, FCFP; Stewart Harris, MD, MPH, FCFP, FACPM; Grant Russell, MD, PhD; Susan Webster-Bogaert BSc. (KIN), MA; Richard Birtwhistle MD, MSc, FCFP

Purpose: The Quality Improvement and Innovation Partnership (QIIP) offered a quality improvement (QI) opportunity to Ontario’s primary healthcare (PHC) teams to target chronic disease management, prevention, access to care and office efficiency. A comprehensive mixed method evaluation of the effectiveness of this initiative included a qualitative component.

The purpose of this study was to (1) describe the learning experiences of participants, (2) identify participation facilitators and barriers, and (3) explore the perceived improvements of participating PHC teams in QI.

Method: A qualitative evaluation study. Purposive sampling was used to identify 10 PHC teams from the 114 participating teams. Iterative process was used to select key-informants from these teams. Semi-structured telephone interviews (40-90 min) were conducted with 31 PHC team members, 7 QI coaches and 4 QIIP program administrators. Thematic analysis was performed. NVivo9 software was used for coding.

Results: Most participants expressed positive experiences and improvements in QI methodology, team functioning, disease management and prevention and access to care. Keys to success included team champions and team readiness regarding openness to innovation, motivation for change, EMR proficiency and awareness of time commitment. Variation in perceived improvement was related to team readiness, models of care and settings of practice (rural/urban). Rural practices found it more challenging to apply advanced access than urban ones.

Conclusions: While team champions and team readiness were features of success, rurality and practice models had an influence on levels of success. This study has implications for ongoing QI initiatives in primary health care in Ontario.

9:40 - 9:55 Dockside 6

THE PRESCRIBING TRENDS BY NURSE PRACTITIONERS TO OLDER ADULTS IN ONTARIO: 2000 – 2010 Presenter: Joan E. Tranmer, RN, PhD Affiliation: Queen's University, Nursing, Kingston Authors: J. Tranmer, RN, PhD, L. VanDenKerkhof, RN, DrPH, D. Edge, RN, PhD., K. Sears, RN, PhD., L. Levesque, BScPharm, PhD Statement of Purpose: In 2010, nurse practitioners (NPs) employed in Ontario, primarily in the primary care setting numbered 1,424 a four-fold increase since 2000. The goals of this study were: (1) to describe the trend of medication prescription to persons ≥ 65 years of age in Ontario by NPs, from 2000 to 2010, (2) to describe the common classes of medication prescription and (3) to determine geographical variation in patterns by Local Health Integration Network (LHIN). Methods: We conducted a population-based retrospective cohort study and identified all NPs certified between 1998 and 2010 in Ontario who had dispensed medications to patients ≥ 65 years during this time period. As a comparator, we identified all prescription medications dispensed to patients ≥ 65 years by family physicians in the same time period. Results: The number and proportion of NPs who dispensed medication to patients ≥65 years increased from 2000 to 2010 [44/340 (12.9%) to 888/1424 (62.4%)]. The number and proportion of medications dispensed for chronic conditions by NPs increased; in 2010, 9 out 10 medications dispensed were for chronic conditions. There was substantial variation in the proportion of NPs dispensing medication per older population across LHINs, with central urban regions having the lowest proportion. Conclusions: NP prescribing to older adults, and in particular medications related to chronic conditions, has increased substantially across the 10 years. The geographical variation suggests that the integration of NPs into primary health care has not been consistent. Further research needs to explore the health outcomes associated with NP prescribing practice patterns.

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Concurrent Oral Paper Session II

11:30 - 11:45 Dockside 4

THE NURSE PRACTITIONER TRACKING STUDY: MONITORING THE INTEGRATION OF NPS INTO ONTARIO'S HEALTHCARE SYSTEM Presenter: Irene Koren Affiliation: Laurentian University, Centre for Rural and Northern Health Research Co- Presenter: Ellen Rukholm Authors: Irene Koren, Ellen Rukholm, Oxana Mian Major primary health care reform in the mid-1990’s led to revival of the nurse practitioner (NP) role in Canada. NPs are recognized as an important part of the health human resource strategy to improve access to health care professionals, particularly in small, rural and underserved communities. Since the inception of The Nurse Practitioner Workforce Multi-Year Tracking Study (NP-TS) in 2006, the number of NPs practicing in Ontario has increased annually. Also, the breadth and distribution of NPs across practice settings has changed. With the implementation of new models for health care delivery and an increasing emphasis on team-based practice and integrated human resources initiatives, regular tracking studies can facilitate heath human resource planning and identification of strategies to promote optimal role utilization. Purpose: to inquire into the work of NPs in different settings to provide information about contextual factors that influence practice. Methodology: Multi-year data from the NP-TS commissioned by the Ontario Nursing Secretariat, Ministry of Health and Long-Term Care and conducted by the Centre for Rural and Northern Health Research (2006-2012). Results: The findings provide a picture of NP employment and practice in a variety of settings in Ontario’s health care system. Factors supporting NP role development and integration as members of interprofessional teams are explored. The unique contributions of NPs to the healthcare of the communities they serve are presented. Conclusion: Although the implementation of the NP role has made considerable progress in the last decade, full integration is yet to be realized.

9:40 - 9:55 Dockside 8

TOWARD SEAMLESS PATIENT CARE Presenter: Dr. Roberta Heale Affiliation: Laurentian University, School of Nursing, Sudbury The purpose of the research was to explore the concept of seamlessness in health care and to identify ways to enhance primary health care services in Ontario. The research was conducted in two phases; a review of targeted international and provincial health care systems followed by interviews with expert panelists who offered perspectives about changes to move Ontario closer to achieving seamless health care. To begin, the concept of seamless health care was analyzed and a framework was developed to allow for a consistent review of health systems. A review of six countries and provincial health systems focused on healthcare service delivery and funding models that link primary health care to hospital and community services. The next phase included interviews with expert panelists who critiqued the health systems review. The panelists were chosen from across Ontario and represented a variety of positions and perspectives. Main concepts and recommendations from each interview were analyzed and summarized into themes. These themes touched on what was deemed necessary to enhance the seamlessness of health care. Themes included patient experiences and perspectives; the need for real time, evaluative data; the potential integration of health and social services; creation of mechanisms for accountability within the primary health care sector; the need for multi-year funding commitments; the need to address the unintended outcomes of physician funding models in primary health care; the urgent need to revitalize the community health and long-term care sectors and the essential need for a comprehensive Electronic Health Record system.

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11:30 - 11:45 Dockside 5

THE VALIDATION OF PRACTICE-BASED SURVEY TOOLS FOR USE IN PRIMARY HEALTH CARE PERFORMANCE MEASUREMENT IN CANADA Presenter: Ali Moses McKeag, MSc. Affiliation: Project Lead, Primary Health Care Information, Canadian Institute for Health Information (CIHI) Authors: Ali Moses McKeag, MSc.; Brenda Tipper, M.H.Sc.; Ben Reason, MSc Statement of Purpose: While efforts to improve the coverage and availability of pan-Canadian administrative and electronic medical record datasets are a key part of improving the ability to measure Primary Health Care (PHC) performance, there are important aspects of performance that can only be understood through asking questions of PHC patients, providers and practices. A suite of pan-Canadian standard survey tools to measure patient, provider and practice experiences have been developed by CIHI and their research partners. The next phase of this project will consist of the validation of these surveys in PHC practices. Methodology: CIHI, in partnership with a pan-Canadian PHC research team, will survey a convenience sample of PHC patients, providers and practices. PHC providers will be approached by the survey research team members to request their participation as well as the participation of their practice and patients. Within consenting practices, a research assistant will approach PHC patients to request participation in the waiting room. All participation will be voluntary. Results: At the completion of the current project phase, validated PHC practice-based survey tools will be available for use in all interested jurisdictions for the following end uses: 1) In developing jurisdictional reviews of performance of primary health care; 2) To be shared and available in the public domain for use by organizations and researchers wanting survey instruments to measure PHC performance; 3) To support the reporting of pan-Canadian PHC indicators Conclusion: This presentation will give attendees an opportunity to understand the importance of validation of the pan-Canadian PHC practice based survey tools and provide invaluable feedback to the team working on this initiative.

11:30 - 11:45 Dockside 6

EFFECTIVENESS OF PROVIDING FREE NICO-TINE REPLACEMENT THERAPY THROUGH ON-TARIO FAMILY HEALTH TEAMS: PRELIMINARY FINDINGS Presenter: Dr. Peter Selby, MBBS Affiliation: Centre for Addiction and Mental Health, University of Toronto Authors: Justine Mascarenhas, MSc, Janine Fitz-patrick, MCogSc, Laurie Zawertailo, PhD, Sarwar Hussain, MSc, Rosa Dragonetti, MSc, Peter Selby, MBBS Background: A multi-faceted smoking-cessation program was developed to reduce smoking preva-lence in Ontario and address the need for compre-hensive smoking cessation treatment in primary care practices. The STOP with Family Health Teams (FHTs) program, involving the provision of free nicotine replacement therapy in combination with behavioural support, is currently being imple-mented by practitioners at select Ontario FHTs. Participants are contacted by research staff 3, 6, 9 and 12 months after enrolling to evaluate smoking outcomes. Purpose: To assess interim outcomes regarding the effectiveness of providing free comprehensive smoking cessation interventions to family health team patients. Methods: Baseline characteristics of the partici-pants who have enrolled to date were identified. Quit rates and other smoking cessation outcomes from the 3-month follow-up were determined. Results: 4086 participants were enrolled at 97 Fam-ily Health Teams from July 2011-Jan 2012. Partici-pants (mean age 51years) were 44% male. 48% had an annual household income under $40,000 and 46% self-reported a lifetime mental health diag-nosis. 63% of participants had a moderate level of tobacco dependence; mean baseline cigarette con-sumption was 21 cigarettes per day (range 1-100). Among 3-month follow-up responders, 40% report-ed being abstinent for at least the previous 7 days. Those who reported still smoking at follow-up had a mean daily cigarette consumption of 11 cigarettes; 72% had made at least one 24-hour quit attempt. Conclusions: Integrating the provision of compre-hensive smoking cessation treatment (including free nicotine replacement therapy) into multi-disciplinary Family Health Teams can engage smokers in the quit process and result in successful outcomes.

