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OBJECTIVE: To identify and describe the important rewards and challenges that affect family physicians in Alberta.DESIGN: Web-based qualitative study using the Delphi method.SETTING: Province of Alberta.PARTICIPANTS: Twenty-eight family physicians practising in Alberta.METHODS: The study website presented a description of the project, ethical information, a calendar of events, and contact information. Delphi surveys and demographic questionnaires were password protected. Five rounds of surveys were conducted between May 2004 and January 2005. Participants were notified of each round of surveys and prompted by e-mail if they did not respond.FINDINGS:Participants identified 8 key rewards and 9 key challenges. The research team identified 2 additional challenges that were validated by participants. In order of perceived importance, key rewards were providing diverse and comprehensive care; providing preventive care; having relationships with patients and their families; being an immersed witness to the human condition; providing continuity of care and receiving ongoing feedback; having flexibility and control of practice and job security; maintaining and acquiring skills and knowledge; teaching and sharing knowledge and gaining experience and mentoring. The challenges, in order of perceived need to be addressed, were workload and time pressures and meeting demands; the need to promote the rewards of family practice to those considering joining the profession; overhead and income inequities; getting respect from specialists; the need to ensure that the rewards identified are not adversely affected by primary care reform; lack of availability of specialists, procedures, tests, and other resources; running a practice as a small business; paperwork, telephone calls, and forms; maintaining and acquiring skills and knowledge; patients' expectations; and medicolegal issues, insurance paperwork, and dealing with medical claims related to motor vehicle accidents.CONCLUSION: The rewards and challenges reported by participants outline the positive and negative factors in family practice. The challenges provide a focus for further work. [ABSTRACT FROM AUTHOR]

Aims: Estimate the effectiveness of continuous glucose monitoring (CGM) with remote telemonitoring-enabled virtual diabetes educator visits for improving glycemic management in adults with type 2 diabetes, not on insulin., Methods: Participants with type 2 diabetes, not on insulin, and HbA1c > 7.0 % were enrolled in an open-label randomized trial of 6 weeks of CGM with telemonitoring versus enhanced usual care. Both groups received educator visits. HbA1c was assessed at 12 weeks., Results: Of 105 participants (mean age 57.3 years, 49.5 % females, mean baseline HbA1c 8.0 %), 86 remained at follow-up. Change in HbA1c was -0.69 % (CGM) versus -0.33 % (enhanced usual care). Adjusting for baseline HbA1c, CGM was superior (0.65 % greater HbA1c reduction [95 % CI 0.17-1.12 %], p = 0.008). CGM participants were 92 % (RR = 1.92, 1.19-3.06, p = 0.007) more likely to have an HbA1c reduction ≥ 0.5 %, lost more weight (difference in weight reduction 2.17 kg, 0.22-4.11, p = 0.029) and were more satisfied with their treatment. No treatment-related adverse events were observed., Conclusions: CGM with virtual diabetes educator visits is effective, safe, and acceptable in adults with type 2 diabetes not on insulin and should be considered as an alternative to drug therapy for improving blood glucose., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: TP is an independent community educator. Some of her services have been remunerated by Abbott Laboratories, Boehringer Ingelheim, and Novo Nordisk. DL, DPM, PS, IO-J, JRZ, GR, EMH, and ROY have no conflicts to disclose.., (Copyright © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Objectives: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) provide heart and kidney benefit in adults with diabetes and cardiovascular disease (CVD). Public drug coverage policies for SGLT2i differ by province in Canada. Our study aimed to describe the potential effects of prior authorization / step therapy (PA/ST) and relatively high income-based deductibles, compared to regular benefit status with modest co-pay, on SGLT2i prescriptions in high-risk adults., Methods: Cross-sectional study of individuals age ≥ 65 years with type 2 diabetes and CVD, taking ≥ 1 antihyperglycemic agent from 2019 to 2020, using electronic medical record data from primary care practices. We compared SGLT2i use (2019-2020) in Alberta (PA/ST, modest co-pay), and Manitoba (PA/ST, relatively high income-based deductible), to Ontario (regular benefit status, modest co-pay). Poisson regression was used to adjust for confounders, including age, sex, glycated hemoglobin, and other medication use. Other diabetes medications were estimated as control cases., Results: We included 3,191 adults (average age 75 years, 31% female). SGLT2i use was lowest in Manitoba (15.6%), then Alberta (25.9%), and highest in Ontario (31.9%). After adjustment, compared to Ontario, SGLT2i prescriptions were lower in Alberta (prevalence ratio [PR] 0.80, 95% CI [0.71-0.91], p < 0.001) and Manitoba (PR 0.48 [0.39-0.59], p < 0.001)., Conclusions: PA/ST and relatively high deductibles are associated with reduced SGLT2i prescribing - PA/ST by approximately 20% in Alberta and Manitoba, and relatively high deductibles by an additional relative reduction of 40% in Manitoba. PA/ST and cost-sharing policies should be flexible and responsive to changing evidence of clinical benefit., (Copyright © 2024. Published by Elsevier Inc.)

Introduction: Although antihypertensive medication use is common among frail older adults, observational studies in this population suggest blood pressure (BP) lowering may convey limited benefit and perhaps even harm. This protocol describes an antihypertensive deprescribing trial in frail older adults powered for mortality and morbidity outcomes., Methods and Analysis: Design: Prospective, parallel, randomised, open-label pragmatic trial. Participants: Long-term care (LTC) residents ≥70 years of age, diagnosed with hypertension, with mean systolic BP <135 mm Hg, ≥1 daily antihypertensive medication and no history of congestive heart failure. Setting: 18 LTC facilities in Alberta, Canada, with eligible residents identified using electronic health services data. Intervention: All non-opted-out eligible residents are randomised centrally by a provincial health data steward to either usual care, or continually reducing antihypertensives provided an upper systolic threshold of 145 mm Hg is not exceeded. Deprescribing is carried out by pharmacists/nurse practitioners, using an investigator-developed algorithm. Follow-up: Provincial healthcare databases tracking hospital, continuing care and community medical services. Primary outcome: All-cause mortality. Secondary outcome: Composite of all-cause mortality or all-cause unplanned hospitalisation/emergency department visit. Tertiary outcomes: All-cause unplanned hospitalisation/emergency department visit, non-vertebral fracture, renal insufficiency and cost of care. Also, as assessed roughly 135-days postrandomisation, fall in the last 30 days, worsening cognition, worsening activities of daily living and skin ulceration. Process outcomes: Number of daily antihypertensive medications (broken down by antihypertensive class) and average systolic and diastolic BP over study duration. Primary outcome analysis: Cox proportional hazards survival analysis. Sample size: The trial will continue until observation of 247 primary outcome events has occurred. Current status: Enrolment is ongoing with ~400 randomisations to date (70% female, mean age 86 years)., Ethics and Dissemination: Ethics approval was obtained from the University of Alberta Health Ethics Review Board (Pro00097312) and results will be published in a peer-reviewed journal., Trial Registration Number: NCT05047731., Competing Interests: Competing interests: CAS has received speaker fees from GSK and grant funding from Pfizer Canada. All other authors declare no competing interests related to the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Clinical practice guidelines (CPGs) synthesize high-quality information to support evidence-based clinical practice. In primary care, numerous CPGs must be integrated to address the needs of patients with multiple risks and conditions. The BETTER program aims to improve prevention and screening for cancer and chronic disease in primary care by synthesizing CPGs into integrated, actionable recommendations. We describe the process used to harmonize high-quality cancer and chronic disease prevention and screening (CCDPS) CPGs to update the BETTER program., Methods: A review of CPG databases, repositories, and grey literature was conducted to identify international and Canadian (national and provincial) CPGs for CCDPS in adults 40-69 years of age across 19 topic areas: cancers, cardiovascular disease, chronic obstructive pulmonary disease, diabetes, hepatitis C, obesity, osteoporosis, depression, and associated risk factors (i.e., diet, physical activity, alcohol, cannabis, drug, tobacco, and vaping/e-cigarette use). CPGs published in English between 2016 and 2021, applicable to adults, and containing CCDPS recommendations were included. Guideline quality was assessed using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and a three-step process involving patients, health policy, content experts, primary care providers, and researchers was used to identify and synthesize recommendations., Results: We identified 51 international and Canadian CPGs and 22 guidelines developed by provincial organizations that provided relevant CCDPS recommendations. Clinical recommendations were extracted and reviewed for inclusion using the following criteria: 1) pertinence to primary prevention and screening, 2) relevance to adults ages 40-69, and 3) applicability to diverse primary care settings. Recommendations were synthesized and integrated into the BETTER toolkit alongside resources to support shared decision-making and care paths for the BETTER program., Conclusions: Comprehensive care requires the ability to address a person's overall health. An approach to identify high-quality clinical guidance to comprehensively address CCDPS is described. The process used to synthesize and harmonize implementable clinical recommendations may be useful to others wanting to integrate evidence across broad content areas to provide comprehensive care. The BETTER toolkit provides resources that clearly and succinctly present a breadth of clinical evidence that providers can use to assist with implementing CCDPS guidance in primary care., (© 2024. The Author(s).)

