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Background: Racism has been shown to impact the health of Black persons through its influence on health care, including its expression through implicit biases in provider training, attitudes, and behaviours. Less is known about the experiences of racism in contexts outside of the USA, and how race and racism interact with other social locations and systems of discrimination to shape Black patients' experiences of racism in health care encounters. To help address this gap, this study examined diverse Black individuals' perceived experiences of, and attitudes towards, anti-Black racism and racial discrimination in Canadian health care, specifically in Montreal, Quebec., Methods: This descriptive qualitative study adopted a social constructionist approach. Employing purposive maximal variation and snowball sampling strategies, eligible study participants were: self-identified Black persons aged 18 years and older who lived in Montreal during the COVID-19 pandemic, who could speak English or French, and who were registered with the Quebec medical insurance program. In-depth interviews were conducted, and a Framework Analysis approach guided the systematic exploration and interpretation of data using an intersectionality lens., Results: We interviewed 32 participants, the majority of whom were women (59%), university educated (69%), and modestly comfortable financially (41%), but diverse in terms of age (22 to 79 years), country of origin, and self-defined ethnicity. We identified five major themes demonstrating substantial variations in perceived racism in health care that are influenced by unique social locations such as gender identity, age, and immigration history: (1) no perceptions of racism in health care, (2) ambiguous perceptions of racism in health care, (3) perceptions of overt interpersonal racism in health care, (4) perceptions of covert interpersonal racism in health care (including the downplaying of health concerns, stereotyping, and racial microaggressions), and (5) perceptions of systemic racism in health care., Conclusions: Perceptions of anti-Black racism and racial discrimination in Canadian health care are complex and may include intra-racial group differences. This study begins to address the dearth of empirical research documenting experiences of anti-Black racism in health care in Quebec, highlighting a continued need for serious consideration of the ways in which racism may manifest in the province, as well as a need for anti-racist advocacy. Advancing racial health equity requires greater sensitivity from providers and decision makers to variations in Black patients' health care experiences, towards ensuring that they have access to high quality and equitable health care services., Competing Interests: Declarations Ethics approval and consent to participate Ethics approval was obtained from the Research Ethics Board of the CIUSSS de l’Ouest-de-l’Île-de-Montréal – biomedical subcommittee at the St. Mary’s Research Centre. Verbal informed consent was obtained from all study participants. Consent for publication Not applicable. Competing interests The authors declare no competing interests., (© 2024. The Author(s).)