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11:30 - 11:45 Dockside 8

PAN-CANADIAN PRIMARY HEALTH CARE (PHC) INDICATORS: UPDATED FOR USE BY POLICY-MAKERS AND PHC PROVIDERS Presenter: Michael Terner, MSc, Project Lead Affiliation: Canadian Institute for Health Information Authors: Michael Terner, MSc, Brenda Tipper, MHSc, Ali Moses McKeag, MSc, Olga Krylova, PhD, and Ben Reason, MSc Purpose: In 2006, CIHI published 105 PHC indicators developed to measure and compare PHC performance at multiple levels within jurisdictions across Canada. In 2012, CIHI is releasing an update of priority indicators for use by policy-makers and PHC providers. These indicators are being updated to ensure that they are measureable and reflect current best practice. Methodology: We surveyed policy-makers, researchers, PHC providers and other stakeholders across Canada to identify two sets of indicators - 30 indicators per set - one for policy-makers and a second for providers of PHC. The definitions of these indicators have been reviewed, discussed and updated through (mostly virtual) consultations with approximately 60 stakeholders in five working groups. Results: Within the priority set for policy-makers, we updated the indicators to be used for population-based policy development and planning. Data sources for these indicators include national surveys (e.g., Canadian Community Health Survey), and administrative data (e.g., Scott’s Medical data base). Within the priority set for PHC providers, we updated the indicators to be used for practice-based measurement and quality improvement initiatives. Data sources for these indicators include standardized tools for practice-, provider- and patient-level surveys, and electronic medical records. Conclusions: While updating the PHC indicators, we balanced the need for the indicators to be pan-Canadian, valid and measurable. Each of the two sets of indicators had different objectives, data sources and units of measurements. We updated the definitions of these indicators to ensure they are measurable using available data sources and are reportable for as many Canadian jurisdictions as possible.

11:30 - 11:45 Dockside 7

DIETARY ASSESSMENT PRACTICES AND USE OF ELECTRONIC DIETARY ASSESSMENT TOOLS IN FHTS ONTARIO

Presenter: Carolina Bonilla MD, MSc

Affiliation: Graduate Student, Department of Applied Nutrition, University of Guelph, Guelph

Authors: Carolina Bonilla MD, MSc1; Paula Brauer RD, PhD1; Heather Keller RD, PhD2; Rhona Hanning RD, PhD3; Alba DiCenso RN, PhD4.

1Department of Applied Nutrition, University of Guelph. 2 Department of Kinesiology, University of Waterloo; 3School of Public Health and Health Systems, University of Waterloo and 4 Department of Clinical Epidemiology & Biostatistics, McMaster University.

Family physicians, registered nurses, nurse practitioners, pharmacists and registered dietitians (RDs) are delivering nutrition advice in primary care (PC). However, a number of barriers have been identified in conducting dietary assessment (DA) and providing nutrition advice to their patients. The use of information technology in the form of electronic dietary assessment (E-DA) tools can potentially facilitate this process in team-based care.

The purpose of the study was to explore DA practices and use of E-DA tools in healthcare providers in Family Health Teams (FHTs) Ontario, by using the OMRU model for potential adopters.

Methods: One-hour interdisciplinary focus groups (FGs) interviews. Thematic analysis was the qualitative method of data analysis.

Results: Fifty healthcare providers (11 male and 39 female) participated in 11 interdisciplinary FGs. Participants from ten healthcare disciplines (n=44), executive directors or administrative leads (n=6). Descriptive and interpretative themes were identified. Descriptive themes were: description of when and to whom obtain dietary information, forms of collecting dietary data, dietary counselling strategies, awareness of E-DA tools and recommendations. Interpretative themes were: overall aspects and current challenges of DA, inter-professional practices in the DA context, challenges and facilitators of E-DA tools.

Conclusions: DA and nutrition advice are part of everyday practices in diverse disciplines of healthcare providers. E-DA tools may facilitate DA and dietary advice for providers and their patients in FHTs. However, barriers were identified at the providers, patients and E-DA tools levels.

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11:45 - 12: 00 Dockside 5

ESTIMATING THE PREVALENCE OF NEUROPATHIC PAIN IN A PRIMARY CARE ELECTRONIC MEDICAL RECORD DATABASE

Presenter: Bridget L Ryan, PhD

Affiliation: Western University, Centre for Studies in Family Medicine

Authors: Bridget L Ryan, PhD; Joshua D Shadd, MD CCFP; Scott McKay, MD CCFP; Heather Maddocks, PhD.

CONTEXT: Neuropathic pain, arising from damage or dysfunction of the nervous system, is a clinically important syndrome, but its breadth and burden in primary care are poorly understood.

OBJECTIVE: To develop methods to estimate the prevalence of neuropathic pain among patients in a primary care electronic medical record (EMR) database.

DESIGN: Retrospective cohort study using the DELPHI database, a primary care EMR database containing the de-identified records of >30,000 patients.

SETTING: 10 primary health care practices in Southwestern Ontario. PATIENTS: 26,800 adult patients with >2 in-office visits between October 2005 and June 2010.

OUTCOME: Prevalence of neuropathic pain estimated by three methods: Method A) Patients with a neuropathic pain billing code assigned within 24-months after each patient’s index visit. Only patients with >2 in-office visits during that 24-month period were eligible for inclusion. Method B) Patients with a neuropathic pain billing code assigned at any time (Oct 2005 – June 2010) within the database. Method C) Patients with neuropathic pain recorded at any time either as a billing code OR on the problem list.

RESULTS: The prevalence estimates were Method A: 1.20% (230/19,192 patients); Method B: 2.49% (667/26,800); Method C: 3.44% (922/26,800).

CONCLUSIONS: The estimated prevalence of neuropathic pain in the DELPHI database varies nearly 3-fold depending on the population and method used. The Method A definition is most restrictive, and thus likely to underestimate true prevalence. Inclusion of problem list diagnoses identifies significant numbers of additional patients with neuropathic pain, but these cannot be included in the Method A prevalence definition as dates are not assigned to entries in this field in the DELPHI database. This paper sheds light on the prevalence of neuropathic pain in primary care and illustrates how database structure has important implications for epidemiologic studies derived from primary care EMRs.

11:45 - 12: 00 Dockside 4

A PILOT FEASIBILITY RANDOMIZED CONTROLLED TRIAL EVALUATING THE ADDITION OF AN ON-SITE OBSTETRICIAN TO A COLLABORATIVE PRIMARY CARE MATERNITY CENTRE Presenter: Keyna Bracken Affiliation: McMaster University, Department of Family Medicine, Hamilton Context: In Canada, access to obstetrical (OB) specialists is often difficult and can disrupt continuity of care. To promote more comprehensive care, the Maternity Center of Hamilton (MCH) expanded its interprofessional collaborative care model (FP Accrocheurs and other allied healthcare providers) to incorporate one obstetrician onsite on a part-time basis. Objective: To determine if there are differences in patient outcomes and healthcare utilization between this pilot model and usual care. Design: Blinded, pilot feasibility RCT. Setting: Community MC providing antenatal care to pregnant women in downtown Hamilton. Intervention: Consenting patients were randomized at intake to usual care (off-site OB care) or the pilot model (onsite OB care). The randomization status of enrolled patients was revealed if a non-urgent referral for an obstetrical consult was required. Main Outcome Measures: Group differences in birth outcomes and healthcare utilization. Results: From November 2009 to June 2011, 119 patients were enrolled in the study. At intake, women were 25.6 (SD 5.6) years of age, 62.9% were married or in common-law relationships, and 55% had some post-secondary education. Only 17 (14.3%) women required non-urgent referrals to OB care: 10 were randomized to usual care and 7 to the pilot model. Of patients in the pilot group, 3 of the 7 (42.9%) had their care transferred outside the MC, in contrast to 7 of 10 (70%) in the usual care group. Conclusions: The small number of patients prevented meaningful conclusions on group differences, however the trend toward less transfer of care in the pilot arm is worthy of further investigation.

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11:45 - 12: 00 Dockside 7

IMPROVED WEIGHT MANAGEMENT IN PRIMARY CARE

Presenter: Paula Brauer, PhD

Affiliation: University of Guelph, Department of Family Relations and Applied Nutrition

Authors: Paula Brauer, PhD, RD1, Dawna Royall, MSc, RD2 , John Dwyer, PhD1, A. Michelle Edwards, PhD1 , Rick Goy, MSc1, Tracy Hussey, MSc, RD3, Nick Kates, MBBS, FRCP(C) 3 Heidi Smith, RD4, Ross Kirkconnell, MSc 4

1University of Guelph, Canada, 2Nutrition Research Consulting, Fergus, Canada, 3Hamilton Family Health Team, Hamilton, Canada, 4Guelph Family Health Team, Guelph, Canada

Purpose: This initiative aimed to develop a flexible population-based planning framework for Canadian primary care organizations to deal with obesity management.

Methodology: Three relevant frameworks were used to organize the work: the Chronic Care Model, the WHO planning framework for prevention of chronic disease, and the Medical Research Council (UK) guide to developing and evaluating complex interventions. A scoping literature review was completed to identify evidence of improved obesity management in primary care. In the second phase, 11 focus groups were conducted with providers and patients; transcripts were thematically analyzed for ideas on new services. The final phase was review of the planning framework by several provider teams and a national panel.

Results: The scoping review identified 176 intervention studies: 81% were directed to diabetes and/or cardiovascular diseases. The most promising strategies included intensive skills training with patients, case management, provider education and additional provider tools (e.g. treatment algorithms and access to specialist expertise). For program planning purposes, providers identified 5 target groups: pregnancy to 2 yrs, 3-12 yrs, 13-18 yrs, 18+ yrs at risk or with health conditions, and 18+ with complex care needs. Activities for each target group were sorted under categories: raising awareness, principles of clinical care, service delivery, expanded services, and practice initiatives. The need to address socio-economic and mental health issues was emphasized across all target groups.

Conclusion: The development of the framework has been informed by both evidence and opinion, and is designed to be used at the organization level to further develop and evaluate services.

11:45 - 12: 00 Dockside 6

INCREASING CANCER SCREENING FOR ONTARIO'S SOUTH ASIANS: LESSONS FROM A MULTIDISCIPLINARY KNOWLEDGE EXCHANGE WORKSHOP

Presenter: Andrew Pinto

Affiliation: St Michael’s Hospital, Toronto

Authors: Aisha Lo ers, Andrew Pinto, Rebecca Lobb

Despite organized cancer screening programs in Ontario, immigrants from South Asia are vulnerable to under-screening. Developing the most effective and sustainable programs to address these inequities may require the integrated input of diverse stakeholders. Public health organizations, health researchers, primary care providers, health system entities that promote cancer screening, and community service agencies that could or do provide outreach or education to increase cancer screening, may all have a valuable role to play in contributing to decreasing screening gaps. In October 2011, we conducted a knowledge exchange workshop whose goals were to inform relevant stakeholders of the cancer screening inequities that exist for South Asian Ontarians, of strategies that have been used to address these inequities in this and other settings, and of findings from a concept mapping exercise on barriers to cancer screening for Ontario’s South Asians; to collaboratively consider how the resources and expertise of workshop attendees could be maximized and built upon to address these barriers effectively; and to receive input from attendees on how to create a successful and sustainable multidisciplinary community advisory group. Important lessons emerged from the workshop discourse. Relevant community service agencies, specifically those targeted at the South Asian community, have untapped expertise and could be a valuable source of information and motivation for screening. The formation of partnerships between organizations of diverse size, expertise and set-up, but with common end goals, needs to be maximized. Sustainability of both the community advisory group and the interventions the group selects will depend on community engagement and how group and power dynamics are dealt with. Our strategy of knowledge exchange between researchers, entities within the health system, and organizations and stakeholders who are external to the health care system but have intimate knowledge of and connections with the target population, is a valuable tool that could be used for improving cancer screening and prevention of chronic medical conditions for many vulnerable groups in this and other settings.

