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Context: BETTER WISE is a comprehensive and structured approach for cancer and chronic disease prevention and screening (CCDPS) that addresses cancer survivorship and screens for lifestyle risks and poverty in patients aged 40 to 65. Objective: To describe the impact, barriers and facilitators of BETTER WISE. Study Design and Analysis: Qualitative study: 17 focus groups and 48 key informant interviews were conducted, transcribed and analyzed employing thematic analysis using a constant comparative method. Written feedback (585 feedback forms) from patients was also collected and analyzed. Setting: 13 primary care settings (urban, rural and remote) in Alberta, Ontario, and Newfoundland and Labrador, Canada. Participants: Primary care team members (N=132) including clinicians, managers and clerical staff participated in focus groups or one-on-one key informant telephone interviews. Additionally, patients submitted 585 written feedback forms. Intervention: 1,005 patients were invited for a one-hour visit with a 'prevention practitioner' (PP), a member of the primary care team with training in CCDPS and the BETTER WISE approach. PPs met with patients one-on-one to provide them with an overview of their individual risk for chronic diseases, eligibility for screening, and assistance with lifestyle counselling. Results: Four main themes were identified: 1) Impact on patients: Patients appreciated the BETTER WISE approach and found it empowering. They caught health concerns that were overlooked and reported improved lifestyle changes; 2) Impact on primary care providers (PCPs): PPs reported improved teamwork, increased knowledge of CCDPS, and better relationships with patients and physicians; 3) The main barrier to implementation of BETTER WISE was the onset of the COVID-19 pandemic, which: i) changed prevention visits to phone visits, ii) put screening tests on hold, and iii) added hardship on patients and PCPs as focus shifted to emergencies, acute care, and COVID-19 screening and vaccinations; 4) Facilitators of the implementation of BETTER WISE included: i) buy-in from PPs, physicians, and patients, ii) good relationship and team culture within primary care teams, and iii) alignment with CCDPS activities already happening at the clinics. Conclusion: Despite the interruption of the COVID-19 pandemic, the participating primary care clinics completed the BETTER WISE study and the BETTER WISE approach had a positive impact on patients and PCPs., Presenters Nicolette Sopcak, PhD, Carolina Fernandes, MA, MSc, Melanie Wong, BSc, Daniel Ofosu, Lelaf Khalil, Mary Ann O'Brien, PhD, Tracy Wong, PhD, Donna Manca, MD, [...]

Context: Cancer and chronic disease prevention and screening (CCDPS) guidelines are not consistently applied in primary care. Furthermore, while most patients have multiple risks and conditions, guidelines are focused on a specific disease or organ system. The BETTER program (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) involves an evidence-based intervention provided by an allied health professional within a primary care practice who acquires advanced skills in CCDPS and takes on the role of Prevention Practitioner (PP). Using the BETTER toolkit, created through a rigorous process of knowledge synthesis and harmonization of recommendations, the PP meets with patients for a personalized prevention visit. Objective: To describe the: 1) evidence review process used to identify high-quality clinical practice guidelines (CPGs), 2) harmonization of primary prevention and screening recommendations, and 3) identification, development, and refinement of resources and tools for inclusion in the BETTER toolkit. The BETTER toolkit will be used to inform CCDPS in rural, remote, and urban primary care settings across Canada. Methods: In 2017, the BETTER Program conducted a literature review of evidence-based CPGs published between 2010 and 2016. For this update, high-quality international, Canadian, and Provincial CPGs published between 2016 and 2021, focusing on primary prevention and screening of cancer and chronic disease, and applicable to patients 40-69 years of age were identified. A Clinical Working Group consisting of decision-makers, researchers, clinicians, and a patient representative across Canada was split up into 3 topic review teams. A total of 19 CCDPS topics within scope for BETTER were identified. Topic teams reviewed the literature and synthesized guidelines based on evidence for their topic and updated the toolkits to inform the PP role. Results: Development of an updated care map that considers family history and risk factor assessment that is tailored to the patient and adaptable to diverse practice settings. Conclusions: Synthesized and evidence-based integrated care plans can be used to assess patients' CCDPS risk and preferences in diverse populations in Canada. The updated toolkit will facilitate the application of recommendations for the primary prevention of cancer and chronic disease in patients 40-69 years of age., Presenters Donna Manca, MD, MCLSC, Denise Campbell-Scherer, MD, PhD, Carolina Fernandes, MA, MSc, Eva Grunfeld, MD, PhD, FCFP, Kris Aubrey-Bassler, MD, FCFP, MSc, Aisha Lofters, MD, Katherine Latko, CDE, RD, [...]