Background: A pilot intervention in a participatory research programme in Québec, Canada, used telephone outreach by volunteer patient navigators to help unattached persons from deprived neighbourhoods attach successfully to a family doctor newly-assigned to them from a centralized waiting list. According to our theory-based program logic model we evaluated the extent to which the volunteer navigator outreach helped patients reach and engage with their newly-assigned primary care team, have a positive healthcare experience, develop an enduring doctor-patient relationship, and reduce forgone care and emergency room use., Method: For the mixed-method evaluation, indicators were developed for all domains in the logic model and measured in a telephone-administered patient survey at baseline and three months later to determine if there was a significant difference. Interviews with a subsample of 13 survey respondents explored the mechanisms and nuances of intended effects., Results: Five active volunteers provided the service to 108 persons, of whom 60 agreed to participate in the evaluation. All surveyed participants attended the first visit, where 90% attached successfully to the new doctor. Indicators of abilities to access healthcare increased statistically significantly as did ability to explain health needs to professionals. The telephone outreach predisposed patients to have a positive first visit and have trust in their new care team, establishing a basis for an enduring relationship. Patient-reported access difficulties, forgone care and use of hospital emergency rooms decreased dramatically after patients attached to their new doctors., Conclusions: As per the logic model, telephone outreach by volunteer navigators significantly increased patients' abilities to seek, reach and engage with care and helped them attach successfully to newly-assigned family doctors. This light-touch intervention may have promise to achieve of the intended policy goals for the centralized waiting list to increase population access to appropriate primary care and reduce forgone care., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: Having a regular family physician is associated with many benefits. Formal attachment - an administrative patient-family physician agreement - is a popular feature in primary care, intended to improve access to and continuity of care with a family physician. However, little evidence exists about its effectiveness. In Quebec, Canada, where over 20% of the population is unattached, centralized waiting lists help attach patients. This provides a unique opportunity to observe the influence of attachment in previously unattached patients. The aim was to evaluate changes in access to and continuity of primary care associated with attachment to a family physician through Quebec's centralized waiting lists for unattached patients., Methods: We conducted an observational longitudinal population cohort study, using medical services billing data from public health insurance in the province of Québec, Canada. We included patients attached through centralized waiting lists for unattached patients between 2012 and 2014 (n = 410,140). Our study was informed by Aday and Andersen's framework for the study of access to health services. We compared outcomes during four 12-month periods: two periods before and two periods after attachment, with T0-2 years as the reference period. Outcome measures were number of primary care visits and Bice-Boxerman Concentration of Care Index at the physician and practice level (for patients with ≥2 visits in a given period). We included age, sex, region remoteness, medical vulnerability, and Charlson Comorbidity Index as covariates in regression models fitted with generalized estimating equations., Results: The number of primary care visits increased by 103% in the first post attachment year and 29% in the second year (p < 0.001). The odds of having all primary care visits concentrated with a single physician increased by 53% in the first year and 22% (p < 0.001) in the second year after attachment. At the practice level, the odds of perfect concentration of care increased by 19% (p < 0.001) and 15% (p < 0.001) respectively, in first and second year after attachment., Conclusion: Our results show an increase in patients' number of primary care visits and concentration of care at the family physician and practice level after attachment to a family physician. This suggests that attachment may help improve access to and continuity of primary care., (© 2022. The Author(s).)

Background: The advanced access model was developed 20 years ago and has been implemented in several countries. We aimed to revise and operationalize the pillars and subpillars of the advanced access model based on its contemporary practice by professionals in primary health care., Methods: This multimethod sequential study was informed by a literature review and an expert panel of provincial and local decision-makers, primary health care clinic members (family physicians, nurses and administrative staff), patients and researchers from the province of Quebec. Throughout the consultation process, participants were asked to develop a common vision of the pillars and subpillars that make up the advanced access model and to react to suggested definitions or content., Results: The revised advanced access model is defined by 5 pillars, of which 2 were updated from the original model ("Appointment system" and "Interprofessional practice"), 1 was merged with a revised pillar ("Develop contingency plans" with "Planning of needs and supply") and 1 underwent major transformations ("Backlog reduction" to "Continuous adjustment"). A new pillar concerning communication emerged from the consultation process. Subsequent steps for operationalizing definitions of subpillars confirmed the nature of the revised advanced access pillars and stabilized their content., Interpretation: The overall consultation process resulted in a revised contemporary advanced access model, with strong consensus among participating experts. The revised model will be used to develop a reflective tool for primary health care professionals to evaluate their advanced access practice., Competing Interests: Competing interests: Isabelle Gaboury reports funding to her institution from the Ministry of Health and Social Services. No other competing interests declared., (© 2022 CMA Impact Inc. or its licensors.)

Objective: This study documents the adoption of telehealth by various types of primary healthcare (PHC) providers working in teaching PHC clinics in Quebec during the COVID-19 pandemic. It also identifies the perceived advantages and disadvantages of telehealth., Method: A cross-sectional study was conducted between May and August 2020. The e-survey was completed by 48/50 teaching primary care clinics representing 603/1,357 (44%) PHC providers., Results: Telephone use increased the most, becoming the principal virtual modality of consultation, during the pandemic. Video consultations increased, with variations by type of PHC provider: between 2% and 16% reported using it "sometimes." The main perceived advantages of telehealth were minimizing the patient's need to travel, improved efficiency and reduction in infection transmission risk. The main disadvantages were the lack of physical exam and difficulties connecting with some patients., Conclusion: The variation in telehealth adoption by type of PHC provider may inform strategies to maximize the potential of telehealth and help create guidelines for its use in more normal times., (Copyright © 2021 Longwoods Publishing.)

