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Objective: To describe the techniques currently used by family physicians in Canada to measure blood pressure (BP) for screening for, diagnosing, and treating hypertension., Design: A Web-based cross-sectional survey distributed by e-mail., Setting: Stratified random sample of family physicians in Canada., Participants: Family physician members of the College of Family Physicians of Canada with valid e-mail addresses., Main Outcome Measures: Physicians' self-reported routine methods for recording BP in their practices to screen for, diagnose, and manage hypertension., Results: A total of 774 valid responses were received, for a response rate of 16.2%. Respondents were similar to nonrespondents except for underrepresentation of male physicians. Of 769 respondents, 417 (54.2%) indicated that they used manual office BP measurement with a mercury or aneroid device and stethoscope as the routine method to screen patients for high BP, while 42.9% (330 of 769) reported using automated office BP (AOBP) measurement. The method most frequently used to make a diagnosis of hypertension was AOBP measurement (31.1%, 240 of 771), followed by home BP measurement (22.4%, 173 of 771) and manual office BP measurement (21.4%, 165 of 771). Ambulatory BP monitoring (ABPM) was used for diagnosis by 14.4% (111 of 771) of respondents. The most frequently reported method for ongoing management was home BP monitoring (68.7%, 528 of 769), followed by manual office BP measurement (63.6%, 489 of 769) and AOBP measurement (59.2%, 455 of 769). More than three-quarters (77.8%, 598 of 769) of respondents indicated that ABPM was readily available for their patients., Conclusion: Canadian family physicians exhibit overall high use of electronic devices for BP measurement, However, more efforts are needed to encourage practitioners to follow current Canadian guidelines, which advocate the use of AOBP measurement for hypertension screening, ABPM and home BP measurement for making a diagnosis, and both AOBP and home BP monitoring for ongoing management., (Copyright© the College of Family Physicians of Canada.)

Objective: To highlight the 2015 Canadian Hypertension Education Program (CHEP) recommendations for the diagnosis and assessment of hypertension., Quality of Evidence: A systematic search was performed current to August 2014 by a Cochrane Collaboration librarian using the MEDLINE and PubMed databases. The search results were critically appraised by the CHEP subcommittee on blood pressure (BP) measurement and diagnosis, and evidence-based recommendations were presented to the CHEP Central Review Committee for independent review and grading. Finally, the findings and recommendations were presented to the Recommendations Task Force for discussion, debate, approval, and voting. The main recommendations are based on level II evidence., Main Message: Based on the most recent evidence, CHEP has made 4 recommendations in 2 broad categories for 2015 to improve BP measurement and the way hypertension is diagnosed. A strong recommendation is made to use electronic BP measurement in the office setting to replace auscultatory BP measurement. For patients with elevated office readings, CHEP is recommending early use of out-of-office BP measurement, preferably ambulatory BP measurement, in order to identify early in the process those patients with white-coat hypertension., Conclusion: Improvements in diagnostic accuracy are critical to optimizing hypertension management in Canada. The annual updates provided by CHEP ensure that practitioners have up-to-date evidence-based information to inform practice., (Copyright© the College of Family Physicians of Canada.)

Objective: To explore the experiences of family physicians and pediatricians delivering immunizations, including perceived barriers and supports., Design: Qualitative study using focus groups., Setting: Ten cities throughout British Columbia., Participants: A total of 46 family physicians or general practitioners, 10 pediatricians, and 2 residents., Methods: A semistructured dialogue guide was used by a trained facilitator to explore participants' experiences and views related to immunization delivery in British Columbia. Verbatim transcriptions were independently coded by 2 researchers. Key themes were analyzed and identified in an iterative manner using interpretive description., Main Findings: Physicians highly valued vaccine delivery. Factors facilitating physician-delivered immunizations included strong beliefs in the value of vaccines and having adequate information. Identified barriers included the large time commitment and insufficient communication about program changes, new vaccines, and the adult immunization program in general. Some physicians reported good relationships with local public health, while others reported the opposite experience, and this varied by geographic location., Conclusion: These findings suggest that physicians are supportive of delivering vaccines. However, there are opportunities to improve the sustainability of physician-delivered immunizations. While compensation schemes remain under the purview of the provincial governments, local public health authorities can address the information needs of physicians.