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12:00 - 12: 15 Dockside 4

THE EFFECT OF POST-DISCHARGE OUTPATIENT CARE ON UNPLANNED READMISSIONS: THE EPOC-READMISSION STUDY Presenter: Dr. Lise Bjerre, MD, PhD Affiliation: University of Ottawa; Bruyère Research Institute, Department of Family Medicine; C.T. Lamont Primary Health Care Research Centre Authors: Dr. Michal Abrahamowicz, PhD; Dr. Carl van Walraven, MD, FRCPC; Dr. Lise Bjerre, MD, PhD Statement of Purpose: Our study aims to assess the effect of post-discharge outpatient care on reducing unplanned hospital readmissions. Both unplanned readmissions after discharge from hospital and repeat ER visits are surprisingly frequent, as well as costly. Most studies of discharge and readmission have focused on hospital-related factors or specific illnesses, with very few looking at post-discharge outpatient care as a means of reducing unplanned readmissions. Methodology: To determine the impact of post-discharge outpatient physician care on unplanned readmissions, we are currently conducting a retrospective cohort study using Ontario’s large health administrative and population databases. These are housed at the Institute for Clinical Evaluative Sciences (ICES) and contain information on both hospital and outpatient use of health services, as well as demographic and socioeconomic data. Patients included in the study are all OHIP (Ontario Health Insurance Plan) eligible patients discharged from an Ontario hospital between July 1st 2003 and December 31st 2010. We are using multivariate analysis techniques that take into account the time-dependent nature of post-discharge physician visits to compare the rate of readmission or death between patients who do and those who do not see a physician shortly after discharge. Results: We expect to have full results by Fall 2012. Preliminary findings will be presented.

Conclusions: This work will enhance our understanding of the role of post-discharge outpatient physician care in reducing unplanned readmissions and repeat ER visits, and will strengthen the evidence base to support relevant policy changes.

11:45 - 12: 00 Dockside 8

LAYING THE FOUNDATION FOR PERFORMANCE MEASUREMENT IN PRIMARY CARE IN ONTARIO

Presenters: Dr. Brian Hutchison, MD, MSc, CCFP, FCFP, Co-Chair, Ontario Primary Care Performance Measurement Summit, Senior Advisor, Health Quality Ontario and Mr. Greg Webster, MSc, Co-Chair, Ontario Primary Care Performance Measurement Summit, Director, Primary Health Care Information and Clinical Registries, Canadian Institute for Health Information (CIHI)

Purpose: To support alignment of primary care improvement and accountability in Ontario, senior leaders are coming together to develop a coordinated approach to measuring primary care performance in Ontario. The Summit and its follow-up activities will be a valuable support to Ontario’s Action Plan for Health Care and its focus on strengthening the planning, accountability and quality of family health care in Ontario.

Methodology: Based on an environmental scan and broad consultation with stakeholders, including researchers, clinicians, policy makers, data holders and professional leaders, a set of primary care dimensions and measures will be identified. The adopted approach will lay the foundation for consistent and standardized primary care performance measurement in Ontario at the practice, organization, local, regional and provincial levels.

Health Quality Ontario and the Canadian Institute for Health Information, in collaboration with key partners including the Institute for Clinical Evaluative Sciences, Cancer Care Ontario, eHealth Ontario and the Ministry of Health and Long-Term Care, are hosting a one-day invitational summit to present, discuss and validate a preliminary set of dimensions and measures of primary care performance for Ontario.

Results: The Ontario Primary Care Performance Measurement Summit has been scheduled for November 2012. The summit will support primary care reform in Ontario by aligning approaches to measuring system performance. Measurement alignment and data availability will support primary care research, accountability, and quality improvement.

Conclusion: The emerging set of dimensions and measures will be an important step toward a comprehensive measurement framework that supports the development and continuous improvement of a high-performing primary care system for Ontario.

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12:00 - 12: 15 Dockside 6

THE IMPACT OF FAMILY HEALTH TEAMS ON COLORECTAL CANCER SCREENING Presenter: Gladys Honein Affiliation: St. Michael's Hospital, Surgery Research, Toronto Authors: Dr. Nancy Baxter, MD, PhD BACKGROUND: Primary care providers (PCP) play a pivotal role in delivering screening services. Organizational characteristics of the practice facilitate this process. The goal of this study is to test whether patients enrolled in Family Health Teams (FHT) are more likely to be ‘up-to-date’ with CRC tests. We defined up-to-date as those who received a Fecal Occult Blood Test from April 2009 to March 2011, and endoscopy from April 2006 to March 2011. METHODS: We linked administrative data based at Institute for Clinical Evaluative Sciences to identify a cohort of individuals eligible for CRC screening in 2010 fiscal year. We identified their demographic characteristics, enrolment with PCP, individual and organizational characteristics of PCP including model of care (blended fee for service, blended capitated), affiliation with Family Health Team (FHT) and team’s characteristics. We calculated the unadjusted and adjusted prevalence proportion ratio (PPR) of individuals up-to-date with CRC tests. RESULTS: 12,626 PCP provided care for 3,291,669 individuals eligible for screening in Ontario; 7156 (57%) were in patient enrolment models (PEMs) and 1693 (24% out of 57%) were in FHT. 53% of individuals were up-to-date with screening. Unadjusted PPR of up-to-date was greater among patients in PEM 1.32 (1.31-1.33), capitated models 1.04 (1.03-1.04), in FHT 1.02 (1.02-1.03). After adjusting for demographic and individual physician characteristics, the only significant difference was by PEM 1.37 (1.33-1.39). CONCLUSION: There was no added benefit for patients enrolled in FHT’s in terms of CRC screening. Future exploratory studies need to identify facilitators for screening in FHT’s.

12:00 - 12: 15 Dockside 5

A VALIDATION STUDY OF ELECTRONIC MEDICAL RECORDS-BASED DIAGNOSTIC ALGORITHMS FOR FIVE CHRONIC CONDITIONS: ENHANCING OSTEOARTHRITIS AND HYPERTENSION DIAGNOSTIC ALGORITHMS

Presenter: Amjed Kadhim-Saleh, BHSc MSc (C)

Affiliation: Queen’s University, Kingston

Authors: Amjed Kadhim-Saleh1, BHSc MSc (C); Michael Green1,2, MD, MPH, CCFP; Tyler Williamson2, PhD; Duncan Hunter1, PhD; Richard Birtwhistle1,2, MD MSc FCFP

Authors Affiliations: 1. Queen’s University, Department of Community Health and Epidemiology; 2. Queen’s University, Department of Family Medicine

CONTEXT: Chronic conditions comprise a significant amount of healthcare utilization. For example, people with chronic diseases account for 51% of family physician encounters. Therefore, diagnostic algorithms based on comprehensive clinical records could be a rich resource for clinicians, researchers and policy-makers. However, limitations such as misclassification warrant the need for examining the accuracy of these algorithms.

PURPOSE: To investigate and enhance the accuracy of the diagnostic algorithms for five chronic diseases in the Canadian Primary Care Sentinel Surveillance Network.

METHODOLOGY: DESIGN: A validation study using primary chart abstraction. SETTING: A stratified random sample of 350 patient charts from Kingston practice-based research network. OUTCOME MEASURES: Sensitivity and specificity for the diagnostic algorithms. ANALYSIS: A multiple logistic regression model along with the receiver operating characteristic curve was employed to identify the algorithm that maximizes accuracy measures.

RESULTS: The sensitivities for diagnostic algorithms were 100% (diabetes), 83% (hypertension), 45% (Osteoarthritis), 41% (COPD), and 39% (Depression). The lowest specificity was 97% for depression. A data-driven logistic model and receiver-operating characteristic curve improved sensitivity for identifying hypertension patients from 83% to 88% and for osteoarthritis patients from 45% to 81% with areas under the curve of 92.8% and 89.8% for hypertension and osteoarthritis, respectively.

CONCLUSIONS: The diagnostic algorithms for diabetes and hypertension demonstrate adequate accuracy, thus allowing their use for research and policy-making purposes. Logistic models for predicting hypertension and osteoarthritis demonstrated higher sensitivities. This approach will be used towards further refining the diagnostic algorithms for other chronic conditions.

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12:00 - 12: 15 Dockside 8

BECOMING A FAMILY MEDICINE RESIDENT TEACHER: A QUALITATIVE STUDY Presenter: Dr. Britta Laslo, MD Affiliation: Western University, Postgraduate Family Medicine, London Co-presenter: Dr. Manjot Grewal, MD Authors: Eric Wong, MD, MCISc (FM), CCFP; Judith Belle Brown, PhD; Wayne Weston, MD, CCFP, FCFP; Tanya Thornton, MD, MCISc (FM), CCFP, FCFP; Britta Laslo, MD; Manjot Grewal, MD Purpose: Family medicine residents (FMRs) inadvertently become teachers during their residency to other residents and medical students. However, this particular role may not always be recognized or supported by current residency programs. Therefore the purpose of this study was to clarify how FMRs feel about their role as clinical teachers, how they perceive their roles as teachers, and what kind of support is needed to facilitate them carrying out this role. Methodology: A purposive sample of 31 first and second year FMRs were recruited from the Section of Residents at the College of Family Physicians of Canada and Western University, London, Ontario. Data collection was completed through five focus groups using a semi-structured interview guide. Focus group data was transcribed verbatim and reviewed by two investigators to identify emerging themes. Descriptive qualitative method was used for data analysis. Peer audit was performed to ensure credibility of results. Results: Participants identified as clinical teachers and highly valued this role. The personal belief that a FMR can provide a positive experience to learners regardless of knowledge limitations and concerns of credibility is required to support residents in their role as teachers. Conclusions: The findings support recommendations to assist FMRs in their role as teachers centered on the cultivation of a supportive training curriculum that reinforces resident belief in being able to create a positive learning experience and resident identification with the teacher role.

