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Introduction: In 2011, the Agence de la santé et des services sociaux de Montréal (ASSSM), in partnership with the region's Centres de santé et de services sociaux (CSSS), coordinated the implementation of a program on cardiometabolic risk based on the Chronic Care Model. The program, intended for patients suffering from diabetes or hypertension, involved a series of individual follow-up appointments, group classes and exercise sessions. Our study assesses the impact on patient health outcomes of variations in the implementation of some aspects of the program among the six CSSSs taking part in the study., Methods: The evaluation was carried out using a quasi-experimental "before and after" design. Implementation variables were constructed based on data collected during the implementation analysis regarding resources, compliance with the clinical process set out in the regional program, the program experience and internal coordination within the care team. Differences in differences using propensity scores were calculated for HbA1c results, achieving the blood pressure (BP) target, and two lifestyle targets (exercise level and carbohydrate distribution) at the 6- and 12-month follow-ups, based on greater or lesser patient exposure to the implementation of various aspects of the program under study., Results: The results focus on 1185 patients for whom we had data at the 6-month follow- up and the 992 patients from the 12-month follow-up. The difference in differences analysis shows no clear association between the extent of implementation of the various aspects of the program under study and patient health outcomes., Conclusion: The program produces effects on selected health indicators independent of variations in program implementation among the CSSSs taking part in the study. The results suggest that the effects of this type of program are more highly dependent on the delivery of interventions to patients than on the organizational aspects of its implementation., Competing Interests: The authors have no conflicts of interest to declare.

Purpose: Nurses are identified as a key provider in the management of patients in primary care. The objective of this study was to evaluate patients' experience of care in primary care as it pertained to the nursing role. The aim was to test the hypothesis that, in primary health care organizations (PHCOs) where patients are systematically followed by a nurse, and where nursing competencies are therefore optimally used, patients' experience of care is better., Method: Based on a cross-sectional analysis combining organizational and experience of care surveys, we built 2 groups of PHCOs. The first group of PHCOs reported having a nurse who systematically followed patients. The second group had a nurse who performed a variety of activities but did not systematically follow patients. Five indicators of care were constructed based on patient questionnaires. Bivariate and multivariate linear mixed models with random intercepts and with patients nested within were used to analyze the experience of care indicators in both groups., Results: Bivariate analyses revealed a better patient experience of care in PHCOs where a nurse systematically followed patients than in those where a nurse performed other activities. In multivariate analyses that included adjustment variables related to PHCOs and patients, the accessibility indicator was found to be higher., Conclusion: Results indicated that systematic follow-up of patients by nurses improved patients' experience of care in terms of accessibility. Using nurses' scope of practice to its full potential is a promising avenue for enhancing both patients' experience of care and health services efficiency.

Objective: To assess the degree of collaboration in primary health care organizations between FPs and other health care professionals; and to identify organizational factors associated with such collaboration., Design: Cross-sectional survey., Setting: Primary health care organizations in the Montreal and Monteregie regions of Quebec., Participants: Physicians or administrative managers from 376 organizations., Main Outcome Measures: Degree of collaboration between FPs and other specialists and between FPs and nonphysician health professionals., Results: Almost half (47.1%) of organizations reported a high degree of collaboration between FPs and other specialists, but a high degree of collaboration was considerably less common between FPs and nonphysician professionals (16.5%). Clinic collaboration with a hospital and having more patients with at least 1 chronic disease were associated with higher FP collaboration with other specialists. The proportion of patients with at least 1 chronic disease was the only factor associated with collaboration between FPs and nonphysician professionals., Conclusion: There is room for improvement regarding interprofessional collaboration in primary health care, especially between FPs and nonphysician professionals. Organizations that manage patients with more chronic diseases collaborate more with both non-FP specialists and nonphysician professionals., (Copyright© the College of Family Physicians of Canada.)

Background: Cancer is the leading cause of death in Canada. Early cancer diagnosis could improve patients' prognosis and quality of life. This study aimed to analyze the factors influencing elapsed time between the first help-seeking trigger and cancer diagnosis with respect to the three most common and deadliest cancer types: lung, breast, and colorectal., Methods: This paper presents the qualitative component of a larger project based on a sequential explanatory design. Twenty-two patients diagnosed were interviewed, between 2011 to 2013, in oncology clinics of four hospitals in the two most populous regions in Quebec (Canada). Transcripts were analyzed using the Model of Pathways to Treatment., Results: Pre-diagnosis elapsed time and phases are difficult to appraise precisely and vary according to cancer sites and symptoms specificity. This observation makes the Model of Pathways to Treatment challenging to use to analyze patients' experiences. Analyses identified factors contributing to elapsed time that are linked to type of cancer, to patients, and to health system organization., Conclusions: This research allowed us to identify avenues for reducing the intervals between first symptoms and cancer diagnosis. The existence of inequities in access to diagnostic services, even in a universal healthcare system, was highlighted.