Objective: To provide FPs with detailed knowledge of automated office blood pressure (AOBP) measurement, its potential role in primary care, and its proper use in the diagnosis and management of hypertension., Sources of Information: Comprehensive monitoring and collection of scientific articles on AOBP by the authors since its introduction., Main Message: Automated office blood pressure measurement maintains a role for blood pressure (BP) readings taken in the office setting. Clinical research studies have reported a substantially stronger relationship between awake ambulatory BP measurement and AOBP measurement compared with manual BP recorded during routine visits to the patient's physician. Automated office blood pressure measurement produces mean BP values comparable to awake ambulatory BP and home BP values. Compared with routine manual office BP measurement, AOBP correlates more strongly with awake ambulatory BP measurement, shows less digit preference, is more consistent from visit to visit, is similar both within and outside of the physician's office, virtually eliminates office-induced hypertension, and is associated with less masked hypertension. It is estimated that more than 25% of Canadian primary care physicians are now using AOBP measurement in their office practices. The use of AOBP to diagnose hypertension has been recommended by the Canadian Hypertension Education Program since 2010., Conclusion: There is now sufficient evidence to incorporate AOBP measurement into primary care as an alternative to manual BP measurement.

Objective: To evaluate the effect of the Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) reminder and recall system and pay-for-performance incentives on the delivery rates of cervical and breast cancer screening in primary care practices in Ontario, with or without deployment of nurse practitioners (NPs)., Design: Before-and-after comparisons of the time-appropriate delivery rates of cervical and breast cancer screening using the automated and NP-augmented strategies of the P-PROMPT reminder and recall system., Setting: Southwestern Ontario., Participants: A total of 232 physicians from 24 primary care network or family health network groups across 110 different sites eligible for pay-for-performance incentives., Interventions: The P-PROMPT project combined pay-for-performance incentives with provider and patient reminders and deployment of NPs to enhance the delivery of preventive care services., Main Outcome Measures: The mean delivery rates at the practice level of time-appropriate mammograms and Papanicolaou tests completed within the previous 30 months., Results: Before-and-after comparisons of time-appropriate delivery rates (< 30 months) of cancer screening showed the rates of Pap tests and mammograms for eligible women significantly increased over a 1-year period by 6.3% (P < .001) and 5.3% (P < .001), respectively. The NP-augmented strategy achieved comparable rate increases to the automated strategy alone in the delivery rates of both services., Conclusion: The use of provider and patient reminders and pay-for-performance incentives resulted in increases in the uptake of Pap tests and mammograms among eligible primary care patients over a 1-year period in family practices in Ontario.

Objective: To explore physicians' knowledge, attitudes, and practices related to sexual and mood side effects of hormonal contraceptives, and to compare residents with practising doctors., Design: A mixed-method study with faxed or e-mailed surveys and semistructured telephone interviews., Setting: British Columbia., Participants: A random sample of family doctors, all gynecologists, and all residents in family medicine and gynecology in the College of Physicians and Surgeons of British Columbia registry. A subsample was interviewed., Main Outcome Measures: Estimates of rates of mood and sexual side effects of contraceptives in the practice population and how the physicians informed and advised patients about these side effects., Results: There were 79 residents and 76 practising doctors who completed the questionnaires (response rates of 42.0% and 54.7% of eligible residents and physicians, respectively). The reference sources most physicians reported using gave the rates of sexual and mood side effects of hormonal contraceptives as less than 1%, and yet only 1 (0.6%) respondent estimated similar rates for mood side effects, and 12 (7.8%) for sexual effects among their patients. The most common answers were rates of 5% to 10%, with residents reporting similar rates to practising doctors. Practising doctors were more likely to ask about sexual and mood side effects than residents were (81.1% vs. 24.1% and 86.3% vs. 40.5%, respectively; P < .001). Practising doctors were also more likely to recommend switching to barrier methods (37.3% vs. 16.5%; P = .003) or intrauterine devices (54.7% vs. 38.0%; P = .038) than residents were and more likely to give more responses to the question about how they managed sexual and mood side effects (mean of 1.7 vs. 1.1 responses, P = .001). In 14 of the 15 interviews, practising doctors discussed how they had learned about side effects mainly from their patients and how this had changed their practices., Conclusion: Physicians' perceived rates of mood and sexual side effects from hormonal contraception in the general population were higher than the rate of less than 1% quoted in the product monographs. Practising doctors reported that they learned about the type, frequency, and severity of side effects from their patients.

