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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.)

Unlabelled: Management continuity, operationally defined as "the extent to which services delivered by different providers are timely and complementary such that care is experienced as connected and coherent," is a core attribute of primary healthcare. Continuity, as experienced by the patient, is the result of good care coordination or integration., Objective: To provide insight into how well management continuity is measured in validated coordination or integration subscales of primary healthcare instruments., Method: Relevant subscales from the Primary Care Assessment Survey (PCAS), the Primary Care Assessment Tool - Short Form (PCAT-S), the Components of Primary Care Instrument (CPCI) and the Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS) were administered to 432 adult respondents who had at least one healthcare contact with a provider other than their family physician in the previous 12 months. Subscales were examined descriptively, by correlation and factor analysis and item response theory analysis. Because the VANOCSS elicits coordination problems and is scored dichotomously, we used logistic regression to examine how evaluative subscales relate to reported problems., Results: Most responses to the PCAS, PCAT-S and CPCI subscales were positive, yet 83% of respondents reported having one or more problems on the VANOCSS Overall Coordination subscale and 41% on the VANOCSS Specialist Access subscale. Exploratory factor analysis suggests two distinct factors. The first (eigenvalue=6.98) is coordination actions by the primary care physician in transitioning patient care to other providers (PCAS Integration subscale and most of the PCAT-S Coordination subscale). The second (eigenvalue=1.20) is efforts by the primary care physician to create coherence between different visits both within and outside the regular doctor's office (CPCI Coordination subscale). The PCAS Integration subscale was most strongly associated with lower likelihood of problems reported on the VANOCSS subscales., Conclusion: Ratings of management continuity correspond only modestly to reporting of coordination problems, possibly because they rate only the primary care physician, whereas patients experience problems across the entire system. The subscales were developed as measures of integration and provider coordination and do not capture the patient's experience of connectedness and coherence.

This paper presents an overview of the analytic approaches that we used to assess the performance and structure of measures that evaluate primary healthcare; six instruments were administered concurrently to the same set of patients. The purpose is (a) to provide clinicians, researchers and policy makers with an overview of the psychometric methods used in this series of papers to assess instrument performance and (b) to articulate briefly the rationale, the criteria used and the ways in which results can be interpreted. For illustration, we use the case of instrument subscales evaluating accessibility. We discuss (1) distribution of items, including treatment of missing values, (2) exploratory and confirmatory factor analysis to identify how items from different subscales relate to a single underlying construct or sub-dimension and (3) item response theory analysis to examine whether items can discriminate differences between individuals with high and low scores, and whether the response options work well. Any conclusion about the relative performance of instruments or items will depend on the type of analytic technique used. Our study design and analytic methods allow us to compare instrument subscales, discern common constructs and identify potentially problematic items.

Unlabelled: Respectfulness is one measurable and core element of healthcare responsiveness. The operational definition of respectfulness is "the extent to which health professionals and support staff meet users' expectations about interpersonal treatment, demonstrate respect for the dignity of patients and provide adequate privacy.", Objective: To examine how well respectfulness is captured in validated instruments that evaluate primary healthcare from the patient's perspective, whether or not their developers had envisaged these as representing respectfulness., Method: 645 adults with at least one healthcare contact with their own regular doctor or clinic in the previous 12 months responded to six instruments, two subscales that mapped to respectfulness: the Interpersonal Processes of Care, version II (IPC-II, two subscales) and the Primary Care Assessment Survey (PCAS). Additionally, there were individual respectfulness items in subscales measuring other attributes in the Components of Primary Care Index (CPCI) and the first version of the EUROPEP (EUROPEP-I). Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analyses examined fit to operational definition., Results: Respectfulness scales correlate highly with one another and with interpersonal communication. All items load adequately on a single factor, presumed to be respectfulness, but the best model has three underlying factors corresponding to (1) physician's interpersonal treatment (eigenvalue=13.99), (2) interpersonal treatment by office staff (eigenvalue=2.13) and (3) respect for the dignity of the person (eigenvalue=1.16). Most items capture physician's interpersonal treatment (IPC-II Compassionate, Respectful Interpersonal Style, IPC-II Hurried Communication and PCAS Interpersonal Treatment). The IPC-II Interpersonal Style (Disrespectful Office Staff) captures treatment by staff, but only three items capture dignity., Conclusion: Various items or subscales seem to measure respectfulness among currently available validated instruments. However, many of these items related to other constructs, such as interpersonal communication. Further studies should aim at developing more refined measures - especially for privacy and dignity - and assess the relevance of the broader concept of responsiveness.