Aims: We describe an innovative research protocol to: (a) examine patient-level longitudinal associations between nurse staffing practices and the risk of adverse events in acute care hospitals and; (b) determine possible thresholds for safe nurse staffing., Design: A dynamic cohort of adult medical, surgical and intensive care unit patients admitted to 16 hospitals in Quebec (Canada) between January 2015-December 2019., Methods: Patients in the cohort will be followed from admission until 30-day postdischarge to assess exposure to selected nurse staffing practices in relation to the subsequent occurrence of adverse events. Five staffing practices will be measured for each shift of an hospitalization episode, using electronic payroll data, with the following time-varying indicators: (a) nursing worked hours per patient; (b) skill mix; (c) overtime use; (d) education mix and; and (e) experience. Four high-impact adverse events, presumably associated with nurse staffing practices, will be measured from electronic health record data retrieved at the participating sites: (a) failure-to-rescue; (b) in-hospital falls; (c) hospital-acquired pneumonia and; and (d) venous thromboembolism. To examine the associations between the selected nurse staffing exposures and the risk of each adverse event, separate multivariable Cox proportional hazards frailty regression models will be fitted, while adjusting for patient, nursing unit and hospital characteristics, and for clustering. To assess for possible staffing thresholds, flexible non-linear spline functions will be fitted. Funding for the study began in October 2019 and research ethics/institutional approval was granted in February 2020., Discussion: To our knowledge, this study is the first multisite patient-level longitudinal investigation of the associations between common nurse staffing practices and the risk of adverse events. It is hoped that our results will assist hospital managers in making the most effective use of the scarce nursing resources and in identifying staffing practices that minimize the occurrence of adverse events., (© 2020 John Wiley & Sons Ltd.)

Background: Timely access in primary health care is one of the key issues facing health systems. Among many interventions developed around the world, advanced access is the most highly recommended intervention designed specifically to improve timely access in primary care settings. Based on greater accessibility linked with patients' relational continuity and informational continuity with a primary care professional or team, this organizational model aims to ensure that patients obtain access to healthcare services at a time and date convenient for them when needed regardless of urgency of demand. Its implementation requires a major organizational change based on reorganizing the practices of all the administrative staff and health professionals. In recent years, advanced access has largely been implemented in primary care organizations. However, despite its wide dissemination, we observe considerable variation in the implementation of the five guiding principles of this model across organizations, as well as among professionals working within the same organization. The main objective of this study is to assess the variation in the implementation of the five guiding principles of advanced access in teaching primary healthcare clinics across Quebec and to better understand the influence of the contextual factors on this variation and on outcomes., Methods: This study will be based on an explanatory sequential design that includes 1) a quantitative survey conducted in 47 teaching primary healthcare clinics, and 2) a multiple case study using mixed data, contrasted cases (n = 4), representing various implementation profiles and geographical contexts. For each case, semi-structured interviews and focus group will be conducted with professionals and patients. Impact analyses will also be conducted in the four selected clinics using data retrieved from the electronic medical records., Discussion: This study is important in social and political context marked by accessibility issues to primary care services. This research is highly relevant in a context of massive media coverage on timely access to primary healthcare and a large-scale implementation of advanced access across Quebec. This study will likely generate useful lessons and support evidence-based practices to refine and adapt the advanced access model to ensure successful implementation in various clinical contexts facing different challenges.