Objective: To examine the remuneration model preferences of newly practising family physicians., Design: Mixed-methods study comprising a cross-sectional, Web-based survey, as well as qualitative content analysis of answers to open-ended questions., Setting: British Columbia., Participants: University of British Columbia family practice residents who graduated between 2000 and 2009., Main Outcome Measures: Preferred remuneration models of newly practising physicians., Results: The survey response rate was 31% (133 of 430). Of respondents, 71% (93 of 132) preferred non-fee-for-service practice models and 86% (110 of 132) identified the payment model as very or somewhat important in their choice of future practice. Three principal themes were identified from content analysis of respondents' open-ended comments: frustrations with fee-for-service billing, which encompassed issues related to aggravations with "the business side of things" and was seen as impeding "the freedom to focus on medicine"; quality of patient care, which embraced the importance of a payment model that supported "comprehensive patient care" and "quality rather than quantity"; and freedom to choose, which supported the plurality of practice preferences among providers who strived to provide quality care for patients, "whatever model you happen to be working in.", Conclusion: Newly practising physicians in British Columbia preferred alternatives to fee-for-service payment models, which were perceived as contributing to fewer frustrations with billing systems, improved quality of work life, and better quality of patient care.

Objective: To understand why response rates in clinician surveys are declining., Design: Cross-sectional fax-back survey., Setting: British Columbia., Participants: Random sample of family physicians and all gynecologists in the College of Physicians and Surgeons of British Columbia's registry., Main Outcome Measures: Accuracy of the College of Physicians and Surgeons of British Columbia's registry, and the prevalence and characteristics of physicians with policies not to participate in any surveys., Results: Of 542 physicians who received surveys, 76 (14.0%) responded. On follow-up we found the following: the College of Physicians and Surgeons of British Columbia's registry was inaccurate for 94 (17.3%) listings; 14 (2.6%) physicians were away; 100 (18.5%) were not eligible; and 197 (36.3%) had an office policy not to participate in any surveys. Compared with the respondents, physicians with an office policy not to participate in any surveys were more likely to be men, less likely to be white, more likely to have urban-based practices, and more likely to have been in practice for more than 15 years., Conclusion: Many physicians have an office policy not to participate in any surveys. Owing to the trend of lower response rates, recommendations of minimum response rates for clinician surveys by many journals might need to be reassessed.

Objective: The Provider and Patient Reminders in Ontario: Multi-Strategy Prevention Tools (P-PROMPT) project was designed to increase the rates of delivery of 4 targeted preventive care services to eligible patients in primary care network and family health network practices eligible for pay-for-performance incentives., Design: Self-administered fax-back surveys completed before and after participation in the P-PROMPT project., Setting: Southwestern Ontario., Participants: A total of 246 physicians from 24 primary care network or family health network practices across 110 different sites., Interventions: The P-PROMPT project provided several tools and services, including physician and patient reminders, office management tools, and administrative database integration., Main Outcome Measures: Physicians' views about the delivery of preventive health services and pay-for-performance incentives before and after participation in the P-PROMPT project., Results: The preintervention survey was completed by 86.2% (212 of 246) of physicians and the postintervention survey was completed by 53.3% (131 of 246) of physicians; 46.7% (114 of 246) of the physicians completed both surveys. Overall, 80.5% of physicians indicated that the P-PROMPT project was useful (scores of 5 or higher on a 7-point Likert scale). Patient reminder letters (89.1%), physician approval lists of eligible patients (75.6%), administrative assistance with management fees (79.8%), and annual bonus calculations (75.2%) were rated as the most useful features of the program. Compared with the preintervention survey, there were statistically significant increases in the mean agreement scores that the established target levels and bonuses provided appropriate financial incentive to substantially increase the uptake of mammography (P=.012) and Papanicolaou tests (P=.003) but not to increase uptake of annual influenza vaccination or childhood immunizations. There were statistically significant changes in the mean ratings of relying on an opportunistic approach (P<.001), increased agreement about the effectiveness of the current approach to delivery of preventive care (P<.001), and increased use of preventive management fees to recall patients (P<.001)., Conclusion: The preventive care management program and P-PROMPT were viewed favourably by most respondents and were perceived to be useful in improving delivery of preventive health care services.