Unlabelled: Comprehensiveness relates both to scope of services offered and to a whole-person clinical approach. Comprehensive services are defined as "the provision, either directly or indirectly, of a full range of services to meet most patients' healthcare needs"; whole-person care is "the extent to which a provider elicits and considers the physical, emotional and social aspects of a patient's health and considers the community context in their care." Among instruments that evaluate primary healthcare, two had subscales that mapped to comprehensive services and to the community component of whole-person care: the Primary Care Assessment Tool - Short Form (PCAT-S) and the Components of Primary Care Index (CPCI, a limited measure of whole-person care)., Objective: To examine how well comprehensiveness is captured in validated instruments that evaluate primary healthcare from the patient's perspective., Method: 645 adults with at least one healthcare contact in the previous 12 months responded to six instruments that evaluate primary healthcare. Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analysis examined fit to operational definition, and item response theory analysis examined item performance on common constructs., Results: Over one-quarter of respondents had missing responses on services offered or doctor's knowledge of the community. The subscales did not load on a single factor; comprehensive services and community orientation were examined separately. The community orientation subscales did not perform satisfactorily. The three comprehensive services subscales fit very modestly onto two factors: (1) most healthcare needs (from one provider) (CPCI Comprehensive Care, PCAT-S First-Contact Utilization) and (2) range of services (PCAT-S Comprehensive Services Available). Individual item performance revealed several problems., Conclusion: Measurement of comprehensiveness is problematic, making this attribute a priority for measure development. Range of services offered is best obtained from providers. Whole-person care is not addressed as a separate construct, but some dimensions are covered by attributes such as interpersonal communication and relational continuity.

Unlabelled: Patient evaluations are an important part of monitoring primary healthcare reforms, but there is little comparative information available to guide evaluators in the choice of instruments or to determine their relevance for Canada., Objective: To compare values and the psychometric performances of validated instruments thought to be most pertinent to the Canadian context for evaluating core attributes of primary healthcare., Method: AMONG VALIDATED INSTRUMENTS IN THE PUBLIC DOMAIN, WE SELECTED SIX: the Primary Care Assessment Survey (PCAS); the Primary Care Assessment Tool - Short Form (PCAT-S); the Components of Primary Care Index (CPCI); the first version of the EUROPEP (EUROPEP-I); the Interpersonal Processes of Care Survey, version II (IPC-II); and part of the Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS). We mapped subscales to operational definitions of attributes. All were administered to a sample of adult service users balanced by English/French language (in Nova Scotia and Quebec, respectively), urban/rural residency, high/low education and overall care experience. The sample was recruited from previous survey respondents, newspaper advertisements and community posters. We used common factor analysis to compare our factor resolution for each instrument to that of the developers., Results: Our sample of 645 respondents was approximately balanced by design variables, but considerable effort was required to recruit low-education and poor-experience respondents. Subscale scores are statistically different by excellent, average and poor overall experience, but interpersonal communication and respectfulness scores were the most discriminating of overall experience. We found fewer factors than did the developers, but when constrained to the number of expected factors, our item loadings were largely similar to those found by developers. Subscale reliability was equivalent to or higher than that reported by developers., Conclusion: These instruments perform similarly in the Canadian context to their original development context, and can be used with confidence. Interpersonal and respectfulness scores are most discriminating of excellent, average or poor overall experience and are crucial dimensions of patient evaluations.