Background: Polypharmacy carries the risk of adverse events, especially in people with multimorbidity., Objective: To investigate the prevalence of polypharmacy in community-dwelling adults, the association of multimorbidity with polypharmacy and the use of medications for primary prevention., Methods: Cross-sectional analysis of the follow-up data from the Program of Research on the Evolution of a Cohort Investigating Health System Effects (PRECISE) in Quebec, Canada. Multimorbidity was defined as the presence of three or more chronic diseases and polypharmacy as self-reported concurrent use of five or more medications. Primary prevention was conceptualized as the use of statin or low-dose antiplatelets without a reported diagnostic of cardiovascular disease., Results: Mean age 56.7 ± 11.6, 62.5% female, 30.3% had multimorbidity, 31.9% had polypharmacy (n = 971). The most common drugs used were statins, renin-angiotensin system inhibitors and psychotropics. Compared to participants without any chronic disease, the adjusted odds ratios (ORs) for having polypharmacy were 2.78 [95% confidence interval (CI): 1.23-6.28] in those with one chronic disease, 8.88 (95% CI: 4.06-19.20) in those with two chronic diseases and 25.31 (95% CI: 11.77-54.41) in those with three or more chronic diseases, P < 0.001. In participants without history of cardiovascular diseases, 16.2% were using antiplatelets and 28.5% were using statins. Multimorbidity was associated with increased likelihood of using antiplatelets (adjusted OR: 2.98, 95% CI: 1.98-4.48, P < 0.001) and statins (adjusted OR: 3.76, 95% CI: 2.63-5.37, P < 0.001) for primary prevention., Conclusion: There was a high prevalence of polypharmacy in community-dwelling adults in Quebec and a strong association with multimorbidity. The use of medications for primary prevention may contribute to polypharmacy and raise questions about safety., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To describe the demographic characteristics, health, and health care experiences of adult patients in primary care waiting rooms in Quebec, and to determine which pillars of the Patient's Medical Home (PMH) are a priority to align primary care practices with the PMH model., Design: Baseline survey of a prospective cohort study using self-administered on-site and mailed questionnaires., Setting: Twelve primary care clinics within the geographic boundaries of 4 local health care networks in metropolitan, urban, rural, and remote settings in Quebec., Participants: A total of 1029 adult patients aged between 25 and 75 who were selected during a 1-week period in the 12 primary care clinics; 789 returned questionnaires., Main Outcome Measures: Patients' health profiles, health behaviour patterns, reasons for the visit, and health care experiences., Results: In this 2010 snapshot, 66.8% of patients waited longer than 2 weeks for their appointment, 71.0% of visits were for routine or follow-up care, and longer wait times and patient multimorbidity correlated with more reasons for the visit. After the visit, most patients reported being able to express their most important needs and that the doctor listened well; however, only 28.1% reported that the doctor had explored whether the recommendations would be realistic for them, and only 18.0% indicated that the doctor had explored the personal or family dimensions that affected their health. Among all patients, 56.9% reported having at least 3 chronic conditions (multimorbidity), and 30.3% reported having high or moderate levels of psychological distress. When describing their financial status, 30.7% of patients indicated it was "poor to squeezed or tight." Slightly more than half of patients did not have complementary private health insurance to cover costs of psychological services., Conclusion: In this study, the 4 priority pillars for practices to align with the PMH were timely access, team-based care, comprehensive care, and a patient-centred approach. Widespread implementation of advanced access is an urgent priority in light of persisting difficulties in timely access. Team-based and comprehensive care are needed to address the high prevalence of multimorbidity and psychological distress and to support health behaviour change. Finally, the patient-centred approach needs to underpin every care encounter., (Copyright© the College of Family Physicians of Canada.)