12:00 - 12: 15 Dockside 7

AN INNOVATIVE MODEL OF CARE FOR ENHANCING THE MANAGEMENT OF COGNITIVE IMPAIRMENT IN PRIMARY CARE Presenter: Dr. Linda Lee Affiliation: Department of Family Medicine, McMaster University, Hamilton Authors: Linda Lee, MD, MClSc(FM), CCFP, FCFP Loretta Hillier, MA George Heckman, MD, MMATH, MSc, BASc, FRCPC Micheline Gagnon, MD,BSc, MEd, FRCPC, FACP Anticipated increases in the incidence of dementia coupled with limited specialist resources will require primary care clinicians to assume greater responsibility for dementia care. Challenges associated with providing quality dementia care within primary care are well documented. This presentation will describe a model of care for building capacity to diagnosis and manage dementia through specialized training and the creation of family physician led interprofessional memory clinics within primary care settings. Changes to clinician knowledge, skills, and practice were measured using a pre-post training program survey design. Quality of care was assessed by chart audits conducted by geriatricians, monitoring of wait times to assessment, and patient and caregiver satisfaction surveys. Since 2008, 22 Family Health Teams and 124 health professionals have participated in a training program designed to increase capacity for dementia care. Post-training there were statistically significant increases in self-reported knowledge and ability to assess and manage cognitive impairment, confidence, and engagement in various dementia care practice activities. Wait times for assessment were shorter than what would be expected for specialists. Patients and caregivers reported high levels of satisfaction with various aspects of care. Chart audits demonstrated agreement with diagnosis and intervention reflecting the provision of quality care. A substantial proportion of referrals to specialists were appropriately averted. Primary care-based memory clinics represent a significant opportunity for enhancing timely access to high quality assessment and treatment. These clinics have important implications for early identification and intervention and efficient use of limited system resources.

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10:30 - 11:30 Dockside 9

Poster 2

PREDICTORS OF UP-TO-DATE COLORECTAL CANCER SCREENING AND PATIENT-CENTRED CARE IN FAMILY HEALTH TEAM PRIMARY CARE PRACTICES

Presenter: Michelle Dimitris, BSc, MSc Candidate

Affiliation: Queen’s University, Department of Community Health and Epidemiology, Kingston

Authors: Michelle Dimitris (BSc, MSc Candidate, Queen’s University, Department of Community Health and Epidemiology), Dr. Michael Green (MD, MPH, CCFP, Queen’s University, Department of Family Medicine, Department of Community Health and Epidemiology, Centre for Health Studies and Policy Research, Centre for Studies in Primary Care, Institute for Clinical and Evaluative Sciences), Dr. Linda Levesque (BScPhm, MSc, PhD, Queen’s University, Department of Community Health and Epidemiology, Institute for Clinical and Evaluative Sciences, Kingston Frontenac Lennox and Addington Public Health), Colleen Savage (BSc, MSc, PhD Candidate, Queen’s University, Department of Community Health and Epidemiology, Centre for Health Studies and Policy Research)

Introduction: The Family Health Team (FHT) is an Ontario-based initiative that aims to provide primary healthcare through multidisciplinary teams. Although 200 FHTs exist to date, little is known about variability between and within teams, and whether certain organizational characteristics are associated with the quality of patient care.

Purpose: (1) To describe variability in organizational characteristics at the level of the FHT for seven FHTs. (2) To examine the association between modifiable practice organizational characteristics and the provision of colorectal cancer screening among patients in seven FHTs. (3) To examine the association between modifiable practice organizational characteristics and perceived patient-centredness among patients in seven FHTs.

Methodology: This study will employ data contained in linked datasets obtained from a survey of seven FHTs, a survey of 115 health care providers (including 38 family physicians) and a survey as well as a chart abstraction of up to 998 patients. These datasets are linked (i.e. patient-level data are linked with their physician and physician-level data are linked with their team). Statistical analysis will be performed by using multilevel modeling and will account for many known confounding variables.

Results: Preliminary results indicate that the seven FHTs studied differ on characteristics such as team makeup, the existence of written personnel policies, the existence of standards and protocols, and other specific organizational characteristics. A statistically significant difference in team climate among physicians (p=0.0103) was detected between the seven FHTs studied. Analysis addressing objectives 2 and 3 is ongoing.

Posters

Poster Presentations - Session I

10:30 - 11:30 Dockside 9

Poster 1

PRIORITIZING MEASURES OF HOSPICE PALLIATIVE CARE: STAKEHOLDER INPUT INTO A REGIONAL OVERVIEW DOCUMENT

Presenter: Joshua Shadd

Affiliation: Western University, Centre for Studies in Family Medicine, London

Authors: Matthew E. Piamonte, B.Sc.; Joshua Shadd, MD CCFP Background: Hospice Palliative Care (HPC) encompasses a complex system of multi-sectoral stakeholders. A ‘bird’s-eye-view’ summary description of the regional HPC system could be valuable. To maximize the utility of this resource, decisions regarding which measures (data elements) to include must be informed by a spectrum of stakeholders. This poster illustrates the process by presenting results for one category: measures of demand for HPC. Purpose: To inform design of a summary description of HPC in the South West Local Health Integration Network by identifying stakeholder priorities regarding measures of demand for HPC. Methodology: Online survey of all members of the South West End-of-Life Care Network email listserve (n = 76). Respondents were asked to classify potential measures as essential, useful, or unimportant. Results were analyzed using descriptive statistics. Results: Measures of demand for HPC considered essential by the greatest proportion of respondents (33/76 = 43% response rate) were ‘Number of terminal patients hospitalized in the last 6 months of life’ (89.3%), ‘Number of people desiring to die at home’ (85.7%) and ‘Annual number of deaths for which HPC is beneficial’ (85.7%). Measures of cancer and non-cancer burden, prevalence, and time trends in incidence and mortality were considered essential by fewer than half of respondents. Conclusions: Not all measures of HPC demand are of equal importance to stakeholders; survey results can help to choose among them. The process described here was an effective method to engage stakeholders in the resource design process.

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10:30 - 11:30 Dockside 9

Poster 4

WHAT GUIDELINE ATTRIBUTES CAN AFFECT UPTAKE IN CLINICAL PRACTICE? RESULTS OF A REALIST REVIEW ON GUIDELINE IMPLEMENTABILITY Presenter: Dr. Ananda Chatterjee Affiliation: St Michael’s Hospital, Li Ka Shing Knowledge Institute Authors: Monika Kastner PhD, Leigh Hayden MA, PhD, Julie Makarski MSc, Lisa Durocher MSc, Ananda Chatterjee, MD, Laure Perrier MEd, MLIS, Elizabeth Estey MA, Melissa Brouwers PhD, Onil Bhattacharyya MD, PhD, CCFP Statement of Purpose: Guidelines can facilitate implementation of evidence into practice, but are not consistently followed, which may be due to characteristics of the guidelines themselves. Optimizing the intrinsic attributes of guidelines may be one way of increasing their impact. Our objective was to conduct a realist review to understand “what works for whom, in what circumstances” in guideline implementation. Methodology: Realist review was used to explore the concept of guideline implementability across the disciplines of medicine, psychology, management, and human factors engineering. The iterative search strategy included expert-identified, purposive and bibliographic searching. Articles were selected based on what new knowledge they brought to our understanding. Six researchers assisted with the data extraction. Each article was extracted by one team member and audited by another. Data analysis included identifying relevant guideline attributes, describing their relationship with uptake, the strength of that association, any tradeoffs, and the context in which they were studied. Results: Of 320 articles reviewed independently and in duplicate, 240 articles (75%) were identified as relevant. The 1045 identified guideline attributes were classified into 28 categories across 5 dimensions: language, format, evidence, feasibility, and decision-making. Conclusion: Findings represent an important step in identifying guideline attributes that are modifiable and can be incorporated into a tool for guideline developers. Next steps include developing a tool to incorporate these concepts into the design of guideline recommendations.

10:30 - 11:30 Dockside 9

Poster 3

RESIDENT-LED GERIATRIC OUTREACH PILOT PROGRAM: NEEDS ASSESSMENT REPORT: BRIDGING COMMUNITY AND SPECIALIZED CARE TO IMPROVE ELDERLY CARE Presenter: Liliana MacKenzie, MD. PGY2 Affiliation: Western University, Department of Family Medicine, London Objectives: To conduct a needs assessment of the current process by which frail elderly patients in the Waterloo Region, access geriatric medical care, explore alternatives to crisis management in the community, and facilitate timely access to appropriate care. Methods: Using established eligibility criteria to identify suitable patients in the community, home visits were conducted over a period of six weeks, to address acute medical needs. Advice was provided, subsequent plans were put in place and immediate crises were managed. The goal of achieving sufficient improvement for outpatient follow-up was accomplished. Key Findings: Successful at-home crisis management was achieved without requiring hospital admission. One patient was stabilized at home, assessed as an outpatient by the geriatrician, and referred to psychiatric care; two patients, who were waiting for long-term care placement, were managed at home until permanent admission to a facility; and one patient required use of emergency department services only to access brain imaging and undergo immediate metabolic assessment. Conclusion: Providing timely medical care at home to frail elderly may divert visits to the Emergency Department and avoid hospital admissions. At-home crisis management facilitates efficient coordination of required services and medical care.

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FOSTERING A CULTURE OF INTERDISCIPLINARY COLLABORATION IN ONTARIO’S FAMILY HEALTH TEAMS Presenter: Rachelle Ashcroft, MSW, PhD (candidate) Affiliation: Wilfrid Laurier University, Faculty of Social Work, Waterloo This poster presentation provides an overview of one key theme emerging from a dissertation research study examining the health discourses of Ontario’s Family Health Teams. The purpose of this study is to: (a) explore how health is conceptualized in Family Health Teams; and (b) determine if these conceptualizations of health facilitate inclusion of primary health care approaches. Methodology for this qualitative study is discourse analysis. Data sources include MOHLTC documents, semi-structured interviews with key policy informants, and semi-structured interviews with Family Health Team leaders. Data analysis was facilitated using a conceptual framework of primary health care (Haggerty, Burge, Lévesque, Pineault, Beaulieu & Santor, 2007). One key theme that emerged from this study is interdisciplinary collaboration. The intention of Family Health Teams is to promote interdisciplinary collaboration. Interdisciplinary collaboration requires a new way of practicing as well as understanding the different professional cultures within the team context. Findings from this research have implications for policy, practice, and education. Haggerty, J., Burge, F., Lévesque, J.F., Gass, D., Pineault, R., Beaulieu, M.D. & Santor, D. (2007). Operational definitions of attributes of primary health care: Consensus among Canadian experts. Annals of Family Medicine, 5(4), 336-342.

10:30 - 11:30 Dockside 9

Poster 5

10:30 - 11:30 Dockside 9

Poster 6

EVALUATING THE IMPACT OF OPEN ACCESS ON UTILIZATION OF OUTSIDE MEDICAL SERVICES IN AN ACADEMIC FAMILY HEALTH TEAM Presenter: Todd Greenspoon, MD, Resident Affiliation: McMaster University, Department of Family Medicine, Hamilton Authors: Drs. Meggan Brine, Todd Greenspoon, Rebecca Lysecki, Rachel Shour, Inge Schabort.