Purpose: The aim of this study was to rate the importance of primary healthcare (PHC) attributes in evaluations of PHC organizational models in Canada., Methods: Using the Delphi process, we conducted a consensus consultation with 20 persons recognized by peers as Canadian PHC experts, who rated the importance of PHC attributes within professional and community-oriented models of PHC., Results: ATTRIBUTES RATED AS ESSENTIAL TO ALL MODELS WERE DESIGNATED CORE ATTRIBUTES: first-contact accessibility, comprehensiveness of services, relational continuity, coordination (management) continuity, interpersonal communication, technical quality of clinical care and clinical information management. Overall, while all were important, non-core attributes - except efficiency/productivity - were rated as more important in community-oriented than in professional models. Attributes rated as essential for community-oriented models were equity, client/community participation, population orientation, cultural sensitivity and multidisciplinary teams., Conclusion: Evaluation tools should address core attributes and be customized in accordance with the specific organizational models being evaluated to guide health reforms.

Unlabelled: The operational definition of first-contact accessibility is "the ease with which a person can obtain needed care (including advice and support) from the practitioner of choice within a time frame appropriate to the urgency of the problem"; accommodation is "the way healthcare resources are organized to accommodate a wide range of patients' abilities to contact healthcare providers and reach healthcare services, that is to say telephone services, flexible appointment systems, hours of operation, and walk-in periods.", Objective: To compare how well accessibility is measured in validated subscales that evaluate primary healthcare from the patient's perspective., Method: 645 adults with at least one healthcare contact in the previous 12 months responded to six instruments that evaluate primary healthcare with four subscales that measure accessibility: the Primary Care Assessment Survey (PCAS), the Primary Care Assessment Tool - Short Form (PCAT-S, two subscales) and the first version of the EUROPEP (EUROPEP-I). Scores were normalized to a 0-to-10 scale for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analysis examined fit to operational definition, and item response theory analysis examined item performance on common constructs., Results: The subscales demonstrate similar psychometric measures to those reported by developers. The PCAT-S First-Contact Utilization subscale does not fit the accessibility construct. The remaining three subscales load reasonably onto a single factor, presumed to be accessibility, but the best-fitting model has two factors: "timeliness of obtaining needed care" (PCAT-S First-Contact Access, some EUROPEP-I items) and "how resources are organized to accommodate clients" (PCAS Organizational Access and most of EUROPEP-I organization of care). Items in the PCAS and PCAT-S subscales have good discriminability., Conclusion: Only three of the four subscales measure accessibility; all are appropriate for use in Canada. The PCAT-S First-Contact Access subscale is the best measure for first-contact accessibility, and PCAS Organizational Accessibility has good metric properties and measures for accommodation.

Unlabelled: The operational definition of relational continuity is "a therapeutic relationship between a patient and one or more providers that spans various healthcare events and results in accumulated knowledge of the patient and care consistent with the patient's needs.", Objective: To examine how well relational continuity is measured in validated instruments that evaluate primary healthcare from the patient's perspective., Method: 645 adults with at least one healthcare contact in the previous 12 months responded to six instruments that evaluate primary healthcare. Five subscales map to relational continuity: the Primary Care Assessment Survey (PCAS, two subscales), the Primary Care Assessment Tool - Short Form (PCAT-S) and the Components of Primary Care Index (CPCI, two subscales). Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analysis examined fit to operational definition, and item response theory analysis examined item performance on common constructs., Results: All subscales load reasonably well on a single factor, presumed to be relational continuity, but the best model has two underlying factors corresponding to (1) accumulated knowledge of the patient and (2) relationship that spans healthcare events. Some items were problematic even in the best model. The PCAS Contextual Knowledge subscale discriminates best between different levels of accumulated knowledge, but this dimension is also captured well by the CPCI Accumulated Knowledge subscale and most items in the PCAT-S Ongoing Care subscale. For relationship-spanning events, the items' content captures concentration of care in one doctor; this is captured best by the CPCI Preference for Regular Provider subscale and, to a lesser extent, by the PCAS Visit-Based Continuity subscale and one relevant item in the PCAT-S Ongoing Care subscale. But this dimension correlates only modestly with percentage of reported visits to the personal doctor. The items function as yes/no rather than ordinal options, and are especially informative for poor concentration of care., Conclusion: These subscales perform well for key elements of relational continuity, but do not capture consistency of care. They are more informative for poor relational continuity.