Objective: To examine FPs' attitudes toward birth for those providing intrapartum care (IPC) and those providing only antepartum care (APC)., Design: National, cross-sectional Web- and paper-based survey., Setting: Canada., Participants: A total of 897 Canadian FPs: 503 providing both IPC and APC (FPIs), 252 providing only APC but who previously provided IPC (FPPs), and 142 providing only APC who never provided IPC (FPNs)., Main Outcome Measures: Respondents' views (measured on a 5-point Likert scale) on routine electronic fetal monitoring, epidural analgesia, routine episiotomy, doulas, pelvic floor benefits of cesarean section, approaches to reducing cesarean section rates, maternal choice and the mother's role in her own child's birth, care providers' fears of vaginal birth for themselves or their partners, and safety by mode or place of birth., Results: Results showed that FPIs and FPPs were more likely than FPNs were to take additional training or advanced life support courses. The FPIs consistently demonstrated more positive attitudes toward vaginal birth than did the other 2 groups. The FPPs and FPNs showed significantly more agreement with use of routine electronic fetal monitoring and routine epidural analgesia (P < .001). The FPIs displayed significantly more acceptance of doulas (P < .001) and more disagreement with the pelvic floor benefits of cesarean section than other FPs did (P < .001). The FPIs were significantly less fearful of vaginal birth for themselves or their partners than were FPPs and FPNs (P < .001). All FP groups agreed on rejection of elective cesarean section, in the absence of indications, for themselves or their partners and on support for vaginal birth in the presence of uterine scar. While all FP groups supported licensed midwifery, three-quarters thought home birth was more dangerous than hospital birth and showed ambivalence toward birth plans. Only 7.8% of FPIs would choose obstetricians for their own or their partners' maternity care., Conclusion: The FPIs had a more positive, evidence-based view of birth. It is likely that FPs providing only APC are influencing women in their practices toward a relatively negative view of birth before referral to obstetricians, FPIs, or midwives for the actual birth. The relatively negative views of birth held by FPs providing only APC need to be addressed in family practice education and in continuing education.

Objective: To examine patients' use of and satisfaction with the nurse-staffed Telephone Health Advisory Service (THAS) and physician after-hours care in a rostered Family Health Organization, as well as physicians' satisfaction with both types of services., Design: Cross-sectional telephone survey., Setting: A Family Health Organization in Hamilton, Ont., Participants: Nineteen family physicians and their patients who used an after-hours service during 9 selected weeks between March and December of 2007., Main Outcome Measures: Distribution of encounters directed to the on-call physician or to the THAS; types of health problems; and patient and physician satisfaction., Results: A total of 817 calls were recorded from 774 patients. Of these patients, 606 were contacted and 94.4% (572/606) completed encounter-specific surveys: 358 completed the on-call physician survey and 214 completed the THAS survey. Mean age of respondents was 40.8 years; most were women, and approximately one-third called on behalf of children. Most calls (66.8%, 546/817) were made directly to the on-call physicians. The most common problems were respiratory (34.3%, 271/789), gastrointestinal (10.1%, 80/789), and genitourinary (9.3%, 73/789). Most patients reported being very satisfied with the after-hours care provided by the THAS (62.5%, 125/200) or the on-call physicians (70.9%, 249/351). Almost all callers who bypassed the THAS knew about it (89.8%, 316/352), but either felt their problems were too serious or wished to talk to a physician. Most physicians agreed or strongly agreed that they were satisfied with their colleagues' on-call care (81.0%, 17/21); 47.6% (10/21) agreed that the THAS was helpful in managing on-call duty., Conclusion: When direct after-hours physician contact is available, a minority of patients uses a nurse-staffed triage. Physicians find the arrangements onerous and would prefer to see after-hours care managed and remunerated differently.