Objective: Building on Existing Tools To improvE chronic disease pRevention and screening in primary care Wellness of cancer survIvorS and patiEnts (BETTER WISE) was designed to assess the effectiveness of a cancer and chronic disease prevention and screening (CCDPS) programme. Here, we compare outcomes in participants living with and without financial difficulty., Design: Secondary analysis of a cluster-randomised controlled trial., Setting: Patients of 59 physicians from 13 clinics enrolled between September 2018 and August 2019., Participants: 596 of 1005 trial participants who responded to a financial difficulty screening question at enrolment., Intervention: 1-hour CCDPS visit versus usual care., Outcome Measures: Eligibility for a possible 24 CCDPS actions was assessed at baseline and the primary outcome was the percentage of eligible items that were completed at 12-month follow-up. We also compared the change in response to the financial difficulty screening question between baseline and follow-up., Results: 55 of 265 participants (20.7%) in the control group and 69 of 331 participants (20.8%) in the intervention group reported living with financial difficulty. The primary outcome was 29% (95% CI 26% to 33%) for intervention and 23% (95% CI 21% to 26%) for control participants without financial difficulty (p=0.01). Intervention and control participants with financial difficulty scored 28% (95% CI 24% to 32%) and 32% (95% CI 27% to 38%), respectively (p=0.14). In participants who responded to the financial difficulty question at both time points (n=302), there was a net decrease in the percentage of participants who reported financial difficulty between baseline (21%) and follow-up (12%, p<0.001) which was similar in the control and intervention groups. The response rate to this question was only 51% at follow-up., Conclusion: The BETTER intervention improved uptake of CCDPS manoeuvres in participants without financial difficulty, but not in those living with financial difficulty. Improving CCDPS for people living with financial difficulty may require a different clinical approach or that social determinants be addressed concurrently with clinical and lifestyle needs or both., Trial Registration Number: ISRCTN21333761., Competing Interests: Competing interests: DPM, EG, AKL and CF are directors of a Canadian not-for-profit organisation, The BETTER Institute, which provides training and implementation support to practices, organisations and communities interested in adopting or adapting the BETTER approach. There are no other competing interests to report., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Cancer and chronic diseases are a major cost to the healthcare system and multidisciplinary models with access to prevention and screening resources have demonstrated improvements in chronic disease management and prevention. Research demonstrated that a trained Prevention Practitioner (PP) in multidisciplinary team settings can improve achievement of patient level prevention and screening actions seven months after the intervention., Methods: We tested the effectiveness of the PP intervention in a pragmatic two-arm cluster randomized controlled trial. Patients aged 40-65 were randomized at the physician level to an intervention group or to a wait-list control group. The intervention consisted of a patient visit with a PP. The PP received training in prevention and screening and use of the BETTER WISE tool kit. The effectiveness of the intervention was assessed using a composite outcome of the proportion of the eligible prevention and screening actions achieved between intervention and control groups at 12-months., Results: Fifty-nine physicians were recruited in Alberta, Ontario, and Newfoundland and Labrador. Of the 1,005 patients enrolled, 733 (72.9%) completed the 12-month analysis. The COVID-19 pandemic occurred during the study time frame at which time nonessential prevention and screening services were not available and in-person visits with the PP were not allowed. Many patients and sites did not receive the intervention as planned. The mean composite score was not significantly higher in patients receiving the PP intervention as compared to the control group. To understand the impact of COVID on the project, we also considered a subset of patients who had received the intervention and who attended the 12-month follow-up visit before COVID-19. This assessment demonstrated the effectiveness of the BETTER visits, similar to the findings in previous BETTER studies., Conclusions: We did not observe an improvement in cancer and chronic disease prevention and screening (CCDPS) outcomes at 12 months after a BETTER WISE prevention visit: due to the COVID-19 pandemic, the study was not implemented as planned. Though benefits were described in those who received the intervention before COVID-19, the sample size was too small to make conclusions. This study may be a harbinger of a substantial decrease and delay in CCDPS activities under COVID restrictions., Trial Registration: ISRCTN21333761. Registered on 19/12/2016. http://www.isrctn.com/ISRCTN21333761 ., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Purpose: The BETTER WISE (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care for Wellness of Cancer Survivors and Patients) intervention is an evidence-based approach to prevention and screening for cancers and chronic diseases in primary care that also includes comprehensive follow-up for breast, prostate and colorectal cancer survivors. We describe the process of harmonizing cancer survivorship guidelines to create a BETTER WISE cancer surveillance algorithm and describe both the quantitative and qualitative findings for BETTER WISE participants who were breast, prostate or colorectal cancer survivors. We describe the results in the context of the COVID-19 pandemic., Methods: We reviewed high-quality survivorship guidelines to create a cancer surveillance algorithm. We conducted a cluster randomized trial in three Canadian provinces with two composite index outcome measured 12 months after baseline, and also collected qualitative feedback on the intervention., Results: There were 80 cancer survivors for whom we had baseline and follow-up data. Differences between the composite indices in the two study arms were not statistically significant, although a post hoc analysis suggested the COVID-19 pandemic was a key factor in these results. Qualitative finding suggested that participants and stakeholders generally viewed BETTER WISE positively and emphasized the effects of the pandemic., Conclusions and Implications for Cancer Survivors: BETTER WISE shows promise for providing an evidence-based, patient-centred, comprehensive approach to prevention, screening and cancer surveillance for cancer survivors in the primary care setting., Trial Registration: ISRCTN21333761. Registered on December 19, 2016, http://www.isrctn.com/ISRCTN21333761 ., (© 2023. The Author(s).)