Introduction: Chronic disease management requires substantial services integration. A cardiometabolic risk management program inspired by the Chronic Care Model was implemented in Montréal for patients with diabetes or hypertension. One of this study's objectives was to assess the impact of care coordination between the interdisciplinary teams and physicians on patient participation in the program, lifestyle improvements and disease control., Methods: We obtained data on health outcomes from a register of clinical data, questionnaires completed by patients upon entry into the program and at the 12-month mark, and we drew information on the program's characteristics from the implementation analysis. We conducted multiple regression analyses, controlling for patient sociodemographic and health characteristics, to measure the association between interdisciplinary team coordination with primary care physicians and various health outcomes., Results: A total of 1689 patients took part in the study (60.1% participation rate). Approximately 40% of patients withdrew from the program during the first year. At the 12-month follow-up (n = 992), we observed a significant increase in the proportion of patients achieving the various clinical targets. The perception by the interdisciplinary team of greater care coordination with primary care physicians was associated with increased participation in the program and the achievement of better clinical results., Conclusion: Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.

Physicians' gender can have an impact on many aspects of patient experience of care. Organization processes through which the influence of gender is exerted have not been fully explored. The aim of this article is to compare primary health care (PHC) organizations in which female or male doctors are predominant regarding organization and patient characteristics, and to assess their influence on experience of care, preventive care delivery, use of services, and unmet needs. In 2010, we conducted surveys of a population stratified sample (N = 9180) and of all PHC organizations (N = 606) in 2 regions of the province of Québec, Canada. Patient and organization variables were entered sequentially into multilevel regression analyses to measure the impact of gender predominance. Female-predominant organizations had younger doctors and nurses with more expanded role; they collaborated more with other PHC practices, used more tools for prevention, and allotted more time to patient visits. However, doctors spent fewer hours a week at the practice in female-predominant organizations. Patients of these organizations reported lower accessibility. Conversely, they reported better comprehensiveness, responsiveness, counseling, and screening, but these effects were mainly attributable to doctors' younger age. Their reporting unmet needs and emergency department attendance tended to decrease when controlling for patient and organization variables other than doctors' age. Except for accessibility, female-predominant PHC organizations are comparable with their male counterparts. Mean age of doctors was an important confounding variable that mitigated differences, whereas other organization variables enhanced them. These findings deserve consideration to better understand and assess the impacts of the growing number of female-predominant PHC organizations on the health care system.

Background: End-of-life policies are hotly debated in many countries, with international evidence frequently used to support or oppose legal reforms. Existing reviews are limited by their focus on specific practices or selected jurisdictions. The objective is to review international time trends in end-of-life practices., Methods: We conducted a systematic review of empirical studies on medical end-of-life practices, including treatment withdrawal, the use of drugs for symptom management, and the intentional use of lethal drugs. A search strategy was conducted in MEDLINE, EMBASE, Web of Science, Sociological Abstracts, PAIS International, Worldwide Political Science Abstracts, International Bibliography of the Social Sciences and CINAHL. We included studies that described physicians' actual practices and estimated annual frequency at the jurisdictional level. End-of-life practice frequencies were analyzed for variations over time, using logit regression., Results: Among 8183 references, 39 jurisdiction-wide surveys conducted between 1990 and 2010 were identified. Of those, 22 surveys used sufficiently similar research methods to allow further statistical analysis. Significant differences were found across surveys in the frequency of treatment withdrawal, use of opiates or sedatives and the intentional use of lethal drugs (X 2  > 1000, p < 0.001 for all). Regression analyses showed increased use of opiates and sedatives over time (p < 0.001), which could reflect more intense symptom management at the end of life, or increase in these drugs to intentionally cause patients' death., Conclusion: The use of opiates and sedatives appears to have significantly increased over time between 1990 and 2010. Better distinction between practices with different legal status is required to properly interpret the policy significance of these changes. Research on the effects of public policies should take a comprehensive look at trends in end-of-life practice patterns and their associations with policy changes.

Size of primary health care (PHC) practices is often used as a proxy for various organizational characteristics related to provision of care. The objective of this article is to identify some of these organizational characteristics and to determine the extent to which they mediate the relationship between size of PHC practice and patients' experience of care, preventive services, and unmet needs. In 2010, we conducted population and organization surveys in 2 regions of the province of Quebec. We carried out multilevel linear and logistic regression analyses, adjusting for respondents' individual characteristics. Size of PHC practice was associated with organizational characteristics and resources, patients' experience of care, unmet needs, and preventive services. Overall, the larger the size of a practice, the higher the accessibility, but the lower the continuity. However, these associations faded away when organizational variables were introduced in the analysis model. This result supports the hypothesized mediating effect of organizational characteristics on relationships between practice size and patients' experience of care, preventive services, and unmet needs. Our results indicate that size does not add much information to organizational characteristics. Using size as a proxy for organizational characteristics can even be misleading because its relationships with different outcomes are highly variable., (© The Author(s) 2016.)