Unlabelled: The operational definition of interpersonal communication is "the ability of the provider to elicit and understand patient concerns, to explain healthcare issues and to engage in shared decision-making if desired.", Objective: To examine how well interpersonal communication is captured in validated instruments that evaluate primary healthcare from the patient's perspective., Method: 645 adults with at least one healthcare contact in the previous 12 months responded to instruments that evaluate primary healthcare. Eight subscales measure interpersonal communication: the Primary Care Assessment Survey (PCAS, two subscales); the Components of Primary Care Index (CPCI, one subscale); the first version of the EUROPEP (EUROPEP-I); and the Interpersonal Processes of Care Survey, version II (IPC-II, four subscales). Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation) factor analysis examined fit to operational definition, and item response theory analysis examined item performance., Results: Items not pertaining to interpersonal communication were removed from the EUROPEP-I. Most subscales are skewed positively. Normalized mean scores are similar across subscales except for IPC-II Patient-Centred Decision-Making and IPC-II Hurried Communication. All subscales load reasonably well on a single factor, presumed to be interpersonal communication. The best model has three underlying factors corresponding to eliciting (eigenvalue = 26.56), explaining (eigenvalue = 2.45) and decision-making (eigenvalue = 1.34). Both the PCAS Communication and the EUROPEP-I Clinical Behaviour subscales capture all three dimensions. Individual subscales within IPC-II measure each sub-dimension., Conclusion: The operational definition is well reflected in the available measures, although shared decision-making is poorly represented. These subscales can be used with confidence in the Canadian context to measure this crucial aspect of patient-centred care.

Canadian politicians, decision-makers, clinicians and researchers have come to agree that reforming primary care services is a key strategy for improving healthcare system performance. However, it is only more recently that real transformative initiatives have been undertaken in different Canadian provinces. One model that offers promise for improving primary care service delivery is the family medicine group (FMG) model developed in Quebec. A FMG is a group of physicians working closely with nurses in the provision of services to enrolled patients on a non-geographic basis. The objectives of this paper are to analyze the FMG's potential as a lever for improving healthcare system performance and to discuss how it could be improved. First, we briefly review the history of primary care in Quebec. Then we present the FMG model in relation to the four key healthcare system functions identified by the World Health Organization: (a) funding, (b) generating human and technological resources, (c) providing services to individuals and communities and (d) governance. Next, we discuss possible ways of advancing primary care reform, looking particularly at the family health team (FHT) model implemented in the province of Ontario. We conclude with recommendations to inspire other initiatives aimed at transforming primary care.

Health services utilization has been the object of many books and papers in the literature. Measures associated with utilization are often a function of volume of services. The objective of this paper is to present a comprehensive approach to the evaluation of health services utilization and of associated measures, using databases. Based on the theoretical framework of Starfield (1998), we analyze health services utilization with the help of indicators that are not directly linked to volume but that indirectly provide an estimate, while also documenting the qualitative aspects of utilization. The indicators mark accessibility, continuity, comprehensiveness and productivity of care. Once the concepts have been defined, we propose their operationalization using the databases. We then present the advantages of multidimensional conceptualization of health services utilization through a simultaneous analysis of these indicators. Researchers and decision-makers in public health and health planning have much to gain from this innovative multidimensional approach, which presents a dynamic conceptualization of health services utilization based on health administrative data.This paper was originally published in French, in the journal Pratiques et Organisation des Soins 2011 42(1): 11-18.

Two main avenues are advocated to improve the capability of healthcare systems to satisfy the public's needs and expectations: more resources and better organization. This paper sheds some light on this debate. It assesses the extent to which patients' positive rating of their healthcare experience and the extent to which they use services are related to the availability of healthcare resources. Findings indicate that patients' evaluations of their care experience and use of services were higher when the availability of resources was either limited or average. In no case were positive ratings of services and greater use of them associated with greater resource availability. Thus, simply adding resources runs the risk of diminishing, rather than improving, users' healthcare experience.