Objectives: We sought to validate, or refute, the common belief that bedtime diuretics are poorly tolerated due to nocturia., Design: Prespecified prospective cohort analysis embedded within the randomised BedMed trial, in which hypertensive participants are randomised to morning versus bedtime antihypertensive administration., Setting: 352 community family practices across 4 Canadian provinces between March 2017 and September 2020., Participants: 552 hypertensive patients (65.6 years old, 57.4% female) already established on a single once-daily morning antihypertensive and randomised to switch that antihypertensive to bedtime. Of these, 203 used diuretics (27.1% thiazide alone, 70.0% thiazide/non-diuretic combinations) and 349 used non-diuretics., Intervention: Switching the established antihypertensive from morning to bedtime, and comparing the experience of diuretic and non-diuretic users., Primary and Secondary Outcome Measures: Primary outcome: Adherence to bedtime allocation time at 6 months (defined as the willingness to continue with bedtime use, not an assessment of missed doses). Secondary 6-month outcomes: (1) nocturia considered to be a major burden and (2) increase in overnight urinations/week. All outcomes were self-reported and additionally collected at 6 weeks., Results: At 6 months: Adherence to bedtime allocation time was lower in diuretic users than non-diuretic users (77.3% vs 89.8%; difference 12.6%; 95% CI 5.8% to 19.8%; p<0.0001; NNH 8.0), and more diuretic users considered nocturia a major burden (15.6% vs 1.3%; difference 14.2%; 95% CI 8.9% to 20.6%; p<0.0001; NNH 7.0). Compared with baseline, diuretic users experienced 1.0 more overnight urinations/week (95% CI 0.0 to 1.75; p=0.01). Results did not differ between sexes., Conclusions: Switching diuretics to bedtime did promote nocturia, but only 15.6% found nocturia a major burden. At 6 months, 77.3% of diuretic users were adherent to bedtime dosing. Bedtime diuretic use is viable for many hypertensive patients, should it ever become clinically indicated., Trial Registration Number: NCT02990663., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at https://www.icmje.org/disclosure-of-interest/ and declare: SRG is the nominated principal applicant of two grants from governmental sources that are funding the BedMed trial (from Alberta Innovates, and the Canadian Institutes of Health Research); RSP is CEO of 'mmHg', a digital health company and maker of software solutions for BP monitoring; MDH is the recipient of several grants from pharmaceutical and device companies related to interventions geared at stroke treatment. He holds two device patents related to stroke imaging, has chaired or sat on the data safety monitoring boards of five other cardiovascular trials, is the President of the Canadian Neurological Sciences Federation, a member of the board of the Canadian Stroke Consortium, and has private stock ownership in two companies targeting imaging interventions (Circle and PureWeb)., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: To apply a case definition to a Northern Alberta-based primary care practice population and to assess the sex-specific characteristics of young-onset metabolic syndrome (MetS). Design: We carried out a cross-sectional study to identify and estimate the prevalence of MetS using electronic medical record (EMR) data and perform descriptive comparative analyses of demographic and clinical characteristics between males and females. Setting: Northern Alberta Primary Care Research Network (NAPCReN) consists of EMR patient data from 77 physicians among 18 clinics. Participants: Patients with one or more clinic visit between 2015 and 2018, between 18 and 40 years old, residing in Northern Alberta. Main Outcome Measures: Comparison of prevalence in MetS between sexes as well as sex-specific distribution of MetS characteristics [body mass index (BMI), fasting blood glucose, glycated hemoglobin, triglycerides, and high-density lipoprotein cholesterol (HDL-C), presence of hypertension, and presence of diabetes]. Results: Of 15,766 patients, 4.4% ( n  = 700) had young-onset MetS based on recorded data, prevalence was nearly twice as high in males (6.1%, n  = 354) compared with females (3.5%, n  = 346). The most prevalent risk factor for MetS consisted of having an elevated BMI for both females (90.9%) and males (91.5%). In the presence of MetS, more females had lower HDL-C [68.2% females (F) vs. 52.5% males (M)], and higher prevalence of diabetes (21.4% F vs. 9.0% M), whereas more males had hypertriglyceridemia (60.4% F vs. 79.7% M) and hypertension (12.4% F vs. 15.8% M). Females also had consistently higher percentages of absent laboratory data compared with males when identified as having MetS and BMI ≥25 kg/m 2 . Conclusions: Males have nearly twice the prevalence of young-onset MetS compared with females, with notable sex-specific differences in the manifestation of MetS, although we suspect that this is partially due to underreporting where the absence of anthropomorphic and laboratory investigations point to a lack of testing. Sex-specific screening for MetS, especially among young females of childbearing years, is important for downstream prevention.

Competing Interests: Intérêts concurrents: Rose Yeung a reçu une subvention de recherche du Fonds albertain Novo Nordisk pour le diabète (Fondation de l’Hôpital universitaire, société Novo Nordisk et ministère du Développement économique et du Commerce de l’Alberta). Rose Yeung est directrice médicale du Bureau de l’éducation permanente et du Programme de formation médicale de l’Université de l’Alberta; ce programme est subventionné par le gouvernement de l’Alberta. Darren Lau a reçu des honoraires du Collège des médecins de famille de l’Alberta. Aucun autre intérêt concurrent n’a été déclaré.

Objective: To characterize transitions to acute and residential care and identify variables associated with specific transitions among community-based persons living with dementia (PLWD)., Design: Retrospective cohort study using primary care electronic medical record data linked with health administrative data., Setting: Alberta., Participants: Adults aged 65 years or older living in the community who had been diagnosed with dementia and who saw a Canadian Primary Care Sentinel Surveillance Network contributor between January 1, 2013, and February 28, 2015., Main Outcome Measures: All emergency department visits, hospitalizations, residential care (supportive living and long-term care) admissions, and deaths within a 2-year follow-up period., Results: In total, 576 PLWD were identified who had a mean (SD) age of 80.4 (7.7) years; 55% were female. In 2 years, 423 (73.4%) had at least 1 transition and, of these, 111 (26.2%) had 6 or more. Emergency department visits, including multiple visits, were common (71.4% had ≥1, 12.1% had ≥4). Of those hospitalized (43.8%), nearly all were admitted from the emergency department; the average (SD) length of stay was 23.6 (35.8) days, and 32.9% had at least 1 alternate level of care day. In total, 19.3% entered residential care, most admitted from hospital. Those admitted to hospital and those admitted to residential care were older and had greater historical health system use, including home care. One-quarter of the sample did not have any transitions (or die) during follow-up; they were typically younger and had limited historical health system use., Conclusion: Older PLWD experienced frequent, and frequently compound, transitions that have implications for them, their family members, and the health system. There was also a large proportion without transitions suggesting that appropriate supports enable PLWD to do well in their own communities. The identification of PLWD who are at risk of or who make frequent transitions may allow for more proactive implementation of community-based supports and smoother transitions to residential care., (Copyright © 2023 the College of Family Physicians of Canada.)

Background: An update on the degree to which patients with type 2 diabetes in Canada achieve treatment targets is needed to document progress and identify subgroups that need attention. We sought to estimate the frequency with which patients managed in primary care met treatment targets (i.e., HbA 1c ≤ 7.0%, blood pressure < 130/80 mm Hg and low-density lipoprotein cholesterol [LDL-C] < 2.00 mmol/L), guideline-based use of statins and of angiotensin-convertingenzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs), and the effects of patient age and sex., Methods: We conducted a cross-sectional study of 32 503 and 44 930 adults with diabetes in Canada on June 30, 2015, and 2020, respectively, using electronic medical record data from primary care practices across 5 provinces. We grouped achievement of diabetes targets by age and sex, and compared between groups using logistic regression with adjustment for cardiovascular comorbidities., Results: In 2020, target HbA 1c levels were achieved for 63.8% of women and 58.9% of men. Blood pressure and LDL-C targets were achieved for 45.6% and 45.8% of women, and for 43.1% and 59.4% of men, respectively. All 3 treatment targets were achieved for 13.3% of women and 16.5% of men. Overall, 45.3% and 54.0% of women and men, respectively, used statins; 46.5% of women used ACE inhibitors or ARBs, compared with 51.9% of men. With the exception of blood pressure and HbA 1c levels among women, target achievement was lower among younger patients. Achievement of the LDL-C target, statin use and ACE inhibitor or ARB use were lower among women at any age. From 2015 to 2020, target achievement increased for HbA 1c , remained consistent for LDL-C and declined for blood pressure; use of statins and of ACE inhibitors or ARBs also declined., Interpretation: Target achievement for blood pressure and use of statins and of ACE inhibitors and ARBs declined between 2015 and 2020, and was suboptimal in all patient groups. Widespread quality improvement is needed to increase evidence-based therapy for people with diabetes., Competing Interests: Competing interests: Rose Yeung has received research funding from Novo Nordisk Alberta Diabetes Fund (University Hospital Foundation, Novo Nordisk and Alberta Economic Development and Trade). Rose Yeung is medical director of the University of Alberta Office of Lifelong Learning and Physician Learning Program; the Physician Learning Program is funded by the Government of Alberta. Darren Lau reports payment from the Alberta College of Family Physicians. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

