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Interview Guide. At each time point of the vignette (Table 1), the interviewer asked the following questions. Interviewers were permitted to ask follow-up questions for clarification. 1) What action would you take if the patient was presented to you at this stage with this history? 2) Are there any other resources you would consider at this stage? (DOCX 11 kb)

To measure the effect of nurse practitioner and pharmacist consultations on the appropriate use of medications by patients.We studied patients in the intervention arm of a randomized controlled trial. The main trial intervention was provision of multidisciplinary team care and the main outcome was quality and processes of care for chronic disease management.Patients were recruited from a single publicly funded family health network practice of 8 family physicians and associated staff serving 10 000 patients in a rural area near Ottawa, Ont.A total of 120 patients 50 years of age or older who were on the practice roster and who were considered by their family physicians to be at risk of experiencing adverse health outcomes.A pharmacist and 1 of 3 nurse practitioners visited each patient at his or her home, conducted a comprehensive medication review, and developed a tailored plan to optimize medication use. The plan was developed in consultation with the patient and the patient's doctor. We assessed medication appropriateness at the study baseline and again 12 to 18 months later.We used the medication appropriateness index to assess medication use. We examined associations between personal characteristics and inappropriate use at baseline and with improvements in medication use at the follow-up assessment. We recorded all drug problems encountered during the trial.At baseline, 27.2% of medications were inappropriate in some way and 77.7% of patients were receiving at least 1 medication that was inappropriate in some way. At the follow-up assessments these percentages had dropped to 8.9% and 38.6%, respectively (P.001). Patient characteristics that were associated with receiving inappropriate medication at baseline were being older than 80 years of age (odds ratio [OR] = 5.00, 95% CI 1.19 to 20.50), receiving more than 4 medications (OR = 6.64, 95% CI 2.54 to 17.4), and not having a university-level education (OR = 4.55, 95% CI 1.69 to 12.50).We observed large improvements in the appropriate use of medications during this trial. This might provide a mechanism to explain some of the reductions in mortality and morbidity observed in other trials of counseling and advice provided by pharmacists and nurses.NCT00238836 (ClinicalTrials.gov).

To explore the challenges Canadian family physicians face in providing dementia care.Qualitative study using focus groups.Academic family practice clinics in Calgary, Alta, Ottawa, Ont, and Toronto, Ont.Eighteen family physicians.We conducted 4 qualitative focus groups of 4 to 6 family physicians whose practices we had audited in a previous study. Focus group transcripts were analyzed using the principles of thematic analysis.Five major themes related to the provision of dementia care by family physicians emerged: 1) diagnostic uncertainty; 2) the complexity of dementia; 3) time as a paradox in the provision of dementia care; 4) the importance of patients' families; 5) and familiarity with patients. Participants expressed uncertainty about diagnosing dementia and a strong need for expert verification of diagnoses owing to the complexity of dementia. Time, patients' family members, and familiarity with patients were seen as both barriers and enablers in the provision of dementia care.Family physicians face many challenges in providing dementia care. The results of this study and the views of family physicians should be considered in the development and dissemination of future dementia guidelines, as well as by specialist colleagues, policy makers, and those involved in developing continuing physician education about dementia.

To determine what proportion of patients with dementia seen by family physicians are assessed and managed according to the recommendations of the Canadian Consensus Conference on Dementia (CCCD).Retrospective medical record review.Outpatient services in university-affiliated family practice clinics in Calgary, Alta; Ottawa, Ont; and Toronto, Ont.One hundred sixty patients who were diagnosed with dementia between January 1, 2000, and June 1, 2004.Use of the Mini-Mental State Examination (MMSE); collateral history; physical examination maneuvers; initial laboratory tests; diagnostic imaging; caregiver identification, assessment, and referral; driving assessment; specialist referral patterns; and other recommendations of the CCCD.The average age of patients assessed was 83 years; most patients (66.3%) were female. More than half (54.1%) were diagnosed with Alzheimer disease or vascular dementia. More than 25% of patients were not given a specific diagnosis: 13.1% were labeled as "dementia," and 12.5% as "not yet diagnosed." For most patients (69.6%) a collateral history was obtained and a primary caregiver identified (79.4%). Few physicians, however, assessed caregiver stress (33.1%) or referred caregivers for support (12.5%). Most patients (80.6%) seen by their family physicians for cognitive changes underwent at least one MMSE. The average score on the first MMSE was 23.5 (of 30) points. Most physicians ordered appropriate "basic" blood tests as part of their assessment. Forty percent of patients had computed tomographic examinations within 3 months of reporting symptoms of cognitive difficulties to their family physicians. Of these, 25% met the criteria for computed tomographic scan as recommended by the guidelines. Only 36.5% were asked about driving status or safety concerns and had this inquiry documented. Of those, 15.5% were referred for driving evaluations and 12.5% were reported to the Ministry of Transportation.There is fair to good compliance with recommendations of the 1999 CCCD guidelines. There is, however, little assessment of caregiver coping and referral of caregivers for support. Similarly, there is little assessment of driver safety and referral for formal driving evaluations. Computed tomographic imaging as part of the evaluation of dementia is overused.