Objective: To explore women's perspectives on the acceptability and content of reminder letters for screening mammography from their family physicians, as well as such letters' effect on screening intentions., Design: Cross-sectional mailed survey followed by focus groups with a subgroup of respondents., Setting: Ontario., Participants: One family physician was randomly selected from each of 23 family health networks and primary care networks participating in a demonstration project to increase the delivery of preventive services. From the practice roster of each physician, up to 35 randomly selected women aged 50 to 69 years who were due or overdue for screening mammograms and who had received reminder letters from their family physicians within the past 6 months were surveyed., Main Outcome Measures: Recall of having received reminder letters and of their content, influence of the letters on decisions to have mammograms, and interest in receiving future reminder letters. Focus group interviews with survey respondents explored the survey findings in greater depth using a standardized interview guide., Results: The response rate to the survey was 55.7% (384 of 689), and 45.1% (173 of 384) of responding women reported having mammograms in the past 6 months. Among women who recalled receiving letters and either making appointments for or having mammograms, 74.8% (122 of 163) indicated that the letters substantially influenced their decisions. Most respondents (77.1% [296 of 384]) indicated that they would like to continue to receive reminders, and 28.9% (111 of 384) indicated that they would like to receive additional information about mammograms. Participants in 2 focus groups (n = 3 and n = 5) indicated that they thought letters reflected a positive attitude of physicians toward mammography screening. They also commented that newly eligible women had different information needs than women who had had mammograms done in the past., Conclusion: Reminder letters were considered by participants to be useful and appeared to influence women's decisions to undergo mammography screening.

Objective: To compare rates of mammography screening among women in family practices, based on a sequential sample of eligible women presenting to the practices during an 8-week period, with rates found in a full audit of all eligible patients., Design: Chart review., Setting: Twenty community-based family practices in south-central Ontario., Participants: Family physicians and their female patients 52 to 71 years old who had had at least 1 visit to the office during the past 3 years., Intervention: Eligible patients were sampled by 2 approaches: sequential sampling of patients coming for appointments during an 8-week period and a full practice audit of all eligible women., Main Outcome Measure: Mammography rates found using the 2 approaches., Results: The mean time-appropriate rate of mammography screening based on the sequential sample was 66.4%. The mean time-appropriate rate of mammography screening for the full practice audit was 58.8%. The sequential sample rate was higher than that of the full audit by 7.6%; differences ranged from -6.5% to 24.9% among practices. Regression analysis indicated a positive and significant correlation between rates based on the data generated by the 2 different approaches (r2 = 0.50)., Conclusion: A rate of mammography screening based on a sequential sample can reasonably approximate the actual rate of mammography screening that would be found based on a full practice audit.

Objective: To identify patient and physician characteristics associated with family physicians recording blood pressure (BP) measurements in the medical charts of their elderly patients., Design: Retrospective review of patients' charts during a 12-month period and baseline questionnaire on the sociodemographic and practice characteristics of family physicians participating in the Community Hypertension Assessment Trial. The chart review collected data on patients' demographics, cardiovascular risk factors, antihypertensive medications, number of visits to family physicians, and number of BP readings recorded., Setting: Non-academic family practices in Hamilton and Ottawa, Ont., Participants: Data were abstracted from the charts of 55 randomly selected regular elderly patients (65 years old and older) from each of 28 participating family practices (N = 1540 charts)., Main Outcome Measure: Number of recordings of BP measurements in medical charts during a 12-month period., Results: About 16% (241/1540) of elderly patients had not had their BP recorded in their charts during the 12-month review period. Among this 16%, almost half (47%, 114/241) had not had a BP measurement recorded during the previous 24 months. Multivariate analysis indicated that the likelihood of BP recording increased with the number of visits made to family physicians and was greater among patients taking antihypertensive medications or diagnosed with hypertension. Physicians who had more recently graduated from medical school (< or = 24 years) were more likely to record BP measurements., Conclusion: Hypertension guidelines recommend that, for patients at risk, BP be measured and recorded at each office visit. Although more than 84% of older patients had at least 1 BP reading documented in their charts, patients who were already diagnosed with hypertension or who made frequent visits to the office were more likely to have their BP measured and recorded. A more systematic approach to monitoring elderly patients who visit their family physicians less frequently or who are not currently diagnosed with hypertension is needed.