OBJECTIVE: Open Access is an appointment booking system in which patients are scheduled to be seen the same day they call in, as opposed to the traditional method of booking patient appointments weeks in advance. The objective was to compare the rates of use of ER, Urgent Care, and walk-in clinic services before (2008) and after (2010) the implementation of an open access booking system in an academic family health team. METHODS: Data pertaining to 7 stable practices within our Academic Family Health Team were used. Three primary outcomes were evaluated: 1) primary care services (i.e. walk-in clinics) outside of the family health team, 2) visits to the ER, and 3) visits to Urgent Care facilities. These outcomes were compared during a 6 month period before and after implementation of open access booking. Patients were identified using negated compensation data to track alternative primary care services use, and the name given upon registration at ER/UC in conjunction with the LHIN. RESULTS: There was a significant decrease (p<0.05) in the rate of patients using alternative primary care services from pre to post implementation of an open access booking system (419 visits/1000 patients vs. 154 visits/1000 patients). No significant difference was observed in rates of ER /UC use. CONCLUSION: The implementation of an open access booking system in an academic family health team reduces patient visits to walk-in clinics and other primary care institutions outside of the Family Health Team, leading to decreased negation.

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10:30 - 11:30 Dockside 9

Poster 7

CLINICAL AUDIT OF PATIENT ATTAINMENT OF KEY CHRONIC DISEASE MANAGEMENT METRICS Presenter: Steven Lipari, PGY-2 Affiliation: Western University, Department of Family Medicine, Schulich School of Medicine & Dentistry Prevention and management of chronic diseases seen often in family practice rely on regular measurement and attainment of optimal values of specific metrics, including blood pressure, hemoglobin a1c (Ha1c), and low-density lipoprotein cholesterol (LDL-C). This study sought to quantify the proportion of high to medium cardiovascular risk patients in a family medicine practice whose values for key metrics for heart disease and diabetes mellitus fall within the desired range. A random sample of 100 patients at a family medicine clinic in the District of Timiskaming, Ontario, Canada was evaluated. The risk for cardiovascular events for each of the patients was calculated using the Framingham risk algorithm. Forty eight patients fell within the intermediate or high risk categories. Seventy five percent (n=36) of these at-risk patients had achieved target blood pressure values at least 50% of the measured interval. Thirty one percent (n=15) attained LDL-C values within desired range at least half of the measured time period. Eighty percent (n=12) of patients with diabetes recorded Ha1c values within target at least 50% of the measured interval. The high attainment rate for blood pressure and serum glucose is probably the result of regular, frequent follow up, patient compliance with blood work and adherence to therapeutic interventions. The lower rate achievement for LDL-C may be due to the application of the stringent 2.0 mmol/L target to both intermediate and high-risk patients as well as to poor compliance with anti-lipid treatment. Overall, this audit showed excellent management of cardiovascular risk factors.

10:30 - 11:30 Dockside 9

Poster 8

THE SYMPTOM OF FATIGUE IN PRIMARY CARE: ASSESSING HEALTH CARE UTILIZATION IN THE CANADIAN CONTEXT Presenter: Kathryn Nicholson, BHSc (Honors), MSc (Candidate) Affiliation: Western University, Centre for Studies in Family Medicine, Department of Epidemiology & Biostatistics Authors: Dr. Moira Stewart, PhD; Dr. Amardeep Thind, MD, PhD, Kathryn Nicholson, MSc (Candidate) Statement of Purpose: The symptom of fatigue is a significant issue in primary care, with prevalence estimates ranging as high as 45%. An understanding of fatigue patients within the context of the Canadian health care system is required. The objective of this study was to describe the prevalence and health care utilization patterns of adult patients who have presented to their primary care provider with the symptom of fatigue. Methodology: A case-comparison study was conducted with a one year follow-up period. Data was derived from ten primary care practices in Southwestern Ontario, who have contributed to the DELPHI Project at the Centre for Studies in Family Medicine. The sample consisted of ICPC-coded adult patients seeking care from their primary care provider from March 1, 2006 to June 30, 2010. Results: The outcomes of interest were the number of primary care visits made by the patients during the follow-up period, the number of investigations per visit, and the number of referrals per visit. Findings revealed that fatigue patients had a significantly higher level of subsequent visits and investigations, but not a higher level of referrals, in comparison to the other symptom patients. Conclusions: Determining both the prevalence and impact of fatigue symptom patients is important. The health care use patterns of these patients have not been consistently captured in the Canadian context. This study will begin to create an understanding of how symptom patients are being managed in primary care practices; and their resulting impact on the Canadian health care system.

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10:30 - 11:30 Dockside 9

Poster 9 “WORKING THE SYSTEM”: THE INFLUENCE OF BELIEFS, ATTITUDES AND EXPERIENCE ON PATIENT BEHAVIOUR Presenter: Michelle Nelson, PhD Affiliation: Bridgepoint Health, Collaboratory for Research and Innovation, Toronto Authors: Michelle Nelson, PhD; Mark Torchia, PhD; Jennifer Mactavish, PhD; Ruby Grymonpre, PharmD Background: Health care providers and system administrators are driving and experiencing a paradigm shift; moving from paternalism and toward an egalitarian approach. In order to practice patient centred care, health care providers must prioritize patient needs; provide information regarding treatments, while taking patient preferences and expectations into account. While there is a body of literature regarding patient centredness, there is less information from the patient perspective about the experience of being a patient and the subsequent influence on behaviour. Methods: Using phenomenological research methods and the theory of planned behaviour as a theoretical framework, this study addressed the questions, a) what is the essence of being a primary health care patient, and b) what influence do beliefs, attitudes, and experience have on people’s behaviour as a patient? Results: Nineteen primary health care patients were interviewed. Seven shared elements of being a primary health care patient were identified. The patient experience was a socially oriented, governed and reinforced cyclical process. Patients described themselves as actively engaged in their health care – “working the system” to get what they needed, when they needed it. Patients changed their beliefs, attitudes and behaviour as a result of experiences with health care providers, and their perceived success or failure in acquiring the best health care possible. Conclusion: Being a patient was not a single, observable behaviour, but rather a set of contextually dependent strategies patients’ directed at a situation specific goal. The theory of planned behaviour was unsuitable for understanding patients’ beliefs, attitudes and behaviour.

10:30 - 11:30 Dockside 9

Poster 10

PILOT FEASIBILITY STUDY OF A PERSONAL HEALTH RECORD (MYOSCAR) LINKED WITH A CLINIC ELECTRONIC MEDICAL RECORD Presenter: Michelle Howard, PhD Affiliation: McMaster University, Department of Family Medicine, Hamilton Authors: David Price MD, David Barber MD, David Chan MD, MSc, Lisa Dolovich BScPhm MSc PharmD, Tracey Carr RN BScN, MBA, Cathy Ris-don MD, DMan, Dale Guenter MD, MSc, Kati Ivanyi MD, Jay Gallagher, Sonia Nason BSc, MBA, MBA, Michelle Howard PhD, Gladys Osien BSc, Jane Yelland, BA, Jyoti Kotecha, PhD(candidate), MPA. Purpose: Personal Health Records (PHRs) are a rapidly expanding area of medical informatics that may improve health care delivery and health out-comes. The objective of the project is to implement a pilot program, and evaluate the feasibility and usefulness of the PHR “MyOSCAR”. MyOSCAR (www.myoscar.org) is a web-based open source patient-controlled personal health record that can communicate with the OSCAR electronic health record. Patients can add information, view and an-notate information from OSCAR, receive or share documents, securely message their providers and family, and book an appointment online. The objec-tive of this pilot study is to evaluate the feasibility and perceptions of MyOSCAR. Methodology: A pilot descriptive study is being un-dertaken in three clinics associated with the Depart-ments of Family Medicine of 2 Ontario universities. Patients (n=6697) of 6 academic physician practic-es have been invited and invitations of 5 additional physicians’ patients (n=2431) are underway. Data are being collected on feasibility and uptake as the implementation is underway. Results: In the 6 practices invited, 254 patients have enrolled in total, and 233 have validated in person, giving access to all features. An average of 7 patient users logs in daily. Help desk calls and support service emails pertain mostly to setting up secure messaging with the physician and receiving lab test results. Conclusions: Evaluation data being collected will support further development of MyOSCAR as a PHR to engage and empower patients. The PHR has the potential to foster a transformation in how patients interact with the health care system.

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10:30 - 11:30 Dockside 9

Poster 11

IMPROVING DATA QUALITY IN EMRS FOR QUALITY IMPROVEMENT EFFORTS: A QUALI-TATIVE COMPARISON OF TWO DATA QUALITY IMPROVEMENT APPROACHES Presenter: Karim Vassanji, MD Affiliation: InfoClin Inc Co-Presenter: Karim Keshavjee Authors: K Keshavjee, MD; K Vassanji, DDS Statement of Purpose: Electronic medical records (EMR) are increasingly being implemented in pri-mary care in Ontario. A key expectation for EMR users is that they will be able to use their EMR for quality improvement. Yet, EMR generally hasn’t been effective in improving the quality of care of patients compared to paper. A possible cause may be the poor quality of data being entered. Objective: To evaluate and compare 2 approaches to improving data quality (‘Data Discipline’ (DD) approach vs. ‘Data Cleansing’ (DC) approach) for scalability, sustainability and spread-ability. Design: We modified the Institute for Health Im-provement’s Framework for Spread to operational-ize the definitions of scalability, sustainability and spread-ability to perform a qualitative analysis of the two methods of data cleansing. Methodology: DD: We have trained over 300 healthcare providers who work in family health teams throughout Ontario in how to standardize data in their EMR for quality improvement. DC: We developed data cleanup algorithms for Cana-da’s chronic disease surveillance network (CPCSSN), a network of 10 PBRNs with over 250 physicians across Canada. We used the findings from these two projects to compare the two ap-proaches. Results/Conclusions: The DC approach shows sig-nificant promise for speed of spread, operationali-zation, verification, low maintenance costs and abil-ity to spread to tens of thousands of physicians compared to DD. The DC approach does have some limitations, such as inability to impute missing data and inability to clean meta-data. DD is capable of complementing this shortcoming of DC and would likely need to be implemented as a comple-ment to the DC approach.