Healthcare systems performance is the focus of intense policy and media attention in most countries. Quebec (Canada) is no exception, where successive governments have struggled for decades with apparently intractable problems in care accessibility overall, poor performance, and rising costs. This article explores the underlying causes of the disconnection between the high salience of healthcare system dysfunctions in both media and policy debates and the lack of policy change likely to remedy those dysfunctions. Academically, public policies' evolution is usually conceptualized as the product of complex, long-term interactions among diverse groups with specific power sources and preferences. In this context, we wanted to examine empirically whether divergences in stakeholders' views concerning various healthcare reform options could explain why certain policy changes are not implemented despite consensus on their programmatic coherence. The research design was an exploratory sequential design. Data were analyzed narratively as well as graphically using a method derived from social network analysis and graph theory. Results showed striking intergroup convergence around a programmatically sound policy package centred on the general objective of strengthening primary care delivery capacities. Those results, interpreted in light of political science elitist perspectives on the policy process, suggest that the incapacity to reform the system might be explained by one or two groups' having a de facto veto in policy-making., (Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.)

Context: Significant reforms are needed to improve healthcare system performance in Quebec. Even though the characteristics of high-performing healthcare systems are well-known, Quebec's reforms have not succeeded in implementing many critical elements. Converging evidence from political science models suggests stakeholders' preferences are central in determining policy content, adoption, and implementation., Objective: To analyze whether doctors', nurses', pharmacists' and health administrators' preferences could explain the observed inability to implement known characteristics of high-performing healthcare systems., Design: A questionnaire on various propositions identified in the scientific literature was sent to 2,491 potential respondents., Results: Overall response rate was 37%. There was considerable consensus on identified solutions to improve the healthcare system. Resistance was observed in two major areas: information systems and changes directly affecting doctors' practice. The groups' positions cannot explain the inability to implement important characteristics of high-performing systems. The findings raise new questions on the actual sources of resistance., (Copyright © 2018 Longwoods Publishing.)

Purpose: In a primary care context favoring group practices, we assessed the validity of 2 new continuity measures (both versions of known provider continuity, KPC) that capture the concentration of care over time from multiple physicians (multiple provider continuity, KPC-MP) or from the physician seen most often (personal provider continuity, KPC-PP)., Methods: Patients with diabetes or cardiovascular disease (N = 765) were approached in the waiting rooms of 28 primary care clinics in 3 regions of the province of Quebec, Canada; answered a survey questionnaire measuring relational continuity, interpersonal communication, coordination within the clinic, coordination with specialists, and overall coordination; and gave permission for their medical records to be reviewed and their medical services utilization data for the previous 2 years to be accessed to measure KPC. Using generalized linear mixed models, we assessed the association between KPC and the patients' responses., Results: Among the 5 different patient-reported measures or their combination, KPC-MP was significantly related with overall coordination of care: for high continuity, the odds ratio (OR) = 2.02 (95% CI, 1.33-3.07), and for moderate continuity, OR = 1.61 (95% CI, 1.06-2.46). KPC-MP was also related with the combined continuity score: for high continuity, OR = 1.52 (95% CI, 1.11-2.09), and for moderate continuity, OR = 1.48 (95% CI, 1.10-2.00). KPC-PP was not significantly associated with any of the survey measures., Conclusions: The KPC-MP measure, based on readily available administrative data, is associated with patient-perceived overall coordination of care among multiple physicians. KPC measures are potentially a valuable and low-cost way to follow the effects of changes favoring group practice on continuity of care for entire populations. They are easy to replicate over time and across jurisdictions., (© 2014 Annals of Family Medicine, Inc.)

Background: No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care., Methods: We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling., Results: The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0-35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8-14.4), presence of allied health professionals (15.3; 95% CI 5.4-25.2) and/or specialist physicians (19.6; 95% CI 8.3-30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0-12.4) and average organizational access to the practice (4.9; 95% CI 2.6-7.2). The number of physicians (1.2; 95% CI 0.6-1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1-2.5) were modestly associated with high-quality care., Interpretation: We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.