The aim of the BETTER WISE intervention is to address cancer and chronic disease prevention and screening (CCDPS) and lifestyle risks in patients aged 40-65. The purpose of this qualitative study is to better understand facilitators and barriers to the implementation of the intervention. Patients were invited for a 1-h visit with a prevention practitioner (PP), a member of a primary care team, with specific skills in prevention, screening, and cancer survivorship. We collected and analyzed data from 48 key informant interviews and 17 focus groups conducted with 132 primary care providers and from 585 patient feedback forms. We analyzed all qualitative data using a constant comparative method informed by grounded theory and then employed the Consolidated Framework for Implementation Research (CFIR) in a second round of coding. The following key elements were identified: (1) Intervention characteristics-relative advantage and adaptability; (2) Outer setting-PPs compensating for increased patient needs and decreased resources; (3) Characteristics of individuals-PPs (patients and physicians described PPs as compassionate, knowledgeable, and helpful); (4) Inner setting-network and communication (collaboration and support in teams or lack thereof); and (5) Process-executing the implementation (pandemic-related issues hindered execution, but PPs adapted to challenges). This study identified key elements that facilitated or hindered the implementation of BETTER WISE. Despite the interruption caused by the COVID-19 pandemic, the BETTER WISE intervention continued, driven by the PPs and their strong relationships with their patients, other primary care providers, and the BETTER WISE team., Competing Interests: Competing interestDPM and CF are Directors of a Canadian not-for-profit organization, The BETTER Institute, which provides training and implementation support to practices, organizations, and communities interested in adopting or adapting the BETTER approach. There are no other competing interests to declare that are relevant to the content of this article., (© The Author(s) 2023.)

Purpose: Electronic consultation (eConsult) is a freely-available secure online platform connecting primary care providers (PCPs) to geneticists. Our purpose was to determine whether eConsult is effective in improving genetics service delivery in primary care., Methods: PCP questionnaires regarding eConsult's utility, geneticists' tracking form assessments of eConsult type and appropriateness, and geneticists' interviews on implementing eConsult were carried out., Results: In 2 regions of Ontario, Canada, from January 2019 to June 2020, there were 305 genetics eConsults. For 169 (55%), PCPs indicated receiving good advice for a new course of action; for 110 (36%), referral was now avoided; and for 261 (86%), eConsult was perceived valuable for patient management. Of the 131 geneticist-completed tracking forms, cancer questions were most common (68, 52%). For 63 (48%), geneticists disagreed/strongly disagreed PCPs should know the answer to the referral question. From the interview data, it was observed that geneticists described eConsult positively and suggested how it might improve access and efficiencies if integrated into genetic service delivery. Dealing with eConsults virtually could reduce waitlists, and suggesting appropriate investigations for PCPs could improve efficiencies., Conclusion: eConsult offers a potential solution for receiving timely genetics advice and avoiding unnecessary patient referrals, however, greater effect on access and wait times will need systematic integration into PCP and geneticist practice., Competing Interests: Conflict of Interest C.L. and E.K. are cofounders of the Champlain BASE eConsult Service, but they have no commercial interest in the service and do not retain any proprietary rights. As Coexecutive Directors of the Ontario eConsult Centre of Excellence, they receive salary support from the Ontario Ministry of Health. E.K. answers occasional electronic consultations (less than 1 per month) as a specialist through the service for which she is reimbursed. All other authors report no conflicts of interest., (Copyright © 2022 American College of Medical Genetics and Genomics. Published by Elsevier Inc. All rights reserved.)

Introduction: Sleep-time blood pressure correlates more strongly with adverse cardiovascular events than does daytime blood pressure. The BedMed trial evaluates whether bedtime antihypertensive administration, as compared with conventional morning use, reduces major adverse cardiovascular events. METHODS AND ANALYSIS: Design Prospective randomised, open-label, blinded end-point trial. Participants Hypertensive primary care patients using blood pressure lowering medication and free from glaucoma. Setting Community primary care providers in 5 Canadian provinces (British Columbia, Alberta, Saskatchewan, Manitoba and Ontario) are mailing invitations to their eligible patients. Social media campaigns (Google, Facebook) are additionally running in the same provinces. Intervention Consenting participants are allocated via central randomisation to bedtime vs morning use of all antihypertensives. Follow-up (1) Telephone or email questionnaire at 1 week, 6 weeks, 6 months and every 6 months thereafter, and (2) accessing linked governmental healthcare databases tracking hospital and community medical services. Primary outcome Composite of all-cause death, or hospitalisation for myocardial infarction/acute-coronary syndrome, stroke or congestive heart failure. Secondary outcomes Each primary outcome element on its own, all-cause hospitalisation or emergency department visit, long-term care admission, non-vertebral fracture, new glaucoma diagnosis, 18-month cognitive decline from baseline (via Short Blessed Test). Select other outcomes Self-reported nocturia burden at 6 weeks and 6 months (no, minor or major burden), 1-year self-reported overall health score (EQ-5D-5L), self-reported falls, total cost of care (acute and community over study duration) and mean sleep-time systolic blood pressure after 6 months (via 24-hour monitor in a subset of 302 sequential participants). Primary outcome analysis Cox proportional hazards survival analysis. Sample size The trial will continue until a projected 254 primary outcome events have occurred. Current status Enrolment ongoing (3227 randomised to date)., Ethics and Dissemination: BedMed has ethics approval from six research ethics review boards and will publish results in a peer-reviewed journal., Trial Registration Number: NCT02990663., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The prevalence of metabolic syndrome is growing worldwide, yet remains underinvestigated in Canadian young adults. We sought to explore the use of a harmonized case definition specific to early-onset metabolic syndrome and determine its feasibility in assessing the prevalence of metabolic syndrome among electronic medical record (EMR) data of young adults in Northern Alberta., Methods: We conducted a cross-sectional study using a sample of EMR data from young adult patients aged 18-40 years and residing in Northern Alberta, who had an encounter with a participating primary care clinic between June 29, 2015, and June 29, 2018. Physical examination, laboratory investigation and disease diagnosis data were collected. A case definition and algorithm were developed to assess the feasibility of identifying metabolic syndrome, including measures for body mass index (BMI), blood pressure (BP), dysglycemia, hypertriglyceridemia, high-density lipoprotein cholesterol, diabetes and hypertension., Results: Among 15 766 young adults, the case definition suggested the prevalence of metabolic syndrome was 4.4%, 95% confidence interval (CI) 4.1%-4.7%. The most frequent 3-factor combination (41.6%, 95% CI 37.9%-45.3%) of metabolic syndrome criteria consisted of being overweight or obese, having elevated BP and hypertriglyceridemia. Half of metabolic syndrome cases (51.3%, 95% CI 47.6%-55.0%) were missing measures for fasting blood glucose, and one-fifth were missing a hemoglobin A 1c (HbA 1c ) level. Notably, most young adults with a BMI of 25 or greater were missing HbA 1c (68.7%, 95% CI 67.6%-69.8%), fasting blood glucose (84.0%, 95% CI 83.2%-84.8%) and triglyceride testing (79.0%, 95% CI 78.1%-79.9%)., Interpretation: We have shown that our case definition is feasible in identifying early-onset metabolic syndrome using EMR data; however, the degree of missing data limits the feasibility in assessing prevalence. Further investigation is required to validate this case definition for metabolic syndrome in the EMR data, which may involve comparing this definition to other validated metabolic syndrome case definitions., Competing Interests: Competing interests: Jamie Boisvenue received studentship funding from the Alberta Diabetes Institute for the duration of this project. Roseanne Yeung reports grants from AstraZeneca, personal fees from Merck, personal fees from Novo Nordisk and personal fees from Sanofi, outside the submitted work. Carlo Oliva, Donna Manca and Jeffrey Johnson have no disclosures. No other competing interests were declared., (Copyright 2020, Joule Inc. or its licensors.)