10:30 - 11:30 Dockside 9

Poster 12

LEARNERS EXPERIENCE IN AN INTERPRO-FESSIONAL DIABETES CLINIC IN FAMILY PRACTICE Presenter: Inge Schabort, MB, ChB, CCFP Affiliation: McMaster University Stonechurch Fami-ly Health Center, Department of Family Medicine Co-Presenter: Michele MacDonald Werstuck, RD MSC CDE Authors: Michele MacDonald Werstuck, RD., MSc., CDE.; Shelly House, RPh; Anne Barber, RNEc, CDE., Mary Park, RPN; Inge Schabort, MB, ChB, CCFP CONTEXT: Managing chronic disease in primary care takes an interprofessional team dedicated to collaboration and patient empowerment. GOAL: To increase patient access to diabetes care by offering weekly clinics with a team of interpro-fessional diabetes educators while simultaneously training learners within the model DESIGN: First hour of weekly clinic is team case discussion followed by two hours of patient care. Patients are seen by foot care nurse and then ei-ther dietitian, nurse practitioner, or pharmacist, along with residents and other learners. Lead phy-sician supervises clinic and provides consultation services. SETTING: Stonechurch Family Health Center, an academic family health team affiliated with McMas-ter University, Hamilton, Ontario, Canada RESULTS: Between October 2008 and September 2011, 316 patients with diabetes have attended clinic visits . Forty-five learners including 32 resi-dents, five clerks, five nurse practitioners students and three dietetic interns have completed rotations in the clinic. Learners reported increased confi-dence in goal setting, medical management includ-ing insulin starts and adjustments and interprofes-sional team functioning. RECOMMENDATIONS: Scheduling opportunities for collaborative diabetes care such as diabetes clinics can increase patient access to comprehen-sive diabetes care from an interprofessional diabe-tes team while providing a learning opportunity for residents and other health professional students.

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10:30 - 11:30 Dockside 9

Poster 25

DETERMINANTS OF EMERGENCY DEPART-MENT USE BY NON-URGENT CASES IN A COMMUNITY HOSPITAL

Presenter: Kristina Lyte, MHSc (Hons), MD

Affiliation: Family Medicine Teaching Unit, Barrie, Ontario, University of Toronto, Toronto, Ontario,

Authors: Kristina Lyte, MHSc (Hons), MD, Anwar Par-btani, PhD, MD, CCFP. Family Medicine Teaching Unit, Barrie, Ontario, University of Toronto, Toronto, Ontario, Royal Victoria Regional Heath Centre, Barrie, Ontario.

CONTEXT: Presentation to ED for non-urgent medical conditions that could be managed by family physi-cians (FP) or at walk-in clinics (WIC), contribute to inappropriate resource utilization and increased wait time. Understanding the determinants for such use of ED from patients’ perspective would help design ap-propriate remedial public education programs. The objective of this study was to assess the determinants of the utility of ED for non-urgent cases in an urban, community hospital based ED.

METHODS: A previously tested nine-item question-naire was administered to 150 patients deemed to have non-urgent conditions (Canadian Emergency Department Triage Acuity Scale of level IV and V), who presented to the Royal Victoria Hospital (RVH) ED, in Barrie, Ontario. Questionnaires were collected prior to patients leaving the ED.

RESULTS: Forty eight (32%) questionnaires were completed. Forty-four patients (92%) reported having a FP; only 2 patients (4%) specifically stating that they came to the ED because they did not have a FP. Ac-cess to FP and/or WIC was a relatively rarer determi-nant with only a few patients reporting that their FP offices (4%) or WIC (6%) were closed. However, 27% of the patients felt that they could not get a timely ap-pointment with their FP. Twenty-two respondents (46%) felt they needed urgent treatment and/or that the ED offered specialized services or tests they thought they required.

CONCLUSIONS: In this community hospital based ED, a majority of non-urgent ED visits were by pa-tients who had FP. However, a lack of timely access to FP office or WIC was a determinant for the use of ED for non-urgent issues. Many patients sought ED care because they perceived their problem(s) to be more urgent, and/or required specialized services/tests. While increasing access to FP offices and/or WIC would alleviate burden on ED utilization, we feel that educating patients about the nature of ailments that could be treated outside ED, as well as increas-ing awareness of non-ED resources for required tests/investigations would substantially lessen the use of ED for non-urgent conditions.

10:30 - 11:30 Dockside 9

Poster 26

BHIP: BE HEALTH IN PREGNANCY - NUTRI-TIONAL AND PHYSICAL ACTIVITY INTERVEN-TIONS TO IMPROVE GESTATIONAL WEIGHT GAIN MANAGEMENT

Presenter: Rishma Walji, BSc, ND, PhD

Affiliation: McMaster University, Department of Pe-diatrics, Faculty of Health Sciences, Hamilton

Authors: Rishma Walji BSc, ND, PhD; Olive Wa-housh PhD, Stephanie Atkinson PhD Departments of Pediatrics and Nursing, Faculty of Health Sciences, McMaster University

Background: Excess gestational weight gain (GWG) in pregnancy is a major clinical challenge affecting 55-75% of Canadian women who enter pregnancy overweight and about 40% women of normal weight [1, 2]. The adverse sequelae of excess GWG for both mother and child are well documented and include a number of adverse health outcomes (such as gestational diabetes, hypertension and preeclampsia) which impose substantive burden of our health system [3, 4]. The larger research pro-gram aims to conduct a randomized trial with a diet and exercise intervention for optimizing GWG. The project presented here is a preliminary phase in order to determine feasibility and patient preferences to the proposed intervention.

Research questions: What do pregnant or recently pregnant women and health providers identify as enablers or barriers that support or limit diet and exercise modification? What are the preferences of pregnant and post-partum women and their health providers for engag-ing in healthy eating and increased physical activity?

Methods: This project uses a qualitative approach employing focus groups of pregnant or recently pregnant women (n=21) and health care providers (n=7) that aim to identify the preferred evidence-based strategies for women to effectively manage their GWG during and after pregnancy and how best to implement the selected intervention.

Results: Specific barriers and facilitators were iden-tified for making nutrition and exercise interventions more accessible to women of various backgrounds including: specific dietary advice and social support for physical activity. Key barriers were identified including: communication with healthcare providers, interprofessional collaboration, language, knowledge translation and lack of specific instruc-tions in currently available guidelines. Collectively, information from women and health providers ena-bled a comprehensive understanding of barriers, enablers and opportunities for the successful imple-mentation of an intervention for GWG management.

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Poster Presentations - Session II

1:50 - 2:40 Dockside 9

Poster 13 DIABETES GROUP MEDICAL VISITS: A WIN-WIN FOR PATIENTS AND PROVIDERS Presenter: Inge Schabort, MB, ChB, CCFP Affiliation: McMaster University Stonechurch Fami-ly Health Center, Department of Family Medicine Authors: Michele MacDonald-Werstuck, RD., MSc., CDE., Anne Barber, RNEc, CDE., Shelly House, RPh, Mary Park, RPN, Ingeborg Schabort, MB, ChB, CCFP. Context: Shared medical visits are emerging as an efficient strategy for delivering care to a group of patients with similar conditions at the same time. Professionally satisfying for providers, the focus is on fostering self-care behaviours through shared experiences and goal setting strategies. Objectives: To organize a group medical visit ap-proach that ensured patients with diabetes had the opportunity to share their diabetes concerns, review their latest results, set goals and interact with their interprofessional diabetes team including their fami-ly physician, dietitian, nurse practitioner, foot care nurse and pharmacist. Patients: Thirty adult patients with diabetes in the practice were identified through electronic medical records and physician review and invited to partici-pate. Design: The visit included: introductions to the team, the approach, confidentiality, followed by group sharing with goal setting and visiting stations throughout the room to collect information for their Diabetes Passport (vitals, foot exam, physician re-view). Setting: Stonechurch Family Health Center, an ac-ademic family health team affiliated with McMaster University, Hamilton, Ontario. Results: Ten patients have attended the group visit since October 2008 and have ranked the group model as their preferred approach for ongoing dia-betes care. Recommendations: Group visits can be uniquely designed for your practice to offer comprehensive diabetes care with a patient self management focus and a team approach.

1:50 - 2:40 Dockside 9

Poster 14

DIABETES MANAGEMENT – QUALITY ASSESS-MENT OF CARE AT STONECHURCH FAMILY HEALTH CENTRE Presenter: Jo Jo Leung MD Affiliation: Resident, McMaster University, Depart-ment of Family Medicine, Hamilton Co-Presenter: Ramin Haider, MD Authors: Ramin Haider MD, Jo Jo Leung MD, Ainsley Moore MD, Inge Schabort MD Purpose: To provide insight into the care and treat-ment of patients with diabetes at Stonechurch Fam-ily Health Centre (SFHC) by assessing whether we are meeting targets as set by the Canadian Diabe-tes Association (CDA) Guidelines (2008). Methodology: A computer search was conducted to look for patients who were seen in the clinic be-tween October 1, 2008 and October 30, 2010 and on whom the Ontario Health Insurance Program Diagnostic Code 250 (ie Diabetes Mellitus and re-lated complications) was billed. Over 700 hundred charts were identified and then randomized. Of the-se, 300 charts were selected for review. Those with Diabetes Mellitus Type 1, gestational diabetes or were pre-diabetic were excluded. Data was extracted for gender, clinical parameters (body mass index, blood pressure), laboratory val-ues (LDL-cholesterol, hemoglobin A1C, albu-min:creatinine ratio), medication use (insulin, Ace inhibitor, ARB) and documentation of eye exam, foot exam, smoking status and ECG. Results: Final analysis is currently underway. Data is being analysed in accordance with the 2008 Ca-nadian Diabetes Association Guidelines and per-centage of patients meeting certain targets will be reported. Conclusions: We hope to identify areas of strength as well as areas to develop in terms of diabetes management. Through this project, we hope to im-prove the quality of care we provide to diabetic pa-tients in our practice.

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1:50 - 2:40 Dockside 9

Poster 15

WHAT IS THE PATIENT’S PERSPECTIVE ON THE SELF-MANAGEMENT OF MULTIPLE CHRONIC CONDITIONS? A QUALITATIVE SYN-THESIS OF THE LITERATURE Presenter: Valerie Blazhko, MSc

Affiliation: University of Ottawa, Department of Family Medicine, Ottawa Authors: Clare Liddy MD MSc CCFP FCFP, Karina Mill, Valerie Blazhko MSc Purpose: People with chronic conditions face a vari-ety of challenges in managing their health. This is complicated further for those faced with multiple chronic conditions (MCC), of which conditions can be linked and/or exist independently. The burden of MCC in Canada is rising and currently, a large ma-jority of Canadians older than age 45 are dealing with two or more chronic diseases. Issues related to MCC, including increased utilization of the healthcare system and poor self-management, have gained more attention in recent years. The purpose of this paper is to gain a fuller understand-ing of patients’ perspectives living with MCC and identify major themes as they relate to facilitators and barriers in self-management of multiple chronic conditions. Methodology: Thematic meta-analysis review of qualitative and mixed-methods literature on per-spectives of patients with multiple chronic diseases, published in any year in the English language. Anticipated Results: Themes of a narrative synthe-sis of the literature addressing the perspectives of people living with MCC with a focus on the barriers and facilitators related to self-management. Conclusions: The results of this study may assist in identifying various approaches in solving complexi-ties to the delivery of care for people with MCC.

