Showing papers in "Canadian Family Physician in 2017"

Deprescribing proton pump inhibitors: Evidence-based clinical practice guideline.

Abstract: Objective To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper or stop proton pump inhibitors (PPIs); to focus on the highest level of evidence available and seek input from primary care professionals in the guideline development, review, and endorsement processes. Methods Five health professionals (1 family physician, 3 pharmacists, and 1 gastroenterologist) and 5 nonvoting members comprised the overall team; members disclosed conflicts of interest. The guideline process included the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, with a detailed evidence review in in-person, telephone, and online meetings. Uniquely, the guideline development process included a systematic review of PPI deprescribing trials and examination of reviews of the harm of continued PPI use. Narrative syntheses of patient preferences and resource-implication literature informed recommendations. The team refined guideline content and recommendation wording through consensus and synthesized clinical considerations to address common front-line clinician questions. The draft guideline was distributed to clinicians and then to health care professional associations for review and revisions made at each stage. A decision-support algorithm was developed in conjunction with the guideline. Recommendations This guideline recommends deprescribing PPIs (reducing dose, stopping, or using "on-demand" dosing) in adults who have completed a minimum of 4 weeks of PPI treatment for heartburn or mild to moderate gastroesophageal reflux disease or esophagitis, and whose symptoms are resolved. The recommendations do not apply to those who have or have had Barrett esophagus, severe esophagitis grade C or D, or documented history of bleeding gastrointestinal ulcers. Conclusion This guideline provides practical recommendations for making decisions about when and how to reduce the dose of or stop PPIs. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients.

Diagnosis and management of psoriasis

Abstract: Objective To provide primary care clinicians with an up-to-date and practical overview of the diagnosis and management of psoriasis. Quality of evidence PubMed, MEDLINE, EMBASE, and Cochrane databases were searched for relevant meta-analyses, randomized controlled trials, systematic reviews, and observational studies about the diagnosis and management of psoriasis. Main message Psoriasis is a chronic, multisystem inflammatory disease with predominantly skin and joint involvement. Beyond the physical dimensions of disease, psoriasis has an extensive emotional and psychosocial effect on patients, affecting social functioning and interpersonal relationships. As a disease of systemic inflammation, psoriasis is associated with multiple comorbidities, including cardiovascular disease and malignancy. The diagnosis is primarily clinical and a skin biopsy is seldom required. Depending on the severity of disease, appropriate treatment can be initiated. For mild to moderate disease, first-line treatment involves topical therapies including corticosteroids, vitamin D3 analogues, and combination products. These topical treatments are efficacious and can be safely initiated and prescribed by primary care physicians. Patients with more severe and refractory symptoms might require further evaluation by a dermatologist for systemic therapy. Conclusion Many patients with psoriasis seek initial evaluation and treatment from their primary care providers. Recognition of psoriasis, as well as its associated medical and psychiatric comorbidities, would facilitate timely diagnosis and appropriate management with effective and safe topical therapies and other medical and psychological interventions, as needed. More severe and refractory cases might warrant referral to a dermatologist for further evaluation and possible systemic therapy.

Virtual reality for pain and anxiety management in children.

Abstract: Question Pain and anxiety are common in children who need procedures such as administering vaccines or drawing blood. Recent reports have described the use of virtual reality (VR) as a method of distraction during such procedures. How does VR work in reducing pain and anxiety in pediatric patients and what are the potential uses for it? Answer Recent studies explored using VR with pediatric patients undergoing procedures ranging from vaccinations and intravenous injections to laceration repair and dressing changes for burn wounds. Interacting with immersive VR might divert attention, leading to a slower response to incoming pain signals. Preliminary results have shown that VR is effective, either alone or in combination with standard care, in reducing the pain and anxiety patients experience compared with standard care or other distraction methods.

Deprescribing antihyperglycemic agents in older persons: Evidence-based clinical practice guideline.