Introduction: Overweight in children is a serious public health problem. The use of different weight classification systems in research and clinical practice results in variable the estimate of prevalences of overweight, which complicates follow-up of this health problem in the population. The study compared three child body weight classification systems by estimating the prevalence of overweight established by each system., Method: In 2010, a study was conducted in 259 five-year-old children at the time of routine childhood vaccination. The children's height and weight were measured. The prevalence of overweight was determined and compared to the International Obesity Task Force (IOTF), the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) criteria., Results: According to the IOTF, 16.6% of children of the study were overweight (obesity 3.1%). According to the CDC, 24.3% of children were overweight (obesity 9.1%) and according to WHO, the prevalence was 26.3% (obesity 6.2%). According to the IOTF criteria, obesity affected more girls than boys (2.7% vs. 0.4%), whereas similar proportions were observed with the other two systems., Conclusion: This study demonstrates that the prevalence of overweight in children varies considerably depending on the classification system used. These results support the need to consider the system used in clinical practice and in research when monitoring the course of the prevalence of this health problem.

Objective: To evaluate how a primary care reform, which aimed to promote interprofessional and interorganizational collaborative practices, affected patients' experiences of the core dimensions of primary care., Design: Before-and-after comparison of patients' perceptions of care at the beginning of family medicine group (FMG) implementation (15 to 20 months after accreditation) and 18 months later., Setting: Five FMGs in the province of Quebec from various settings and types of practice., Participants: A random sample of patients was selected in each FMG; a total of 1046 participants completed both the baseline and follow-up questionnaires., Main Outcome Measures: Patients' perceptions of relational and informational continuity, organizational and first-contact accessibility, attitude and efficiency of the clinic's personnel and waiting times (service responsiveness), physician-nurse and primary care physician-specialist coordination, and intra-FMG collaboration were assessed over the telephone, mostly using a modified version of the Primary Care Assessment Tool. Additional items covered patients' opinions about consulting nurses, patients' use of emergency services, and patients' recall of health promotion and preventive care received., Results: A total of 1275 patients were interviewed at the study baseline, and 82% also completed the follow-up interviews after 18 months (n = 1046). Overall, perceptions of relational and informational continuity increased significantly (P < .05), whereas organizational and first-contact accessibility and service responsiveness did not change significantly. Perception of physician-nurse coordination remained unchanged, but perception of primary care physician-specialist coordination decreased significantly (P < .05). The proportion of participants reporting visits with nurses and reporting use of FMGs' emergency services increased significantly from baseline to follow-up (P < .05)., Conclusion: This reorganization of primary care services resulted in considerable changes in care practices, which led to improvements in patients' experiences of the continuity of care but not to improvements in their experiences of the accessibility of care.

Objective: Care in rheumatoid arthritis (RA) is optimized by involvement of rheumatologists. We wished to determine whether patients suspected of having new-onset RA in Québec consulted with a rheumatologist, to document any delay in these consultations, and to determine factors associated with prompt consultation., Methods: Physician reimbursement administrative data were obtained for all adults in Québec. Suspected new-onset cases of RA in the year 2000 were defined operationally as a physician visit for RA (based on the International Classification of Diseases, Ninth Revision diagnostic codes), where there had been no prior visit code to any physician for RA in the preceding 3 years. For those patients who were first diagnosed by a nonrheumatologist, Cox regression modeling was used to identify patient and physician characteristics associated with time to consultation with a rheumatologist., Results: Of the 10,001 persons coded as incident RA by a nonrheumatologist, only 27.3% consulted a rheumatologist within the next 2.5-3.5 years. Of those who consulted, the median time from initial visit to a physician for RA to consultation with a rheumatologist was 79 days. The strongest predictors of shorter time to consultation were female sex, younger age, being in a higher socioeconomic class, and having greater comorbidity., Conclusion: Our data suggest that the vast majority of patients suspected of having new-onset RA do not receive rheumatology care. Further action should focus on this issue so that outcomes in RA may be optimized.