BackgroundThe Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Family Practice (BETTER) trial demonstrated the effectiveness of an approach to chronic disease prevention and screening (CDPS) through a new skilled role of a 'prevention practitioner'(PP). The PP has appointments with patients 40-65 years of age that focus on primary prevention activities and screening of cancer (breast, colorectal, cervical), diabetes and cardiovascular disease and associated lifestyle factors. There are numerous and occasionally conflicting evidence-based guidelines for CDPS, and the majority of these guidelines are focused on specific diseases or conditions; however, primary care providers often attend to patients with multiple conditions. To ensure that high-level evidence guidelines were used, existing clinical practice guidelines and tools were reviewed and integrated into blended BETTER tool kits. Building on the results of the BETTER trial, the BETTER tools were updated for implementation of the BETTER 2 program into participating urban, rural and remote communities across Canada.MethodsA clinical working group consisting of PPs, clinicians and researchers with support from the Centre for Effective Practice reviewed the literature to update, revise and adapt the integrated evidence algorithms and tool kits used in the BETTER trial. These resources are nuanced, based on individual patient risk, values and preferences and are designed to facilitate decision-making between providers across the target diseases and lifestyle factors included in the BETTER 2 program. Using the updated BETTER 2 toolkit, clinicians 1) determine which CDPS actions patients are eligible to receive and 2) develop individualized 'prevention prescriptions' with patients through shared decision-making and motivational interviewing.ResultsThe tools identify the patients' risks and eligible primary CDPS activities: the patient survey captures the patient's health history; the prevention visit form and integrated CDPS care map identify eligible CDPS activities and facilitate decisions when certain conditions are met; and the 'bubble diagram' and 'prevention prescription' promote shared decision-making.ConclusionThe integrated clinical decision-making tools of BETTER 2 provide resources for clinicians and policymakers that address patients' complex care needs beyond single disease approaches and can be adapted to facilitate CDPS in the urban, rural and remote clinical setting.Trial registrationThe registration number of the original RCT BETTER trial was ISRCTN07170460 .

BackgroundPrimary care provides most of the evidence-based chronic disease prevention and screening services offered by the healthcare system. However, there remains a gap between recommended preventive services and actual practice. This trial (the BETTER Trial) aimed to improve preventive care of heart disease, diabetes, colorectal, breast and cervical cancers, and relevant lifestyle factors through a practice facilitation intervention set in primary care.MethodsPragmatic two-way factorial cluster RCT with Primary Care Physicians' practices as the unit of allocation and individual patients as the unit of analysis. The setting was urban Primary Care Team practices in two Canadian provinces. Eight Primary Care Team practices were randomly assigned to receive the practice-level intervention or wait-list control; 4 physicians in each team (32 physicians) were randomly assigned to receive the patient-level intervention or wait-list control. Patients randomly selected from physicians' rosters were stratified into two groups: 1) general and 2) moderate mental illness. The interventions involved a multifaceted, evidence-based, tailored practice-level intervention with a Practice Facilitator, and a patient-level intervention involving a one-hour visit with a Prevention Practitioner where patients received a tailored 'prevention prescription'. The primary outcome was a composite Summary Quality Index of 28 evidence-based chronic disease prevention and screening actions with pre-defined targets, expressed as the ratio of eligible actions at baseline that were met at follow-up. A cost-effectiveness analysis was conducted.Results789 of 1,260 (63%) eligible patients participated. On average, patients were eligible for 8.96 (SD 3.2) actions at baseline. In the adjusted analysis, control patients met 23.1% (95% CI: 19.2% to 27.1%) of target actions, compared to 28.5% (95% CI: 20.9% to 36.0%) receiving the practice-level intervention, 55.6% (95% CI: 49.0% to 62.1%) receiving the patient-level intervention, and 58.9% (95% CI: 54.7% to 63.1%) receiving both practice- and patient-level interventions (patient-level intervention versus control, P < 0.001). The benefit of the patient-level intervention was seen in both strata. The extra cost of the intervention was $26.43CAN (95% CI: $16 to $44) per additional action met.ConclusionsA Prevention Practitioner can improve the implementation of clinically important prevention and screening for chronic diseases in a cost-effective manner.