Objective: To determine whether the canalith repositioning maneuver (CRM) is effective for treating benign paroxysmal positional vertigo when it is used by family physicians in primary care settings., Design: Randomized, prospective, double-blind, sham-controlled trial., Setting: An academic family practice in Hamilton, Ont., Participants: Eighty-one patients 18 years or older whose dizziness was confirmed by the Dix-Hallpike (DH) vertigo-triggering maneuver and who had no contraindications to the CRM., Interventions: At the first visit, the intervention group received the CRM and the control group received a sham maneuver. Both groups received the CRM at the second and third visits 1 and 2 weeks later., Main Outcome Measures: Negative results of the DH test or self-reported resolution of vertigo after the initial treatment., Results: Eighty-one patients were randomized and received the first treatment. After the first treatment, 34.2% of patients in the intervention group and 14.6% of patients in the control group had negative DH test results (relative risk 2.3, 95% confidence interval 1.03 to 5.2, P = .04); and 31.6% of patients in the intervention group and 24.4% of patients in the control group reported resolution of dizziness (relative risk 1.2, 95% confidence interval 0.7 to 1.9, P = .48). One week later, patients in both intervention and control groups received the CRM, and 61.8% and 57.1% of them, respectively, had negative DH test results (P = .81). By week 3, approximately 75% of patients in both groups had improved., Conclusion: A statistically significant proportion of patients in the CRM group returned to a negative response to the DH maneuver immediately after the first treatment. Family physicians can use the CRM to treat benign paroxysmal positional vertigo and potentially avoid delays in treatment and unnecessary referrals., Trial Registration Number: NCT00182273 (ClinicalTrials.gov).

Objective: To examine age-specific prevalence and correlates of urinary incontinence (UI) among community-dwelling women., Design: A questionnaire survey used a modified Dillman method., Setting: Two family practice clinics in Hamilton, Ont., Participants: Questionnaires were mailed to 1082 women 45 years old and older. Ninety women were disqualified; 606 recipients responded., Main Outcome Measures: Self-reported prevalence of UI and potential risk factors., Results: Overall response rate was 61% (606/992); 51% (311/606; 95% confidence interval 47.3% to 55.3%) reported an episode of UI during the last month. Of the 311 women reporting UI, 35.7% perceived it as a problem, 27% had had it for less than a year, 41.9% had had it for 1 to 4 years, and 31.1% had had it for 5 years or longer. Three kinds of UI were reported: 34% (106/311) reported stress UI, 14.5% (45/311) reported urge UI, and 51.4% (160/311) reported a mixed pattern. In multivariate analysis, the overall prevalence of incontinence increased significantly with "usually having a cough," "being troubled by swollen ankles," "giving birth," "ever smoking cigarettes," and "being troubled by headaches." Stress UI was associated with "usually having a cough" and "ever smoking cigarettes." Urge UI was associated with "having troubles with constipation" and "swollen ankles." Mixed incontinence was associated with "get sick more than other people," "usually having a cough," "taken hormones for menopause," and body mass index in the 50th to 75th percentile or greater. Age was not significantly associated with prevalence of UI or any of its subtypes. Only 40% of incontinent women indicated they had discussed urine loss with their physicians; 70% of these women felt satisfied with physicians' responses., Conclusion: Incontinence occurs in more than half of community-dwelling women 45 years old and older. Almost one of five women in the community reported UI that affected normal activities. Treating the effect of incontinence will require further understanding of women's coping skills and self-perceptions. Prevalence does not appear to increase with age.

Objective: To examine how prenatal care providers responded to a new provincial policy of offering HIV testing to all prenatal patients, and to determine factors associated with self-reported high testing rates., Design: Cross-sectional mailed survey., Setting: Outpatient practices in three Ontario health-planning regions., Participants: Prenatal care providers: 784 family physicians, 200 obstetricians, and 103 midwives were sent questionnaires and were eligible to participate., Main Outcome Measures: Self-reported testing of 80% or more prenatal patients ("high testers") and associated practice characteristics, attitudes, and counseling practices., Results: Response rate was 57% (622/1087): 43% of respondents were high testers. Family physicians were most likely and midwives least likely to be high testers. High testers tended to report that they had adequate knowledge of HIV testing, that HIV risk among their patients warranted testing all of them, and that testing should be routine. Encouraging women to test and not providing written information or choice were independently associated with high testing rates., Conclusion: Strongest predictors of high prenatal HIV testing rates were attitudes and practices that favoured a routine approach to testing and that placed little emphasis on informed consent.

Objective: To compare characteristics of family physicians planning to discontinue or stay in intrapartum care., Design: Self-administered questionnaire., Setting: Department of Family Practice at Children's and Women's Health Centre of British Columbia., Participants: Ninety-five family physicians who attended at least one birth at the Health Centre between April 1997 and August 1998., Main Outcome Measures: Intention to leave or stay in family practice maternity care, physician characteristics and beliefs., Results: Forty-five percent (43/95) of family physicians planned to leave maternity care within the next 5 years. Physicians planning to leave had more negative attitudes about the alternative birthing centre, doulas, and practising in free-standing settings without on-site obstetricians; were more likely to report missing personal events because they had put their maternity patients first; were less likely to make housecalls during women's labour; and were more likely to be paid through fee-for-service., Conclusion: Being paid by fee-for-service, having negative attitudes toward non-traditional maternity care, and conflict between maternity care and personal life were associated with intention to leave intrapartum care.