Dietary modifications are key health behaviour recommendations for the prevention and management of hypertension, a leading contributor of global disease burden. Despite this, few primary care physicians discuss nutrition with their patients. This study describes the barriers and facilitators to the provision of dietary advice for hypertension prevention and management among Canadian physicians. A validated 62-item cross-sectional survey was distributed online to 103 Canadian primary care physicians between 2017 and 2019. Eighty participants were included in the analyses. The majority of participants were based in Ontario (68.7%) and saw 10-24 patients per week (53.5%). Fewer than half (47.5%) of participants were knowledgeable about the recommended sodium level by Hypertension Canada (< 2000 mg/day) and 38.8% felt it was difficult to know which foods are high or low in sodium. Approximately one quarter felt the findings about sodium and hypertension and cardiovascular disease are controversial. Other significant barriers were: not enough time to talk to patients about diet (76.3%), belief that patients are not truthful about their diet (76.3%), patients would not follow their advice (46.8%), and that it was difficult to keep up with so many guidelines (50.0%). Many identified that electronic medical record tools (80.8%), access to dietitians (84.9%), or more nutrition education in medical training (65.8%) would help facilitate advice. Given the importance of diet and the central role of physicians in motivating dietary change among patients, approaches are required to address identified barriers and facilitators to providing dietary advice to reduce the burden of hypertension.

Objectives: This study evaluated the use of Healthy Conversation Skills (a client-centered communication approach to behaviour change) in supporting women to achieve optimal gestational-weight-gain and health behaviours., Methods: Seventy pregnant women were randomised to the control or intervention group. Study visits and phone calls were delivered by Registered Dietitians (RDs) to women in the intervention and control groups. The intervention RD was trained in Healthy Conversation Skills while the control RD was not. Diet, physical activity and gestational-weight-gain were assessed at baseline and again at follow-up in the intervention and control groups., Results: Women in the intervention group improved their diet score between baseline and visit 2, while the control group did not. At 34 weeks, women in the control group reported being sedentary for longer than women in the intervention group. There were no differences in total gestational-weight-gain between the groups., Conclusions: Pregnant women who interacted with an RD using Healthy Conversation Skills reported positive outcomes in health behaviours., Practice Implications: Healthy Conversation Skills shows promise as an approach to initiate, and maintain discussions promoting health behaviour change in pregnancy., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Objective: To determine the stability of warfarin anticoagulation using a nationally representative sample of Canadian primary care patients and providers., Design: Prospective cohort study., Setting: Primary care practices associated with the Canadian Primary Care Sentinel Surveillance Network., Participants: Adult warfarin users with 7 or more evaluable international normalized ratio (INR) readings., Main Outcomes Measures: International normalized ratio time in therapeutic range (TTR) determined using the Rosendaal method; TTR above 75% was considered good INR control and TTR below 60% was considered poor INR control. The primary outcome was the proportion of all warfarin users (using an INR target range of 2.0 to 3.5) with good INR control during their first year taking warfarin who have poor INR control the following year. Secondary outcomes included the TTR using an INR target of 2.0 to 3.0 when restricted to patients with known atrial fibrillation (AF) or venous thromboembolism (VTE); and the proportion of INR values below the target of 2.0 and above the targets of 3.0 and 3.5 in the year before the availability of other oral anticoagulants., Results: Among 18 303 adult warfarin users (mean age of 71.0 years, 46.6% female), the median TTR (INR target range of 2.0 to 3.5) was 77.4% (interquartile range of 64.6% to 86.4%). The TTR was above 75% in 56.0% of patients and below 60% in 19.3% of patients. Of those exhibiting good INR control in year 1 of anticoagulation therapy, only 10.2% had poor control the following year. When restricted to patients with known AF or VTE (89.7% with AF and 13.5% with VTE), and assuming an INR target range of 2.0 to 3.0, the TTR was 67.8% (interquartile range of 54.8% to 77.9%). Of these patients, 27.9% had INR values below 2.0, and 19.4% and 8.6% had values above 3.0 and 3.5, respectively., Conclusion: Primary care warfarin management produces a TTR comparable to that in randomized trials, with out-of-range INR values 3 times more likely to predispose to thrombosis (INR of < 2.0) than to hemorrhage (INR of > 3.5). A history of good INR control does predict future INR stability and meaningfully informs decisions to switch established warfarin users onto newer agents., (Copyright© the College of Family Physicians of Canada.)

Background: There is a pressing need to reduce the burden of chronic disease and improve healthcare system sustainability through improved cancer and chronic disease prevention and screening (CCDPS) in primary care. We aim to create an integrated approach that addresses the needs of the general population and the special concerns of cancer survivors. Building on previous research, we will develop, implement, and test the effectiveness of an approach that proactively targets patients to attend an individualized CCDPS intervention delivered by a Prevention Practitioner (PP). The objective is to determine if patients randomized to receive an individualized PP visit (vs standard care) have improved cancer surveillance and CCDPS outcomes. Implementation frameworks will help identify and address facilitators and barriers to the approach and inform future dissemination and uptake., Methods/design: The BETTER WISE project is a pragmatic two-arm cluster randomized controlled trial embedded in a mixed methods design, including a qualitative evaluation and an economic assessment. The intervention, informed by the expanded chronic care model and previous research, will be refined by engaging researchers, practitioners, policy makers, and patients. The BETTER WISE tool kit includes blended care pathways for cancer survivors (breast, colorectal, prostate) and CCDPS including lifestyle risk factors and screening for poverty. Patients aged 40-65, including both cancer survivors and general population patients, will be randomized at the physician level to an intervention group or to a wait-list control group. Once the intervention is completed, patients randomized to wait-list control will be invited to receive a prevention visit. The main outcome, calculated at 12-months follow-up, will be an individual patient-level summary composite index, defined as the proportion of CCDPS actions achieved relative to those for which the patient was eligible at baseline. A qualitative evaluation will capture information related to program outcome, implementation (facilitators and barriers), and sustainability. An economic assessment will examine the projected cost-benefit impact of investing in the BETTER WISE approach., Discussion: This project builds on existing work and engages end users throughout the process to develop, implement, and determine the effectiveness of a multi-faceted intervention that addresses CCDPS and cancer survivorship in primary care settings., Trial Registration: ISRCTN21333761 . Registered on December 19, 2016.

Background: Chronic disease prevention and screening (CDPS) has been identified as a top priority in primary care. However, primary care providers often lack time, evidence-based tools, and consistent guidelines to effectively address CDPS. Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER) is a novel approach that introduces a new role, that of the prevention practitioner; the prevention practitioner meets with patients, one on one, to undertake a personalised CDPS visit. Understanding patients' perspectives is important for clinicians and other stakeholders aiming to address and integrate CDPS., Aim: To describe patients' perspectives regarding visits with a prevention practitioner in BETTER 2, an implementation study that was carried out after the BETTER trial and featured a higher proportion of patients in rural and remote locations., Design & Setting: Qualitative description based on patient feedback surveys, completed by patients in three primary care clinics (urban, rural, and remote) in Newfoundland and Labrador, Canada., Method: Patients' perspectives were assessed based on responses from 91 feedback forms. In total, 154 patients (aged 40-65 years) received ≥1 prevention visit(s) from a prevention practitioner and were asked to provide written feedback. In addition to demographics, patients were asked what they liked about their visit(s), what they would have liked to be different, and invited to make any other comments. Qualitative description was used to analyse the data., Results: Four main themes emerged from patients' feedback: value of visit (patients appreciated the visit with a prevention practitioner); visit characteristics (the visit was personalised, comprehensive, and sufficiently long); prevention practitioners' characteristics (professionalism and interpersonal skills); and patients' concerns (termination of the programme and access to preventative care)., Conclusion: Patients appreciated the visits they received with a prevention practitioner and expressed their desire to receive sustained CDPS in primary care., Competing Interests: The authors declare that no competing interests exist.