Objective: To measure the association between primary healthcare (PHC) organizational types and patient coverage for clinical preventive services (CPS)., Method: Study conducted in Quebec (2005), including a population-based survey of patients' experience of care (N=4,417) and a survey of PHC clinics., Outcome Measures: Patient-reported CPS delivery rates and CPS coverage scores. Multiple logistic regressions used to assess factors associated with higher probability of receiving CPS., Results: CPS delivery rates were higher among patients with a regular source of PHC. Higher CPS score was associated with having a public (OR 1.79; 95% CI 1.35-2.37) or mixed (OR 1.22; 95% CI 1.01-1.48) type of organization as source of PHC compared to a private one, and having had a high number of visits to the regular source of PHC in the past two years (≤6: OR 1.83; 95% CI 1.41-2.38) compared to a single visit., Conclusion: Public and mixed PHC organizations seem to perform better. CPS delivery is strongly associated with having a regular source of care.

Emergency room utilization in Canada is considerably higher than in other industrialized countries. Despite significant investments, recurrent emergency room crises persist. Focusing particularly on the situation in Quebec, this paper examines the evolution of Canada's and Quebec's healthcare systems over the past 40 years and identifies the key developments that resulted in today's problems and the challenges that must be addressed. In this historical overview, we argue that emergency room problems arise from past decisions that gave hospitals a predominant role in the healthcare system and partly modified their original mission, as well as from counterproductive funding modalities. Other decisions have also weakened primary care services, which are strongly focused on acute health problems and are poorly coordinated with the rest of the system. Symptomatic remedies have only eased the pressure on emergency rooms, but the real solution is more complex and must address the historical residues that are paralyzing our healthcare system.

This study explored whether organizational characteristics of primary care services provided by area of residence in two Quebec regions are related to outcomes of an emergency department (ED) visit among seniors discharged home. Provincial administrative databases on a sample of seniors who made an ED visit and their 30-day outcomes were linked by area of residence to data from a survey of key informants from primary care clinics. Measures of organizational characteristics included three scales derived from principal components analysis and one theoretically derived global score that measured the degree of conformity to characteristics of ideal emerging primary care models. In multivariate analyses, adjusting for patient characteristics, patients living in areas in the lowest quartile for the global score had higher rates of return ED visits without hospitalization. Emerging primary care organizational models along the lines currently being pursued in Quebec may help to reduce the growing burden of ED care of seniors.

The quest for greater efficiency in health systems encourages governments to bring together two fields of practice that have largely developed in parallel in industrialized countries: public health and healthcare. Current healthcare reform in the province of Quebec formally integrates these two fields within a common governance structure. The objective of this paper is to discuss the issues arising from the integration of public health services into the planning and delivery of local healthcare services, and its potential effect on the overall performance of the healthcare system. The authors begin by describing the characteristics of these two sectors; then, they discuss current reforms in Quebec and the impact of various transitions (epidemiological, technological and organizational) that bring the sectors into greater convergence. The paper concludes with a discussion of obstacles and potential opportunities at two levels: (a) the development of population-based planning of services within healthcare organizations, and (b) the articulation of public health and healthcare services concerns at the local level. The ongoing reform in Quebec is a unique opportunity to maximize outcomes from the resources invested in the healthcare system, based on a collective vision for improving health. This paper was originally published in French, in the journal Pratiques et organisation des soins 39(2): 113-24., (Copyright © 2009 Longwoods Publishing.)

Objective: A 2002 survey of primary healthcare sites found that 51% of rural and 33% of urban primary care patients reported using the hospital emergency room (ER) in the last 12 months. We did a secondary analysis to identify urban-rural differences in accessibility-related organizational features that predicted ER use., Methods: We collected information on clinic organization and physicians' practice profiles from 100 primary healthcare sites across Quebec and 2,725 of their regular patients, who reported on ER use. We used hierarchical logistic regression to identify organizational features that predict the probability of ER use by patients., Results: Patient confidence in rapid access at their clinic decreases ER use (OR=0.73). Rural sites offer fewer walk-in services or on-site medical procedures and less proximity to laboratory and diagnostic services, but paradoxically, rural patients are more confident that their own physician will see them for a sudden illness. Patients from clinics offering a larger range of medical procedures on site have lower ER use (OR=0.92 per procedure). Rural physicians tend to divide their time between hospital and primary care; doing in-patient care increases ER use (OR=1.64)., Discussion: Decreased ER use is found in patients of clinics organized to enhance responsiveness to acute needs, especially in rural areas. Although the high rates of ER use in rural areas partly reflect problems with the accessibility of primary care clinics, in a resource-scarce context rural hospital ERs may cover both primary care urgent problems and emergencies.