Background: The BETTER intervention is an effective comprehensive evidence-based program for chronic disease prevention and screening (CDPS) delivered by trained prevention practitioners (PPs), a new role in primary care. An adapted program, BETTER HEALTH, delivered by public health nurses as PPs for community residents in low income neighbourhoods, was recently shown to be effective in improving CDPS actions. To obtain a nuanced understanding about the CDPS needs of community residents and how the BETTER HEALTH intervention was perceived by residents, we studied how the intervention was adapted to a public health setting then conducted a post-visit qualitative evaluation by community residents through focus groups and interviews. Methods: We first used the ADAPT-ITT model to adapt BETTER for a public health setting in Ontario, Canada. For the post-PP visit qualitative evaluation, we asked community residents who had received a PP visit, about steps they had taken to improve their physical and mental health and the BETTER HEALTH intervention. For both phases, we conducted focus groups and interviews; transcripts were analyzed using the constant comparative method. Results: Thirty-eight community residents participated in either adaptation (n = 14, 64% female; average age 54 y) or evaluation (n = 24, 83% female; average age 60 y) phases. In both adaptation and evaluation, residents described significant challenges including poverty, social isolation, and daily stress, making chronic disease prevention a lower priority. Adaptation results indicated that residents valued learning about CDPS and would attend a confidential visit with a public health nurse who was viewed as trustworthy. Despite challenges, many recipients of BETTER HEALTH perceived they had achieved at least one personal CDPS goal post PP visit. Residents described key relational aspects of the visit including feeling valued, listened to and being understood by the PP. The PPs also provided practical suggestions to overcome barriers to meeting prevention goals. Conclusions: Residents living in low income neighbourhoods faced daily stress that reduced their capacity to make preventive lifestyle changes. Key adapted features of BETTER HEALTH such as public health nurses as PPs were highly supported by residents. The intervention was perceived valuable for the community by providing access to disease prevention. Trial registration: #NCT03052959, 10/02/2017. [ABSTRACT FROM AUTHOR]

Introduction: Considerable time and money are invested in continuing medical education (CME) for family physicians (FPs) but the effectiveness is uncertain. The participation of FPs as coordinators and teachers is not well known. The goal of this project was to describe the role of FPs in organizing and teaching CME events that are accredited for Fps. Methods: Information about accredited CME events occurring in Alberta and Nova Scotia was requested from universities, provincial chapters of the College of Family Physicians of Canada, and pharmaceutical companies. Location, coordinating site, organizing committee members, teaching faculty, and format were recorded from each event. The number and proportion of FPs involved in both organizing and teaching CME events accredited for FPs were calculated and compared. Results: A total of 314 CME events were collected, comprising a total of 1,472 hours of CME. From the CME events collected, there were 1,730 organizing committee members and 1,647 teachers. FPs constitute 59% of the organizing committees and 17% of the teachers. Significant differences in the numbers of FP planners and teachers were related to organizing group, format, location, and expected audience composition. Discussion: The accreditation requirement for FPs on organizing committees likely helps preserve a reasonable proportion of FP organizers but not teachers in FP CME. The proportions of true FP planners and teachers may actually be lower than planning documents indicate. Low level of family physician teachers in CME may be due to FPs' not selecting FP teachers, the FP teaching pool's being inadequate, or the organizing committee's being unaware of FPs who are knowledgeable in particular areas. (Contains 4 tables.)

Examines three school districts [Richmond Unified School District (California), Coachella Valley Unified School District (California), and White Pine County School District (Nevada)] that faced financial disaster and then worked their way back to solvency. All three overspent revenues in the general fund, had unrealistic budgets, and lacked internal controls and long-range fiscal planning. Other "yellow flags" are outlined. (MLH)