Background: Family physicians (fps) play a role in aspects of personalized medicine in cancer, including assessment of increased risk because of family history. Little is known about the potential role of fps in supporting cancer patients who undergo tumour gene expression profile (gep) testing., Methods: We conducted a mixed-methods study with qualitative and quantitative components. Qualitative data from focus groups and interviews with fps and cancer specialists about the role of fps in breast cancer gep testing were obtained during studies conducted within the pan-Canadian canimpact research program. We determined the number of visits by breast cancer patients to a fp between the first medical oncology visit and the start of chemotherapy, a period when patients might be considering results of gep testing., Results: The fps and cancer specialists felt that ordering gep tests and explaining the results was the role of the oncologist. A new fp role was identified relating to the fp-patient relationship: supporting patients in making adjuvant therapy decisions informed by gep tests by considering the patient's comorbid conditions, social situation, and preferences. Lack of fp knowledge and resources, and challenges in fp-oncologist communication were seen as significant barriers to that role. Between 28% and 38% of patients visited a fp between the first oncology visit and the start of chemotherapy., Conclusions: Our findings suggest an emerging role for fps in supporting patients who are making adjuvant treatment decisions after receiving the results of gep testing. For success in this new role, education and point-of-care tools, together with more effective communication strategies between fps and oncologists, are needed., Competing Interests: We have read and understood Current Oncology’s policy on disclosing conflicts of interest, and we declare that we have none.

Objective: To assess the proportion of primary care patients who report a family history (FH) of type 2 diabetes, coronary artery disease, breast cancer, or colorectal cancer (CRC); assess concordance of FH information derived from the electronic medical record (EMR) compared with patient-completed health questionnaires; and assess whether appropriate screening was informed by risk based solely on FH., Design: Data from the BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) trial were used. Patients were mailed questionnaires. Baseline FH and screening data were obtained for enrolled patients from the EMR and health questionnaires., Setting: Ontario and Alberta., Participants: Randomly selected patients from 8 family practices., Main Outcome Measures: Agreement on FH between the EMR and questionnaire was determined; logistic regression was used to assess significant predictors of screening., Results: In total, 775 of 789 (98%) patients completed the health questionnaire. The mean age of participants was 52.5 years and 72% were female. A minimum of 12% of patients (range 12% to 36%) had a reported FH of 1 of 4 chronic diseases. Among patients with positive FH, the following proportions of patients had that FH recorded in the EMR compared with the questionnaire: diabetes, 24% in the EMR versus 36% on the questionnaire, κ = 0.466; coronary artery disease, 35% in the EMR versus 22% on the questionnaire, κ = 0.225; breast cancer, 21% in the EMR versus 22% on the questionnaire, κ = 0.241; and CRC, 12% in the EMR versus 14% on the questionnaire, κ = 0.510. There was moderate agreement for diabetes and CRC. The presence of FH was a significant predictor of CRC screening (odds ratio 1.9, 95% CI 1.1 to 3.1)., Conclusion: A moderate prevalence of FH was found for 4 conditions for which screening recommendations vary with risk based on FH. Having patients self-complete an FH was thought to be feasible; however, questions about FH accuracy and completeness from both self-report and EMR remain. Work is needed to determine how to facilitate the adoption of FH tools into practice as well as strategies linking familial risk to appropriate screening.Trial registration number ISRCTN07170460 (ISRCTN Registry)., (Copyright© the College of Family Physicians of Canada.)

Background: BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) is a patient-based intervention to improve chronic disease prevention and screening (CDPS) for cardiovascular disease, diabetes, cancer, and associated lifestyle factors in patients aged 40 to 65. The key component of BETTER is a prevention practitioner (PP), a health care professional with specialized skills in CDPS who meets with patients to develop a personalized prevention prescription, using the BETTER toolkit and Brief Action Planning. The purpose of this qualitative study was to understand facilitators and barriers of the implementation of the BETTER 2 program among clinicians, patients, and stakeholders in three (urban, rural, and remote) primary care settings in Newfoundland and Labrador, Canada., Methods: We collected and analyzed responses from 20 key informant interviews and 5 focus groups, as well as memos and field notes. Data were organized using Nvivo 10 software and coded using constant comparison methods. We then employed the Consolidated Framework for Implementation Research (CFIR) to focus our analysis on the domains most relevant for program implementation., Results: The following key elements, within the five CFIR domains, were identified as impacting the implementation of BETTER 2: (1) intervention characteristics-complexity and cost of the intervention; (2) outer setting-perception of fit including lack of remuneration, lack of resources, and duplication of services, as well as patients' needs as perceived by physicians and patients; (3) characteristics of prevention practitioners-interest in prevention and ability to support and motivate patients; (4) inner setting-the availability of a local champion and working in a team versus working as a team; and (5) process-planning and engaging, collaboration, and teamwork., Conclusions: The implementation of a novel CDPS program into new primary care settings is a complex, multi-level process. This study identified key elements that hindered or facilitated the implementation of the BETTER approach in three primary care settings in Newfoundland and Labrador. Employing the CFIR as an overarching typology allows for comparisons with other contexts and settings, and may be useful for practices, researchers, and policy-makers interested in the implementation of CDPS programs.

Objective: To explore health care provider (HCP) perspectives on the coordination of cancer care between FPs and cancer specialists., Design: Qualitative study using semistructured telephone interviews., Setting: Canada., Participants: A total of 58 HCPs, comprising 21 FPs, 15 surgeons, 12 medical oncologists, 6 radiation oncologists, and 4 GPs in oncology., Methods: This qualitative study is nested within a larger mixed-methods program of research, CanIMPACT (Canadian Team to Improve Community-Based Cancer Care along the Continuum), focused on improving the coordination of cancer care between FPs and cancer specialists. Using a constructivist grounded theory approach, telephone interviews were conducted with HCPs involved in cancer care. Invitations to participate were sent to a purposive sample of HCPs based on medical specialty, sex, province or territory, and geographic location (urban or rural). A coding schema was developed by 4 team members; subsequently, 1 team member coded the remaining transcripts. The resulting themes were reviewed by the entire team and a summary of results was mailed to participants for review., Main Findings: Communication challenges emerged as the most prominent theme. Five key related subthemes were identified around this core concept that occurred at both system and individual levels. System-level issues included delays in medical transcription, difficulties accessing patient information, and physicians not being copied on all reports. Individual-level issues included the lack of rapport between FPs and cancer specialists, and the lack of clearly defined and broadly communicated roles., Conclusion: Effective and timely communication of medical information, as well as clearly defined roles for each provider, are essential to good coordination of care along the cancer care trajectory, particularly during transitions of care between cancer specialist and FP care. Despite advances in technology, substantial communication challenges still exist. This can lead to serious consequences that affect clinical decision making., (Copyright© the College of Family Physicians of Canada.)