Objectives. To assess the extent to which new primary healthcare (PHC) models implemented in two regions of Quebec have improved patient experience of care, unmet needs, and use of services for individuals with and without chronic diseases, compared with other forms of PHC practices. Methods. In 2005 and 2010, we carried out population and organization surveys. We divided PHC organizations into new model practices and other practices and followed the evolution over time of patient experience of care. Results. Patients with chronic diseases had better accessibility but worse continuity of care in the new model practices than in the other practices at both time periods. Through the reform, accessibility decreased evenly in both groups, but continuity and perceived outcomes improved more in the other practices. Use of primary care services decreased more in the new model practices. Among patients without chronic disease, accessibility decreased much less in the new models and responsiveness increased more. There was no significant change in ER attendance and hospitalization. Conclusion. The evolution of patient experience of care has been more favorable for patients without chronic diseases. These findings raise concerns about equity since the aim of the PHC reform was targeting in priority individuals with the greatest needs.

Introduction. Healthcare reforms launched in the early 2000s in Québec, Canada, involved the implementation of new forms of primary healthcare (PHC) organizations: Family Medicine Groups (FMGs) and Network Clinics (NCs). The objective of this paper is to assess how the organizational changes associated with these reforms have impact on patients' experience of care, use of services, and unmet needs. Methods. We conducted population and organization surveys in 2005 and 2010 in two regions of the province of Québec. The design was a before-and-after natural experiment. Changes over time between new models and other practices were assessed using difference-in-differences statistical procedures. Results. Accessibility decreased between 2003 and 2010, but less so in the treatment than in the comparison group. Continuity of care generally improved, but the increase was less for patients in the treatment group. Responsiveness also increased during the period and more so in the treatment group. There was no other significant difference between the two groups. Conclusion. PHC reform in Québec has brought about major organizational changes that have translated into slight improvements in accessibility of care and responsiveness. However, the reform does not seem to have had an impact on continuity, comprehensiveness, perceived care outcomes, use of services, and unmet needs.

Introduction: In 2003, the Quebec government made important changes in its primary healthcare (PHC) system. This reform included the creation of new models of PHC, Family Medicine Groups (e.g. multidisciplinary health teams with extended opening hours and enrolment of patients) and Network Clinics (clinics providing access to investigation and specialist services). Considering that equity is one of the guiding principles of the Quebec health system, our objectives are to assess the impact of the PHC reform on equity by examining the association between socio-economic status (SES) and utilization of healthcare services between 2003 and 2010; and to determine how the organizational model of PHC facilities impacts utilization of services according to SES., Methods: We held population surveys in 2005 (n = 9206) and 2010 (n = 9180) in the two most populated regions of Quebec province, relating to utilization and experience of care during the preceding two years, as well as organizational surveys of all PHC facilities. We performed multiple logistical regression analyses comparing levels of SES for different utilization variables, controlling for morbidity and perceived health; we repeated the analyses, this time including type of PHC facility (older vs newer models)., Results: Compared with the lowest SES, highest SES is associated with less emergency room visits (OR 0.80) and higher likelihood of at least one visit to a PHC facility (OR 2.17), but lower likelihood of frequent visits to PHC (OR 0.69), and higher affiliation to a family doctor (OR 2.04). Differences remained stable between the 2005 and 2010 samples except for likelihood of visit to PHC source which deteriorated for the lowest SES. Greater improvement in affiliation to family doctor was seen for the lowest SES in older models of PHC organizations, but a deterioration was seen for that same group in newer models., Conclusions: Differences favoring the rich in affiliation to family doctor and likelihood of visit to PHC facility likely represent inequities in access to PHC which remained stable or deteriorated after the reform. New models of PHC organizations do not appear to have improved equity. We believe that an equity-focused approach is needed in order to address persisting inequities.