Objective: To compare walk-in clinics with other primary care settings on characteristics associated with best practices in primary care., Design: A mailed self-administered questionnaire asked about organizational and clinical characteristics of primary care practices located in major urban and suburban areas in Ontario., Setting: Four types of fee-for-service group practices: walk-in and urgent-care clinics (WICs), mixed practices (MPs), after-hours clinics (AHCs), and group family practices (GFPs)., Participants: A physician or a staff member involved in practice administration., Main Outcome Measures: The four practice types were compared on organizational characteristics and measures of access, continuing care, comprehensiveness, coordination, and mechanisms for monitoring quality of care., Results: Walk-in clinics, MPs, and AHCs were open more hours during evenings and weekends and were more likely to see patients without appointments; GFPs were more likely to have on-call arrangements. Group family practices saw a larger proportion of patients for whom they provided ongoing care; WICs and MPs reported that more than 60% of their visits were with "regular" patients. Walk-in clinics were less likely to provide preventive services and psychological counseling than were GFPs and MPs. A few WICs, MPs, and GFPs had procedures to support coordination of care or to monitor quality of care., Conclusion: Although WICs, MPs, and AHCs provided walk-in services to Ontario patients, WICs and MPs also provided a substantial amount of ongoing care and preventive services. Independent AHCs appeared to most closely fit the "walk-in clinic" stereotype.

Objective: To determine the knowledge, attitudes, and interest in providing medical abortion reported by family physicians and residents in rural and urban settings., Design: A self-administered mailed survey using the modified Dillman method., Setting: Hamilton and Thunder Bay County in Ontario., Participants: Family medicine residents (n = 93) and physicians (n = 234) in predominantly urban (Hamilton) and rural (Thunder Bay) settings. All faculty family physicians at McMaster University practising general family medicine and all family physicians in Thunder Bay County were surveyed., Main Outcome Measures: Knowledge of, attitudes toward, and interest in providing medical abortion., Results: Overall response rate to the survey was 62.7% (n = 327); 74.2% (69/93) of residents responded; 58.1% (136/234) of physicians responded. Physicians and residents rated their knowledge about medical abortion as poor, but most were interested in receiving more information and training in this area. Many (83.1%, 157/189) reported that medical abortion was an acceptable procedure for family physicians to perform, and 52.0% (64/123) of the physicians would consider providing medical abortions for their patients. Residents training in the more rural Thunder Bay program were less likely to support first-trimester abortions for both medical and nonmedical reasons than those training in Hamilton (P < .05). Male respondents were significantly less supportive of abortion for nonmedical reasons and were less likely to consider providing medical abortions for their patients (P < .05)., Conclusion: Most family physicians and residents showed interest in receiving more information about and training in medical abortion.

Objective: To determine current knowledge, attitudes, and management of urinary incontinence among family physicians in Canada., Design: Cross-sectional mailed survey., Setting: Family physicians in Canada., Participants: A random sample of 1500 members of the College of Family Physicians of Canada., Main Outcome Measures: Self-assessed knowledge, self-reported attitudes, and rating of various tests and treatments in the investigation and management of incontinence., Results: The overall unadjusted response rate was 43.3% (650/1500). Although most respondents reported that urinary incontinence was common in their practices, less than half (46.0%, 284/617) indicated that they clearly understood incontinence and just 37.9% (232/612) had an organized plan for incontinence problems. Only 35.0% (214/612) of respondents felt very comfortable dealing with incontinence. Physical examination, urodynamic studies, urinalysis, and testing blood sugar levels were all considered important investigations by more than 90% of respondents., Conclusion: There are wide variations in knowledge, attitudes, practices, and comfort level among family physicians dealing with urinary incontinence.