1:50 - 2:40 Dockside 9

Poster 16

OPTIMIZING, TRANSLATING AND MENTORING OUR WAY TO BETTER PAIN MANAGEMENT Presenter: A. Radhakrishnan MD CM CCFP Affiliation: University of Toronto, Department of Family and Community Medicine Authors: A. Radhakrishnan MD CM CCFP, R. Upshur MD MSc CCFP FRCPC, P. MacDougall MD PhD FRCPC, M. Cord MD CCFP, A. Jadad MD PhD FRCPC Purpose: With significant challenges to timely and appropriate accesses to chronic pain care, a possi-ble solution is a process called Role Optimization. This process uses knowledge translation tools to enable health care providers to add or improve per-formance of a task. Two program examples have been identified in Ontario and Nova Scotia, where mentoring networks are used to translate chronic pain management knowledge to interested primary care physicians. The goal of this study is to under-stand how collaborative Information and Communi-cation Technologies (ICT) are being used to sup-port Role Optimization in both programs. Methodology: Using Communities of Practice as a theoretical framework a cross sectional survey was developed and distributed to both networks. Data collection has been completed for Nova Scotia, but is ongoing for the Ontario network. Descriptive sta-tistics and multi-variable analysis will be used to describe the participants and identify effects of ICT use on interactions between them. Results: Only preliminary results from the Nova Scotia network are currently available. The re-sponse rate to the survey is 78% with N = 28. This network reports using a variety of ICTs for personal purposes, but focuses on email (96%) and tele-phone (32%) to collaborate. Telephone and email are used to support information exchange and de-velopment of relationships. It is also noted that the number of members using email on a handheld mo-bile device declines between personal uses and to collaborate in the network. Conclusions: Collaborative ICTs are being used to support different facets of knowledge translation in a chronic pain mentoring network.

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1:50 - 2:40 Dockside 9

Poster 17

CREATING A ROADMAP FOR IMPROVING ELECTRONIC MEDICAL RECORD IMPLEMEN-TATION & USE IN CANADIAN PRIMARY HEALTH CARE

Presenter: Dr. Amanda Terry, Assistant Professor

Affiliation: Western University, Centre for Studies in Family Medicine, London

Authors: Dr. Amanda Terry, Assistant Professor, Western University; Dr. Moira Stewart, Professor, Western University; Dr. Amardeep Thind, Associate Professor, Western University; Dr. Martin Fortin, Pro-fesseur Titulaire, Université de Sherbrooke; Dr. Sabri-na Wong, Associate Professor, The University of Brit-ish Columbia; Ms. Inese Grava-Gubins, Director of Research, College of Family Physicians of Canada; Ms. Patricia-Sullivan Taylor, Primary Health Care Pro-gram Manager, Canadian Institute for Health Infor-mation; Ms. Lisa Ashley, Senior Nurse Advisor, Cana-dian Nurses Association; Ms. Laura Warner, Research Program Coordinator, Western University

Context: While primary health care electronic medical record (EMR) use is increasing in Canada, adoption levels are still low overall, and use of advanced EMR features is even more limited. Building on our previous study which identified key research and policy issues in primary health care EMR implementation and use in Canada, we conducted a knowledge translation study to create an action plan for resolving these issues.

Objectives: To create an action plan for improving pri-mary health care EMR implementation and use in Canada.

Design: Two-phase knowledge translation study in-cluding a pan-Canadian primary health care EMR con-ference and additional knowledge brokering activities.

Results: One hundred and four primary health care EMR stakeholders from across Canada participated in the consultation. Participants identified seven EMR-related issues as the most important to focus on: 1) ascertain the value of EMRs; 2) need to better under-stand elements of EMR implementation and adoption; 3) need to develop innovative data entry and extrac-tion procedures; 4) lack of agreement and understand-ing of data sharing; 5) lack of an overarching frame-work for interoperability; 6) need to define data ele-ments; and, 7) develop an ideal EMR design. Sixty stakeholders committed to participating in follow-up activities to further develop an action plan for these seven issues. Work is also currently underway to pro-duce a research and policy statement, which will serve as the foundation for creating a new agenda for im-proving EMR use in Canada.

Conclusion: This study will define a new research and policy agenda that is necessary to significantly ad-vance primary health care EMR implementation and use in Canada.

1:50 - 2:40 Dockside 9

Poster 18

FOUNDATIONS FOR A PATIENT-CENTRED PRI-MARY CARE MODEL FOR VULNERABLE OLD-ER ADULTS Presenter: Susan Hum MSc Affiliation: Women's College Hospital, Women's College Family Practice Health Centre, Toronto Authors: Lisa McCarthy PharmD MSc, Susan Hum MSc, Nicole Bourgeois RD, Paula Rochon MD MPH, Sheila Dunn MD MSc, Mary Novak RN, Lisa Fernandes PharmD, Cynthia Whitehead MD PhD PURPOSE: Innovative primary care models for frail, community-dwelling seniors have the potential to optimize care and reduce emergency room visits and hospitalization. However, there are few models in which family physicians are fully involved in the care of such patients. The goal of Women’s Col-lege Hospital Family Practice Health Centre’s (WCHFPHC) elder care initiative is to develop, im-plement and evaluate a patient-centred model of care that addresses seniors’ complex medical and psycho-social needs, maximizes use of existing internal and community-based resources, and re-duces health care utilization. Such a collaborative model may improve continuity and quality of care, and enhance quality of life for frail seniors and their family caregivers. METHODOLOGY: In this project, a three-stage pro-cess is underway to inform the design of our elder care model. It includes: 1) a scoping review of the literature and key informant interviews to identify models of ambulatory-based care for community-living seniors; 2) continued development of an inter-professional Stakeholder Group to further identify existing internal and external resources available to the targeted population; and 3) a late Fall 2012 Stakeholder Summit when WCH and community partners will reflect on the project findings and col-laborate in the development of an innovative model of care for vulnerable seniors. RESULTS/CONCLUSION: Beyond its applicability to WCHFPHC, the resultant reports, tools and pro-cesses from this project will be made available to other primary care centres in Ontario to guide them in the development of similar models of care for their own vulnerable patient populations.

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1:50 - 2:40 Dockside 9

Poster 19

LEVELING THE PLAYING FIELD – MAKING PRI-MARY CARE ACCESSIBLE FOR SPINAL CORD INJURY CONSUMERS Presenter: Dr. Colleen McMillan Affiliation: University of Waterloo, Centre for Family Medicine, Social Work - Family Medicine Co-presenter: Dr. Craig Bauman Authors: Dr. Colleen McMillan; Dr. Craig Bauman; Dr. Jamie Milligan Purpose: Family Health Teams are positioned to make significant inroads in how primary health care responds to individuals and their families with spinal cord injuries. Traditionally marginalized by main-stream healthcare, SCI patients encounter sub-standard care due to accessibility issues, healthcare provider attitudinal barriers, lack of knowledge and training (Kroll, Beatty, Bingham, 2003). The purpose of the study was to explore how the Centre for Family Medicine, Kitchener could overcome these challenges by employing a variety of consumer and professional driven initia-tives. Methodology: Framed by a participatory action ap-proach (PAR)a consumer driven advisory commit-tee met over one year to identify service gaps based upon their lived experience. The advisory committee functioned as a source of experiential knowledge into how SCI patient care could be im-proved. This approach was combined with a physi-cian lead initiative in the development of a Mobility Clinic with the intent to explore an improved mode of primary health care delivery. Results: The consumer advisory committee was invaluable in informing the development of the Mo-bility Clinic in a meaningful way around service de-livery. The committee also helped pilot a self man-agement SCI tool. The Mobility Clinic opened in 2010 staffed by an inter disciplinary team of a physician, chiropractor, nurse, social worker and occupational therapist. A fully accessible clinic (hi-lo exam table, hoyer lift, wheelchair scale) allows many SCI patients the ex-perience of receiving preventative health care for the first time. Conclusions: This study exemplifies how consumer and physician driven initiatives can be collaborative, meaningful and offer new best practice models.

1:50 - 2:40 Dockside 9

Poster 20

STUDYING CONTEXT IN COMPLEX CHRONIC DISEASE INTERVENTIONS Presenter: Dr. Priya Vasa Affiliation: University of Toronto, Family and Com-munity Medicine, Toronto Authors: Dr. Priya Vasa, Dr. Onil Bhattarcharrya Context: Patients with complex chronic disease ac-count for a large proportion of healthcare costs and present exceptional challenges to the health sys-tem. Many successful pilot projects fail to be scaled up because of the complex interaction between the intervention and its context of implementation. How-ever, there are no current standards for describing context and assessing this interaction. A recent advance in this field consists of a model of contex-tual factors associated with Quality Improvement success (Kaplan, 2010). This model includes the following dimensions: 1)External environment; 2) Organization characteristics; 3) QI support and ca-pacity; 4) Microsystem characteristics; 5) QI team characteristics; and 6) Miscellaneous. Objectives: Explore applicability of validated survey tools to describe and measure contextual factors in chronic disease interventions. A secondary objec-tive is to identify gaps in the literature where further work is required to measure context. Design: Literature review of survey tools to meas-ure contextual factors specified in the Kaplan mod-el; restricted to quality improvement studies in healthcare. Anticipated results: Inventory of well validated scales that measure contextual factors of interest. We will also identify contextual factors for which conceptual definitions require further research be-fore meaningful measurements can be performed. Methodological or conceptual problem: Context is important in program implementation and success; however it is in its early stages of conceptualization. Prior to quantitative analysis of associations be-tween variation in context and intervention out-comes, contextual factors have to be clearly opera-tionalized, and appropriate scales identified or de-veloped for their measurement.

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1:50 - 2:40 Dockside 9

Poster 21

SOCIO-DEMOGRAPHIC FACTORS INFLUENC-ING THE RATES OF ALCOHOL CESSATION AND RELAPSE IN LUNG CANCER SURVIVORS

Presenter: Ehab Fadhel, MD

Affiliation: Princess Margaret Hospital, Applied Molec-ular Oncology, Toronto

Authors: Ehab Fadhel, MD (1), Yonathan B. Brhane, MMath (1), Prakruthi Palepu, BAMS (1), Gautam P. Joshi, MBBS (1), Henrique Hon, MEng (1), Luke Harland (1), Anthony La Delfa, BSc(1), Steven Habbous, MSc (1), Sinead Cuffe, MD (1), Jiayin Dong (1), Andrew Pierre, MD (2), Anthony Brade, MD (3), Natasha B. Leighl, MD (1)(4), Frances A. Shepherd, MD (1)(4), Wei Xu, PhD (5), Geoffrey Liu, MD (1)(4)*, Lawson Eng, Hon BSc(1)*;(1) Ontario Cancer Institute, Princess Margaret Hospital, University Health Network and Department of Medicine; (2) Department of Surgery, University Health Network; (3) Department of Radiation Oncology, University Health Network; (4) Medical Oncology and Hematology; (5) Bio-statistics, Princess Margaret Hospital and Dalla Lana School of Public Health *Co-Senior Authors

Purpose: Improved lung cancer diagnosis and man-agement has resulted in better patient survival. Family practitioners face challenges in long-term manage-ment of this population. We assessed factors influenc-ing changes in drinking habits in this population.