Objective: To assess primary care providers' (PCPs') experiences with, perceptions of, and desired role in personalized medicine, with a focus on cancer., Design: Qualitative study involving focus groups., Setting: Urban and rural interprofessional primary care team practices in Alberta and Ontario., Participants: Fifty-one PCPs., Methods: Semistructured focus groups were conducted and audiorecorded. Recordings were transcribed and analyzed using techniques informed by grounded theory including coding, interpretations of patterns in the data, and constant comparison., Main Findings: Five focus groups with the 51 participants were conducted; 2 took place in Alberta and 3 in Ontario. Primary care providers described limited experience with personalized medicine, citing breast cancer and prenatal care as main areas of involvement. They expressed concern over their lack of knowledge, in some circumstances relying on personal experiences to inform their attitudes and practice. Participants anticipated an inevitable role in personalized medicine primarily because patients seek and trust their advice; however, there was underlying concern about the magnitude of information and pace of discovery in this area, particularly in direct-to-consumer personal genomic testing. Increased knowledge, closer ties to genetics specialists, and relevant, reliable personalized medicine resources accessible at the point of care were reported as important for successful implementation of personalized medicine., Conclusion: Primary care providers are prepared to discuss personalized medicine, but they require better resources. Models of care that support a more meaningful relationship between PCPs and genetics specialists should be pursued. Continuing education strategies need to address knowledge gaps including direct-to-consumer genetic testing, a relatively new area provoking PCP concern. Primary care providers should be mindful of using personal experiences to guide care., (Copyright© the College of Family Physicians of Canada.)

Objective: To explore patient perspectives on and experiences with the coordination and continuity of cancer care., Design: Qualitative study using semistructured telephone interviews., Setting: Canada., Participants: Thirty-eight breast and colorectal cancer survivors 1 to 4 years after diagnosis., Methods: Using a constructivist grounded theory approach, semistructured telephone interviews were conducted with the participants. The interviews were digitally recorded, transcribed verbatim, and proofread. Transcripts were reviewed to create a focused coding scheme that was used to develop categories for participants' experiences., Main Findings: Although this study focused on the continuity of cancer care, patients described their experiences with cancer care in general, concentrating predominantly on their relationships with individual health care providers (HCPs). Based on patients' experiences, several themes were identified as the core components of providing good continuity and well coordinated care. The most important overarching theme was communication, which overlapped with 4 other themes: patient-HCP relationships, the role of HCPs, lack of access to care, and timely and tailored information., Conclusion: Patients believed that good communication between HCPs and patients was key to improving the overall continuity of cancer care. Continuity of care is an important theoretical concept in cancer care, but it is not easily recognized by patients. They perceive the cancer care continuum and continuity of care as cancer care in general, which is typically framed by the individual relationships with their HCPs. Future research and interventions need to focus on finding and testing ways to improve communication to enhance continuity of cancer care., (Copyright© the College of Family Physicians of Canada.)

Background: Recruitment is often a difficult and costly part of any human research study. Social media and other emerging means of mass communication hold promise as means to complement traditional strategies used for recruiting participants because they can reach a large number of people in a short amount of time. With the ability to target a specified audience, paid Facebook advertisements have potential to reach future research participants of a specific demographic. This paper describes the experiences of a randomized controlled trial in Edmonton, Alberta, attempting to recruit healthy pregnant women between 8 and 20 weeks' gestation for participation in a prenatal study. Various traditional recruitment approaches, in addition to paid Facebook advertisements were trialed., Objective: To evaluate the effectiveness of paid advertisements on Facebook as a platform for recruiting pregnant women to a randomized controlled trial in comparison with traditional recruitment approaches., Methods: Recruitment using traditional approaches occurred for 7 months, whereas Facebook advertisements ran for a total of 26 days. Interested women were prompted to contact the study staff for a screening call to determine study eligibility. Costs associated with each recruitment approach were recorded and used to calculate the cost to recruit eligible participants. Performance of Facebook advertisements was monitored using Facebook Ads Manager., Results: Of the 115 women included, 39.1% (n=45) of the women who contacted study staff heard about the study through Facebook, whereas 60.9% (n=70) of them heard about it through traditional recruitment approaches. During the 215 days (~7 months) that the traditional approaches were used, the average rate of interest was 0.3 (0.2) women/day, whereas the 26 days of Facebook advertisements resulted in an average rate of interest of 2.8 (1.7) women/day. Facebook advertisements cost Can $506.91 with a cost per eligible participant of Cad $20.28. In comparison, the traditional approaches cost Cad $1087, with approximately Cad $24.15 per eligible participant. Demographic characteristics of women were similar between the 2 recruitment methods except that women recruited using Facebook were significantly earlier in their pregnancy than those recruited using traditional approaches (P<.03)., Conclusions: Paid Facebook advertisements hold promise as a platform for reaching pregnant women. The relative ease of placing an advertisement, the comparable cost per participant recruited, and the dramatically improved recruitment rates in comparison with traditional approaches highlight the importance of combining novel and traditional recruitment approaches to recruit women for pregnancy-related studies., Trial Registration: ClinicalTrials.gov NCT02711644; https://clinicaltrials.gov/ct2/show/NCT02711644 (Archived by WebCite at http://www.webcitation.org/6kKpagpMk)., Competing Interests: Conflicts of Interest: None declared.

Background: Asthma is the most common chronic condition in children. For many, the disease is inadequately controlled, which can burden the lives of children and their families as well as the health care system. Improved use of the best available scientific evidence by primary care practitioners could reduce the need for hospital care and improve quality of life and asthma control, thereby reducing overall costs to society and families., Objective: The Primary Care Pathway for Childhood Asthma aims to improve the management of children with asthma by (1) providing primary care practitioners with an electronic guide (a clinical pathway) incorporated into the patient's electronic medical record, and (2) providing train-the-trainer education to chronic disease management health professionals to promote the provision of asthma education in primary care., Methods: The research will utilize a pragmatic cluster-controlled design, quantitative and qualitative research methodologies, and economic evaluation to assess the implementation of a pathway and education intervention in primary care. The intervention will be analyzed for effectiveness, and if the results are positive, a strategy will be developed to implement delivery to all primary care practices in Alberta., Results: The research has been successfully funded and ethics approvals have been obtained. Practice recruitment began fall 2015, and we expect all study-related activities to be concluded by March 2018., Conclusions: The proposed pathway and education intervention has the potential to improve pediatric asthma management in Alberta. The intervention is anticipated to result in better quality of care for equal or lesser cost., Clinicaltrial: ClinicalTrials.gov NCT02481037; https://clinicaltrials.gov/ct2/show/NCT02481037 (Archived by WebCite at http://www.webcitation.org/6fPIQ02Ma).

Background: The 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., Methods: A 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., Results: The 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., Conclusion: The 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 Registration: The registration number of the original RCT BETTER trial was ISRCTN07170460 .

Background: The objectives of this paper are to describe the planned implementation and evaluation of the Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care (BETTER 2) program which originated from the BETTER trial. The pragmatic trial, informed by the Chronic Care Model, demonstrated the effectiveness of an approach to Chronic Disease Prevention and Screening (CDPS) involving the use of a new role, the prevention practitioner. The desired goals of the program are improved clinical outcomes, reduction in the burden of chronic disease, and improved sustainability of the health-care system through improved CDPS in primary care., Methods/design: The BETTER 2 program aims to expand the implementation of the intervention used in the original BETTER trial into communities across Canada (Alberta, Ontario, Newfoundland and Labrador, the Northwest Territories and Nova Scotia). This proactive approach provides at-risk patients with an intervention from the prevention practitioner, a health-care professional. Using the BETTER toolkit, the prevention practitioner determines which CDPS actions the patient is eligible to receive, and through shared decision-making and motivational interviewing, develops a unique and individualized 'prevention prescription' with the patient. This intervention is 1) personalized; 2) addressing multiple conditions; 3) integrated through linkages to local, regional, or national resources; and 4) longitudinal by assessing patients over time. The BETTER 2 program brings together primary care providers, policy/decision makers and researchers to work towards improving CDPS in primary care. The target patient population is adults aged 40-65. The reach, effectiveness, adoption, implementation, maintain (RE-AIM) framework will inform the evaluation of the program through qualitative and quantitative methods. A composite index will be used to quantitatively assess the effectiveness of the prevention practitioner intervention. The CDPS actions comprising the composite index include the following: process measures, referral/treatment measures, and target/change outcome measures related to cardiovascular disease, diabetes, cancer and associated lifestyle factors., Discussion: The BETTER 2 program is a collaborative approach grounded in practice and built from existing work (i.e., integration not creation). The program evaluation is designed to provide an understanding of issues impacting the implementation of an effective approach for CDPS within primary care that may be adapted to become sustainable in the non-research setting.