This paper reports on a research collective on primary healthcare (PHC) conducted in Quebec in 2004. Thirty ongoing or recently completed studies were synthesized through a process involving a high degree of exchange among researchers who conducted the original studies, investigators and decision-makers. The viewpoints expressed by decision-makers who participated in the process were analyzed in terms of convergence with and divergence from the researchers' viewpoints. In four cases, there was convergence between the decision-makers' and the researchers' viewpoints, thus increasing the validity of the collective's findings. The main divergence between the two groups' viewpoints concerns the strategy adopted in Quebec to create local health and social services networks. Such divergence reflects the distinction made by Klein between scientific evidence and organizational and political evidence.Our study results illustrate that decision-makers' viewpoints can play an important interpretive and complementary role in producing research syntheses. Although integrating decision-makers' viewpoints into syntheses has been regarded as a strategy for improving the use of research findings, our analysis shows that decision-makers' view-points do not necessarily have to be integrated into syntheses but can, instead, be examined for convergence with or divergence from researchers' viewpoints. This deliberative process can enrich discussions and lead to enlightened decision- and policy making.

Background: Early therapy intervention for children with disabilities may improve functional outcomes. Access to paediatric rehabilitation services can sometimes be difficult., Objectives: To describe waiting time to receive physical therapy (PT) and occupational therapy (OT) services at rehabilitation centres for young children with physical disabilities; to examine factors associated with these waiting times., Design: Prospective cohort., Subjects: Two hundred and six children with physical disabilities, aged 6 to 72 months, referred in 2002-2004 from the Montreal Children's Hospital and Sainte-Justine Hospital to paediatric rehabilitation centres., Measures: Data on date of referral, age, gender and diagnosis were obtained from the hospital databases. Data on date of first PT or OT appointments at the rehabilitation centre, family socio-demographics and disability severity (WeeFIM) were obtained during parental interviews., Results: Half of the sample waited more than 7 and 11 months for PT and OT services, respectively. Shorter waiting time was significantly associated with younger child's age and referral to one particular rehabilitation centre., Conclusion: Children with physical disabilities experience long waiting times for PT and OT rehabilitation services. Strategies to improve timely service delivery are needed.

Objectives: In this paper we focus on governance and the added value of regionalization in the context of health policy implementation. What are regional boards' patterns of action in the governance process?How do these patterns favour policy implementation? ANALYTICAL FRAMEWORK: To enhance our understanding of the role of regional boards in governance processes, we relied on four conceptual constructs that corresponded to models of collective action: political, technocratic, democratic and cognitive. Alongside the four models, we analyzed the impact of governance on health policy implementation using Mazmanian and Sabatier's general analytical framework, which identifies three types of variables that affect public policy implementation: (1) variables related to the complexity of the problem, (2) statutory variables that structure the implementation of the policy and (3) non-statutory variables related to the context., Methods: We conducted a qualitative, longitudinal case study of the regional implemention of the Program to Combat Cancer in Quebec., Findings: This research stresses the added value of a clinico-administrative governance of change, whereby regional boards, in synergy with clinical leaders, participate in the orientation of collective action. Analysis of the regional board's patterns of action reveals the utility of combined technocratic, democratic, political and cognitive actions.

This paper reports on a research collective in primary healthcare (PHC) conducted in Quebec in 2004. A lead team of investigators synthesized 30 ongoing or recently completed studies from project description forms filled out by the participating researchers. The process of the collective is examined by addressing the three main challenges met in the course of its completion, namely, (a) the need to derive an analytical framework to regroup variables in a meaningful way, (b) the assessment of strength of evidence and (c) coping with a mix of quantitative and qualitative studies. Advantages of the collective over other forms of research synthesis include timeliness, low cost relative to the total cost of the studies it comprises and the information it generates and, finally, context linkage, which enhances relevance but which could limit transferability of the findings. Overall, the research collective appears to be a promising tool for research synthesis.