Objective: To determine the proportion of family physicians who diagnose rheumatoid arthritis (RA) correctly and to note how they report they would manage RA patients., Design: Mailed survey (self-administered questionnaire) requesting comments on vignettes., Setting: Province of Quebec., Participants: Computer-generated random sample of family physicians registered with the Quebec College of Family Physicians., Main Outcome Measures: The proportion of family physicians who recognized RA and their reported management strategies., Results: Most respondents recognized the vignette presentation as a case of RA; 133/138 (96.4%) indicated RA as their provisional diagnosis, and all but 1 of the remaining respondents listed RA as a differential diagnosis. Of those who considered RA as a provisional or possible diagnosis, 107 (77.5% of all respondents) suggested referring the patient to a rheumatologist. Among the physicians who suggested referral, none indicated they would initiate disease-modifying antirheumatic drugs (DMARDs)., Conclusion: Almost all respondents considered RA as a provisional or differential diagnosis. Although many suggested referring the patient to a rheumatologist, almost a quarter did not. Initiating DMARDs before referring patients to rheumatologists appears to be rare. Since DMARDs given during the early stages of RA are known to decrease damage and dysfunction, ways to increase their use and optimize care pathways for new-onset inflammatory arthritis are urgently needed.

Background: Almost half of Canadians experience difficulty using print media, according to the 1994 International Adult Literacy Survey. Our objectives were to estimate the prevalence of low-literacy patients in our practice, to determine whether reading grade level is associated with self-perceived health status in primary care, and to evaluate the reading difficulty of commonly used patient education pamphlets., Methods: We surveyed a random sample of 229 patients aged 18 to 85 years presenting for scheduled and walk-in care. Main outcome measures were reading ability as estimated by word decoding skill with the validated Rapid Estimate of Adult Literacy in Medicine (REALM) and self-perceived health status using COOP/WONCA functional health measures. We assessed the reading difficulty of 120 commonly used patient education pamphlets using the Simple Measure of Gobbledygook (SMOG) formula., Results: The prevalence of low-literate patients was 9%. Poor reading ability in English was most likely among patients under 45 years of age not having completed high school, and among those whose maternal language was neither English nor French (immigrants). REALM scores and self-perceived health were weakly correlated but not significant statistically. The mean reading grade level of pamphlets was grade 11.5 (SD: 1.5). Seventy-eight percent of pamphlets required at least a high school reading level., Conclusion: Literacy levels were higher than expected in our patient population; this finding may be due to the rapid assessment tool used, which may have underestimated the difficulty of using print media. Clearly, the vast majority of commonly used patient education materials would not meet the needs of low-literate patients, who may be more likely to experience poorer health. Providers need to be sensitive to the reading limitations of patients and patient education materials should be written at a lower reading level.

Background: Physician mammography referral remains below optimal levels despite a long-standing recommendation that all women ages 50 to 69 years receive screening mammography every 1 to 2 years. The purpose of this study was to determine physician and practice environment predictors of family physicians' screening mammography referral rates to women ages 50-69 years., Method: A cohort of 498 recently-licensed family physicians was followed for 18-months of incipient medical practice. The referral rate was the percentage of new clinically eligible women patients seen in a primary care context who had a screening mammogram ordered by the study physician. Mammograms and independent variables were identified from physician claims to a Canadian universal health insurance agency. The effects of factors in a conceptual framework were assessed using multivariable linear regression., Results: Correlates of higher mammography referral rates were female gender, better general prevention knowledge, the combination of comprehensive inquiry and continuity care, lower patient volume, and lower shared primary care (multivariable model R(2) = 0.47). Factors belonging to practice environment explained more of the observed variance than did physician characteristics., Conclusions: Mammography referral varies enormously and almost half of the variance is explained by physician characteristics and practice preferences. Higher mammography referral is observed in practices with more comprehensive and continuity care., (Copyright 1999 American Health Foundation and Academic Press.)