Methodology: We surveyed alcohol consumption at lung cancer diagnosis. A follow up survey adminis-tered to a subset at a median of 2 years assessed changes in their consumption along with potential pre-dictors (socio-demographic and social environmental factors) of quitting or relapse.

Results: Of 1846 patients, 97% had family doctors, 52% were male, median age was 65 years (range: 23-94), 42% had early-stage cancer, 79% ever-smokers, 71% ever-drinkers. Median drink-years was 91 drink-years (0-5400): 47% drank beer, 54% drank wine, and 46% drank spirits. At follow-up, 53% of current drink-ers quit while 41% of former drinkers restarted drink-ing. Univariate analysis found improved quit rates in younger patients (ORquit=2.14, 95%CI: 1.14-4.01, p=0.01); females (ORquit=1.89, 95%CI: 1.04-3.39, p=0.04); never-smokers (ORquit=2.85, 95%CI: 1.14-7.14, p=0.02); individuals with reduced functional sta-tus (ORquit=3.70, 95%CI: 1.32-10.52,p=9.0E-3), and patients with late-stage disease (ORquit=2.97, 95%CI: 1.56-5.67, p=7.9E-4). Being male (ORrelapse=2.50, 95%CI: 1.20-5.21, p=0.01); having more education (ORrelapse=2.31, 95%CI: 1.09-4.90, p=0.03); and being Caucasian (ORrelapse=12.5, 95%CI: 1.8-544 p=3.0E-3) were associated with higher relapse rates in patients who had quit drinking alcohol at diagnosis.

Conclusions: In lung cancer, male, early-stage, older and improved functional status patients are less likely to quit drinking, while male, more educated, and Cau-casian patients are more likely to relapse. Alcohol modification programs aimed at lung cancer survivors should focus on these individuals.

1:50 - 2:40 Dockside 9

Poster 22

THE CANADIAN PRIMARY HEALTH CARE RE-SEARCH & INNOVATION NETWORK: A PA-TIENT-ORIENTED RESEARCH, TRAINING AND POLICY NETWORK Presenter: Dr. William Hogg, Hons BSc, MSc, MClSc, MD, CCFP, FCFP Affiliation: Bruyère Research Institute, University of Ottawa Authors: Dr. William Hogg, Hons BSc, MSc, MClSc, MD, CCFP, FCFP; Janusz Kaczorowski, MA, PhD; Lisa Dolovich, BScPhm, PharmD, MSc; Richard Birtwhistle, MD, MSc, FCFP; Marshall God-win, MD, MSc, FCFP; Sabrina Wong, MA, PhD; Michelle Prentice, BSc, CK The Canadian Primary Health Care Research & Innovation Network (CPHCRIN) is a newly estab-lished pan-Canadian research, training and policy network, composed of researchers and stakehold-ers in community-based primary health care (CBPHC). Its purpose is to facilitate the scale up of innovative models of CBPHC in order to improve the efficiency and effectiveness of health care in Canada. CPHCRIN is being developed according to the first three of Plastrik and Taylor’s (2006) tasks of network development: (1) inviting members - stakeholders and researchers interested in primary care, public health and population health - to CPHCRIN’s virtual community through introduction, word of mouth, and online fora ; (2) engaging mem-bers, through meetings and online discussions, to identify common values and purpose as a network; (3) coordinating network action, by developing a formal governance structure and a suite of virtual collaboration tools. As of May 2012, a total of 20 national organizations have joined CPHCRIN. Stakeholder advisory and executive committees have been developed. Website networking and col-laboration tools have been launched, and demo-graphic statistics are being compiled. Approximately 160 network members have been identified as us-ing CPHCRIN’s virtual platforms. Members have found a collective purpose in developing mecha-nisms for scaling up innovations, and competing to become a strategy for patient-oriented research (SPOR) network. Progress from their discussions will be presented. CPHCRIN’s rapid growth sug-gests that CBPHC improvement is a priority within Canada, and that virtual collaboration and network-ing software programs can be effective tools for bringing together stakeholders and researchers.

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1:50 - 2:40 Dockside 9

Poster 23 SOCIOECONOMIC- AND GENDER-BASED DIS-PARITIES IN RATES OF HOSPITALIZATION AMONG HUMAN IMMUNODEFICIENCY VIRUS INFECTED PATIENTS IN ONTARIO: A POPULA-TION-BASED STUDY Presenter: Tony Antoniou, BScPhm, PharmD Affiliation: St. Michael's Hospital, Department of Family and Community Medicine, Toronto Authors: Brandon Zagorski, MSc; Mona R. Loufty, MD, MPH; Carol Strike, PhD; Richard H. Glazier, MD, MPH Purpose: To evaluate trends in hospitalization rates among human immunodeficiency virus (HIV)-infected persons living in Ontario, Canada. Methods: Using a validated algorithm, we identified all persons living with HIV (PLWH) in Ontario’s ad-ministrative health-care databases aged 18 years and older between 1992 and 2008, and conducted a population-based study using ecologic and longi-tudinal analyses to quantify the immediate impact of combination antiretroviral therapy (cART) on hospi-talization rates and analyze recent trends (2002 to 2008) in rates of total and HIV-related hospitaliza-tions. Results: The introduction of cART in 1996/97 was associated with more pronounced reductions in rates of total (-91.7 vs. -62.8 per 1000 PLWH; p = 0.002) and HIV-related hospitalizations (- 57.9 vs. -37.3 per 1000 PLWH; p = 0.005) among men rela-tive to women. Between 2002 and 2008, higher rates of total hospitalization were associated with female sex [adjusted relative rate (aRR) 1.16; 95% CI: 1.05 to 1.27] and low socioeconomic status (aRR 1.21; 95% CI: 1.14 to 1.29). Higher rates of HIV-related hospitalizations were associated with low socioeconomic status (aRR 1.30; 95% CI: 1.17 to 1.45). Recent immigrants had lower rates of both total (aRR 0.69; 95% CI 0.60 to 0.80) and HIV-related hospitalizations (aRR 0.77; 95% CI 0.61 to 0.96). Conclusions: Despite universal access to health care and overall declines in hospitalizations, we observed important gender- and socioeconomic-based disparities in hospitalization rates among PLWH living in Ontario, Canada.

1:50 - 2:40 Dockside 9

Poster 24 SMOKING CESSATION AT STONECHURCH FAMILY HEALTH CENTRE: A RETROSPECTIVE COHORT Presenter: Zizzo, S.V. MBBS, MPH, BHSc (Hon Rur Hlth) Affiliation: Senior Resident, Family Medicine, McMaster University, Hamilton In Canada, smoking is the #1 preventable cause of death and disease, killing 3x more than car acci-dents, suicides, drug abuse, murder and AIDS combined1. The advice of a physician is the single strongest determinant of preventive practice5. As a response the Ontario Health Insurance Plan (OHIP) has developed preventive care modules and a number of incentive billing codes for Family Physi-cians to implement in their practice with the goal to encourage, enhance and optimize physician prac-tice of smoking cessation. In this retrospective co-hort, through a chart audit of billing practices, pa-tients at Stonechurch Family Health Centre in Ham-ilton ON Canada who were ever billed a smoking cessation code were identified between November 1 2008 and November 1 2009. Outcomes consid-erations include how many smoking cessation ini-tial and follow-up codes were billed during this time period, a revision correct billing practices according to OHIP, the percentage of smoking population who these services were offered to, and the per-centage of providers engaging in the OHIP spon-sored preventative modules. References: 1. Clinical Tobacco Intervention [http://ctica.org] 2. Canadian Cancer Statistics, 2004 3. Respiratory Disease in Canada, 2001 4. The Canadian Heart and Stroke Foundation [http://www.heartandstroke.ca] 5. Settings for Health Promotion: Linking Theory and Practice. 2000. p.219. 6. Clinical Tobacco Intervention - 5 A’s model [http://www.omacti.org]

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Index by Presenter

Antoniou, Tony .................................................... 41 Ashcroft, Rachelle ............................................... 31 Baird, Judy ............................................................. 18 Bauman, Craig ...................................................... 39 Bjerre, Lise ........................................................... 26 Blazhko, Valerie .................................................. 37 Bonilla, Carolina ................................................. 23 Bracken, Keyna ............................................ 18, 24 Brauer, Paula ....................................................... 25 Chatterjee, Ananda ............................................ 30 Dahrouge, Simone ............................................. 18 Dimitris, Michelle ................................................ 29 Fedhel, Ehab ........................................................ 40 Fitzpatrick, Susan ................................................ 10 Glazier, Richard .................................................. 12 Greenspoon, Todd ............................................ 31 Grewal, Manjot ................................................... 28 Haggerty, Jeannie ......................................... 10, 13 Haider, Ramin ..................................................... 36 Hameed, Saadia ................................................... 16 Han, Han .............................................................. 20 Heale, Roberta .................................................... 21 Hogg, William ....................................................... 40 Honein, Gladys ................................................... 27 Howard, Michelle ........................................ 15, 33 Hum, Susan .......................................................... 38 Hutchison, Brian ........................................... 11, 26 Jeffery, Rebecca .................................................. 17 Kadhim-Saleh, Amjed ........................................ 27 Keshavjee, Karim ................................................ 34 Koren, Irene ........................................................ 21 Kotecha, Jyoti ....................................................... 20 Laslo, Britta .......................................................... 28 Latif, Asma ........................................................... 19

Lee, Linda ....... .................................................... 28 Leung, Jo Jo ........................................................... 36 Lipari, Steven ........................................................ 32 Lyte, Kristina ......................................................... 35 MacDonald-Westruck , Michele ...................... 34 MacKenzie, Liliana ............................................... 30 Maddocks, Heather ............................................. 19 Martin-Rhee, Michelle ........................................ 15 McDonough, Beatrice ......................................... 16 McMillan, Colleen ................................................. 39 Moses McKeag, Ali .............................................. 22 Mukhi, Shaheena .................................................... 15 Muldoon, Laura .................................................... 14 Nelson, Michelle .................................................. 33 Nicholson, Kathryn ............................................. 32 Pinto, Andrew ........................................................ 25 Radhakrishnan, Arun ............................................ 37 Rana, Saleem ......................................................... 19 Rukholm, Ellen ...................................................... 21 Ryan, Bridget .......................................................... 24 Schabort, Inge ............................................... 34, 36 Sehdev, Amrit ....................................................... 17 Selby, Peter ............................................................ 22 Shadd, Joshua .................................................. 14, 29 Sullivan-Taylor, Patricia ...................................... 15 Terner, Michael .................................................... 23 Terry, Amanda ..................................................... 38 Tranmer, Joan ....................................................... 20 Vasa, Priya ............................................................... 39 Vassanji, Karim ..................................................... 34 Walji, Rishma ........................................................ 35 Webster, Greg ..................................................... 26 Zizzo, Steven ........................................................ 41

43

Notes