Objective: To assess the effect of a self-appraisal questionnaire and a workshop for office staff in promoting the baby-friendly office (BFO)., Design: A two-times-three factorial design with a delayed workshop for one of two groups: an early intervention group who attended a workshop for office staff in October 1997 (n = 23) and a late-intervention group who attended in April 1998 (n = 23). Self-appraisals were completed before the workshops by all participants in October 1997, by 37 offices in April 1998, and by 34 offices in October 1998., Setting: Offices of family physicians and primary care pediatricians in Hamilton-Wentworth, Ont., Participants: Staff of 46 offices; 74% (34/46) completed all three assessments., Main Outcome Measures: Degree of change in implementing each of the "10 Steps to Baby-Friendly Office" and overall average BFO score received by each office., Results: Of the 34 offices completing all assessments, none followed all 10 steps. Initial mean score was 4.4 steps (standard deviation 1.4, n = 46). The workshop intervention improved overall mean scores from 4.3 to 5.6 (P < .001, n = 37). Although office staff completed the BFO self-appraisal tool, it alone had no effect on scores. Areas of improvement were noted in providing information to patients and displaying posters to promote breastfeeding. Key steps, such as not advertising breast milk substitutes and not distributing free formula, did not change., Conclusion: The workshop effected a modest but positive change in breastfeeding promotion. The change was maintained at 6 and 12 months after the intervention.

Objective: To determine provincial trends in provision of intrapartum care by general practitioners and family physicians (GP/FPs) for the 11 years from 1984 to 1995., Design: Analyses of provincial Medical Care Fee-for-Service Utilization data for births from 1984-1985 to 1994-1995., Setting: 10 provinces of Canada., Main Outcome Measures: Proportion of vaginal births billed by GP/FPs (expressed as total number of vaginal births billed by GP/FPs divided by total number of vaginal births)., Results: In 1994-1995, the proportion of vaginal births billed by GP/FPs ranged from 77.2% in British Columbia and 70.8% in Nova Scotia to 28.9% in Ontario and 23.6% in Prince Edward Island. These proportions have remained relatively high and stable during the period studied in some provinces, such as British Columbia and Nova Scotia, and have declined steadily and notably in others., Conclusions: Data show that GP/FPs' involvement in vaginal births in most Canadian provinces is decreasing. This trend demonstrates a shift in GP/FPs' practice patterns and could indicate a coming shortage of obstetrical care providers.

Objective: To determine the annual incidence of patient-defined emergencies and patients' use of emergency services at a family medicine teaching unit., Design: Cross-sectional survey., Setting: Hospital-based family medicine teaching unit in Montreal., Participants: Registered patients attending a family medicine teaching unit during 11 consecutive weekdays., Main Outcome Measures: Annual incidence of patient-defined medical emergencies and use of emergency services at the unit., Results: Eligible patients made 815 visits during the study period; 584 usable questionnaires were returned for a response rate of 71.7%. In the previous 12 months, 37% of patients reported at least one medical emergency. For their last emergency, 42% reported using at least one of the emergency services offered by the clinic. Only 19% of patients with after-hours emergencies reported using our on-call system. Although socioeconomic and clinical variables did not predict the incidence of patient-defined emergencies, multivariate analysis revealed three significant predictors for use: patients with the practice for 5 or more years were more likely to use our services, while patients 75 and older and those with emergencies after hours were less likely to use our services., Conclusions: In an urban group family practice, annual incidence of medical emergencies among registered patients was 37%. Those whose most recent emergency occurred after hours used the clinics' emergency on-call services disappointingly little.

Objective: To determine family medicine residents' attitudes toward family practice training in obstetrics and neonatology before and after implementation of a modified obstetrics curriculum at McGill University (MG)., Design: Two-group pretest and posttest. Fifty-seven respondents, 31 at MG, 26 at University of Montreal (UM), were case matched as first-year and second-year residents., Setting: Departments of Family Medicine at MG and UM., Participants: Family medicine residents at MG and UM., Intervention: A modified obstetrics curriculum was introduced at MG (study group); no modifications were introduced at UM (control group). First- and second-year residents' attitudes toward the adequacy of training were assessed through responses to a questionnaire administered in July 1992 and July 1994., Main Outcome Measures: Changes in response scores before and after implementation of the modified curriculum., Results: Repeated multivariate analysis of variance (MANOVA) showed respondents believed family practice obstetrics training was adequate in general, but that family practitioners were inadequately trained in emergency obstetric skills. Scores for items assessing neonatology skills increased significantly in the MG group after the intervention., Conclusions: Residents' overall confidence in their obstetrics training did not appear to improve, but this might be due to a time lag between curriculum modification and attitudinal change. McGill residents' confidence in neonatology skills improved significantly after curriculum modification.