Background: Our randomized controlled trial (The BETTER Trial) found that training a clinician to become a Prevention Practitioner (PP) in family practices improved chronic disease prevention and screening (CDPS). PPs were trained on CDPS and provided prevention prescriptions tailored to participating patients. For this embedded qualitative study, we explored perceptions of this new role to understand the PP intervention., Methods: We used grounded theory methodology and purposefully sampled participants involved in any capacity with the BETTER Trial. Two physicians and one coordinator in each of two cities (Toronto, Ontario and Edmonton, Alberta) conducted eight individual semi-structured interviews and seven focus groups. We used an interview guide and documented research activities through an audit trail, journals, field notes and memos. We analyzed the data using the constant comparative method throughout open coding followed by theoretical coding., Results: A framework and process involving external and internal practice facilitation using the new role of PP was thought to impact CDPS. The PP facilitated CDPS through on-going relationships with patients and practice team members. Key components included: 1) approaching CDPS in a comprehensive manner, 2) an individualized and personalized approach at multiple levels, 3) integrated continuity that included linking the patients and practices to CPDS resources, and 4) adaptability to different practices and settings., Conclusions: The BETTER framework and key components are described as impacting CDPS through a process that involved a new role, the PP. The introduction of a novel role of a clinician within the primary care practice with skills in CDPS could appropriately address gaps in prevention and screening.

The Alberta Pregnancy Outcomes and Nutrition (APrON) study is an ongoing prospective cohort study that recruits pregnant women early in pregnancy and, as of 2012, is following up their infants to 3 years of age. It has currently enrolled approximately 5000 Canadians (2000 pregnant women, their offspring and many of their partners). The primary aims of the APrON study were to determine the relationships between maternal nutrient intake and status, before, during and after gestation, and (1) maternal mood; (2) birth and obstetric outcomes; and (3) infant neurodevelopment. We have collected comprehensive maternal nutrition, anthropometric, biological and mental health data at multiple points in the pregnancy and the post-partum period, as well as obstetrical, birth, health and neurodevelopmental outcomes of these pregnancies. The study continues to follow the infants through to 36 months of age. The current report describes the study design and methods, and findings of some pilot work. The APrON study is a significant resource with opportunities for collaboration., (© 2012 John Wiley & Sons Ltd.)

Background: Pregnant women were recruited into the Alberta Pregnancy Outcomes and Nutrition (APrON) study in two cities in Alberta, Calgary and Edmonton. In Calgary, a larger proportion of women obtain obstetrical care from family physicians than from obstetricians; otherwise the cities have similar characteristics. Despite similarities of the cities, the recruitment success was very different. The purpose of this paper is to describe recruitment strategies, determine which were most successful and discuss reasons for the different success rates between the two cities., Methods: Recruitment methods in both cities involved approaching pregnant women (< 27 weeks gestation) through the waiting rooms of physician offices, distributing posters and pamphlets, word of mouth, media, and the Internet., Results: Between May 2009 and November 2010, 1,200 participants were recruited, 86% (1,028/1,200) from Calgary and 14% (172/1,200) from Edmonton, two cities with similar demographics. The most effective strategy overall involved face-to-face recruitment through clinics in physician and ultrasound offices with access to a large volume of women in early pregnancy. This method was most economical when clinic staff received an honorarium to discuss the study with patients and forward contact information to the research team., Conclusion: Recruiting a pregnancy cohort face-to-face through physician offices was the most effective method in both cities and a new critically important finding is that employing this method is only feasible in large volume maternity clinics. The proportion of family physicians providing antenatal and post-natal care may impact recruitment success and should be studied further.

Objective: To assess the effects of physician-colleague and coworker abuse on family physicians in Canada., Design: A mixed-methods, bilingual study that included surveys and telephone interviews., Setting: Canada., Participants: Family physicians in active practice who were members of the College of Family Physicians of Canada in 2009., Methods: Surveys were mailed to a random sample of family physicians (N = 3802), and 37 family physicians who had been abused in the past year participated in telephone interviews., Main Findings: A total of 770 surveys (20%) were completed. A small number of respondents reported having been subjected to abuse by physician colleagues (9%) or coworkers (6%) in the previous month. Many of the respondents reported that the same physician colleagues or coworkers were repeat abusers. More than three-quarters (77%) of the physician-colleague abusers were men, whereas more than three-quarters (77%) of the other coworker abusers were women. Interviewed family physicians described feeling humiliated and unappreciated, and developed symptoms of anxiety or depression. As a result of the abuse, some family physicians terminated their employment or refused to work in certain environments. The most striking effect of this abuse was that respondents reported losing confidence in their professional abilities and skills., Conclusion: Although only a small number of family physicians experience abuse by physician colleagues and other coworkers, the effects can be considerable. Victims reported a loss of confidence in their clinical abilities and some subsequently were faced with mental health issues.

Objective: To understand what contributes to good collaborative physician working relationships through identifying the factors that affect working relationships between generalist physicians and specialists., Design: Qualitative study using in-depth interviews., Setting: University and community hospital inpatient family practice settings in Edmonton, Alta., Participants: Eleven physicians from various specialties who graduated between 1977 and 2001., Methods: A grounded-theory approach, including constant comparison and creation of memorandums, helped to conceptualize the main concern and generated a framework for how the main concern was being resolved. A semistructured interview guide was developed and individual, in-depth interviews were audiotaped. Purposeful and theoretical sampling techniques were used. Three researchers participated in the analysis., Main Findings: The findings suggested that when generalist physicians perceived that work had been imposed on them by specialists without negotiation, they felt overwhelmed by the workload. Differing priorities determined whether physicians were left holding the bag or sharing the load. In a system that valued technology and specialized knowledge and skills, the specialists were better able to control resources, set boundaries, and influence learners. This precipitated a culture of protecting valuable specialty resources, increasing physician isolation, and generalists feeling that they were left holding the bag. In order to reverse this cycle, it was important for physicians to develop good working relationships based on accessibility to needed expertise and tests, with negotiated agreements on how to share resources; mutual empowerment, including negotiation of roles and responsibilities to develop flexible relationships with a clear understanding of roles; and concern for fairness by sharing the load., Conclusion: Medical systems that value technology and focused interests might lead to someone being left holding the bag, contributing to generalists feeling overwhelmed and isolated within the system. A comprehensive system that values relationships might help to resolve issues created through perceived inequities in workload, disempowerment, and lack of understanding of roles.

Objective: To increase awareness of the stalking and harassing behaviour physicians sometimes encounter from patients and to explore how best to approach and address this behaviour., Sources of Information: A physician's personal reflection of a stalking incident is combined with a review of the literature. Few studies have addressed this subject., Main Message: Any family physician could be the victim of stalking. Physicians' routines and schedules are often public knowledge because of their availability to their practices; thus they are particularly vulnerable to stalkers. We rarely think of women stalking female family physicians; however, it is likely more common than we realize. Increased awareness of this phenomenon and appropriate interventions could reduce escalation of harassing behaviour. Helpful strategies could include recognizing and addressing the behaviour early, seeking assistance, and documenting all incidents in a separate file that includes tape recordings or other material., Conclusion: We should explore stalking and harassing behaviour openly and become aware of the risks so that we can identify appropriate strategies to avert problems and deal with stalkers.

Physicians lack knowledge on how to help women who have miscarried deal with their emotional distress. We interviewed 16 women 4 and 12 weeks after a miscarriage. The women described their experience of miscarriage and perceptions of what helped or hindered their emotional recovery, particularly physicians' actions. A grief reaction that can be divided into five stages and that was modified through the support of family and friends was identified. The intensity of the grief was related to the personal meaning of the pregnancy.