Background: School screening programs for adolescent idiopathic scoliosis (AIS) have been discontinued in Canada and elsewhere because they were not considered cost-effective. In communities lacking such programs, we expect a significant variety of healthcare pathways and timeframes for patient referrals to orthopaedics. The objectives of this study were: 1) to characterise the healthcare pathways of young children with suspected AIS in a population without school screening; and 2) to investigate the relationships between these healthcare pathways and the appropriateness of referrals to specialised orthopaedic clinics., Methods: This study concerned all children, ages 10 to 18, referred for an initial visit for suspected AIS to any of the five out-patient paediatric orthopaedic clinics of south-western Quebec (Canada). For the 831 participants, referrals to orthopaedics were characterised as appropriate, late, or inappropriate, based on known risk factors for AIS progression and on treatment indications. Parents documented the circumstances of healthcare use prior to the orthopaedic consultation. Relevant predisposing, enabling, and need variables derived from Andersen's Behavioral Model of Health Services Use were also documented. Healthcare pathways were characterised by developing a taxonomy using multiple correspondence analysis prior to hierarchical classification. Associations between the healthcare pathways and appropriateness of referral were assessed using multinomial regression analyses., Results: We constructed a taxonomy of five distinct healthcare pathways: 1) Lay/regular source of care interrelation, 2) Other professionals, 3) Lay/consultation discontinuity, 4) Other medical doctor, and 5) Regular source of care continuity. Laypersons played an important role in AIS suspicion (53% of cases), but did not prevent late referrals. Continuity of care, as opposed to numerous uncoordinated consultations, was an effective strategy to prevent late referrals (OR = 0.32 [0.17-0.59]), but was related to increased probability of inappropriate referrals., Conclusions: We identified two cardinal characteristics that distinguished the healthcare pathways and related significantly to appropriateness of referral status, namely the role of laypersons and the involvement of the regular source of care. This suggests directions for intervention such as advocating for access to a regular source of care, increasing awareness of the disease to medical practitioners' and improving their knowledge of AIS detection and referral criteria.

Introduction: Since 2000, primary care (PC) reforms have been implemented in various Canadian provinces. Emerging organizational models and policies are at various levels of implementation across jurisdictions. Few cross-provincial analyses of these reforms have been realized. The aim of this study is to identify the factors that have facilitated or hindered implementation of reforms in Canadian provinces between 2000 and 2010., Methods: A literature and policy scan identified evaluation studies across Canadian jurisdictions. Experts from British Columbia, Manitoba, Nova Scotia, Ontario and Quebec were asked to review the scope of published evaluations and draft provincial case descriptions. A one-day deliberative forum was held, bringing together researchers (n = 40) and decision-makers (n = 20) from all the participating provinces., Results: Despite a relative lack of published evaluations, our results suggest that PC reform has varied with regard to the scope and the policy levers used to implement change. Some provinces implemented specific PC models, while other provinces designed overarching policies aiming at changing professional behaviour and practice. The main perceived barriers to reform were the lack of financial investment, resistance from professional associations, too overtly prescriptive approaches lacking adaptability and an overly centralized governance model. The main perceived facilitators were a strong financial commitment using various allocation and payment approaches, the cooperation of professional associations and an incremental emergent change philosophy based on a strong decentralization of decisions allowing adaptation to local circumstances. So far the most beneficial results of the reforms seem to be an increase in patients' affiliation with a usual source of care, improved experience of care by patients and a higher workforce satisfaction., Conclusion: PC reforms currently under consideration in other jurisdictions could learn from the factors identified as promoting or hindering change in the provinces that have been most proactive., (Copyright © 2015 Longwoods Publishing.)

Objectives: End-of-life policy reforms are being debated in many countries. Research evidence is used to support different assumptions about the effects of public policies on end-of-life practices. It is however unclear whether reliable international practice comparisons can be conducted between different policy contexts. Our aim was to assess the feasibility of comparing similar end-of-life practices in different policy contexts., Methods: This is a scoping review of empirical studies on medical end-of-life practices. We developed a descriptive classification of end-of-life practices that distinguishes practices according to their legal status. We focused on the intentional use of lethal drugs by physicians because of international variations in the legal status of this practice. Bibliographic database searches were supplemented by expert consultation and hand searching of reference lists. The sensitivity of the search strategy was tested using a set of 77 articles meeting our inclusion criteria. Two researchers extracted end-of-life practice definitions, study methods and available comparisons across policy contexts. Canadian decision-makers were involved to increase the policy relevance of the review., Results: In sum, 329 empirical studies on the intentional use of lethal drugs by doctors were identified, including studies from 19 countries. The bibliographic search captured 98.7% of studies initially identified as meeting the inclusion criteria. Studies on the intentional use of lethal drugs were conducted in jurisdictions with permissive (62%) and restrictive policies (43%). The most common study objectives related to the frequency of end-of-life practices, determinants of practices, and doctors' adherence to regulatory standards. Large variations in definitions and research methods were noted across studies. The use of a descriptive classification was useful to translate end-of-life practice definitions across countries. A few studies compared end-of-life practice in countries with different policies, using consistent research methods. We identified no comprehensive review of end-of-life practices across different policy contexts., Conclusions: It is feasible to compare end-of-life practices in different policy contexts. A systematic review of international evidence is needed to inform public deliberations on end-of-life policies and practice., (© The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.)