Abstract: Objective To develop an evidence-based guideline to help clinicians make decisions about when and how to safely taper, stop, or switch antihyperglycemic agents in older adults. Methods We focused on the highest level of evidence available and sought input from primary care professionals in guideline development, review, and endorsement processes. Seven clinicians (2 family physicians, 3 pharmacists, 1 nurse practitioner, and 1 endocrinologist) and a methodologist comprised the overall team; members disclosed conflicts of interest. We used a rigorous process, including the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach, for guideline development. We conducted a systematic review to assess evidence for the benefits and harms of deprescribing antihyperglycemic agents. We performed a review of reviews of the harms of continued antihyperglycemic medication use, and narrative syntheses of patient preferences and resource implications. We used these syntheses and GRADE quality-of-evidence ratings to generate recommendations. The team refined guideline content and recommendation wording through consensus and synthesized clinical considerations to address common front-line clinician questions. The draft guideline was distributed to clinicians and stakeholders for review and revisions were made at each stage. A decision-support algorithm was developed to accompany the guideline. Recommendations We recommend deprescribing antihyperglycemic medications known to contribute to hypoglycemia in older adults at risk or in situations where antihyperglycemic medications might be causing other adverse effects, and individualizing targets and deprescribing accordingly for those who are frail, have dementia, or have a limited life expectancy. Conclusion This guideline provides practical recommendations for making decisions about deprescribing antihyperglycemic agents. Recommendations are meant to assist with, not dictate, decision making in conjunction with patients.

Pharmacologic management of chronic neuropathic pain: Review of the Canadian Pain Society consensus statement.

Abstract: Objective To provide family physicians with a practical clinical summary of the Canadian Pain Society (CPS) revised consensus statement on the pharmacologic management of neuropathic pain. Quality of evidence A multidisciplinary interest group within the CPS conducted a systematic review of the literature on the current treatments of neuropathic pain in drafting the revised consensus statement. Main message Gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are the first-line agents for treating neuropathic pain. Tramadol and other opioids are recommended as second-line agents, while cannabinoids are newly recommended as third-line agents. Other anticonvulsants, methadone, tapentadol, topical lidocaine, and botulinum toxin are recommended as fourth-line agents. Conclusion Many pharmacologic analgesics exist for the treatment of neuropathic pain. Through evidence-based recommendations, the CPS revised consensus statement helps guide family physicians in the management of patients with neuropathic pain.

Emerging role of HPV self-sampling in cervical cancer screening for hard-to-reach women: Focused literature review.

Abstract: Objective To provide a focused critical review of the literature on the acceptability, feasibility, and uptake of human papillomavirus (HPV) self-sampling among hard-to-reach women. Quality of evidence A focused search to obtain relevant literature published in English between 1997 and 2015 was done using PubMed and EMBASE using search terms including HPV self-test or HPV self-sample or HPV kit in combination with acceptability or feasibility. Only studies that focused on never-screened or underscreened populations were included in this review. Main message Human papillomavirus self-sampling was found to be highly acceptable and feasible among these hard-to-reach women across most studies. Mailing of self-sampling kits has been shown to increase participation among hard-to reach women. Some concerns remain regarding adherence to further follow-up among high-risk women with positive test results for HPV after screening. Conclusion There is a strong body of evidence to support the usefulness of HPV self-sampling in increasing participation of hard-to-reach women in screening programs (level I evidence). Convenience, privacy, ease of use, and, likely, cost-effectiveness of HPV self-sampling are driving forces in its emerging role in cervical cancer screening among hard-to-reach women. Key barriers to participation could be addressed by overcoming disparities in HPV-related knowledge and perceptions about cervical cancer screening.

Shared decision making in preventive health care: What it is; what it is not

Abstract: Shared decision making (SDM) is a process whereby clinicians collaboratively help patients to reach evidence-informed and value-congruent medical decisions. This process is especially relevant in screening for conditions in which there is a close trade-off between harms and benefits. Many screening

Primary care management of opioid use disorders: Abstinence, methadone, or buprenorphine-naloxone?

Abstract: Objective To advise physicians on which treatment options to recommend for specific patient populations: abstinence-based treatment, buprenorphine-naloxone maintenance, or methadone maintenance. Sources of information PubMed was searched and literature was reviewed on the effectiveness, safety, and side effect profiles of abstinence-based treatment, buprenorphine-naloxone treatment, and methadone treatment. Both observational and interventional studies were included. Main message Both methadone and buprenorphine-naloxone are substantially more effective than abstinence-based treatment. Methadone has higher treatment retention rates than buprenorphine-naloxone does, while buprenorphine-naloxone has a lower risk of overdose. For all patient groups, physicians should recommend methadone or buprenorphine-naloxone treatment over abstinence-based treatment (level I evidence). Methadone is preferred over buprenorphine-naloxone for patients at higher risk of treatment dropout, such as injection opioid users (level I evidence). Youth and pregnant women who inject opioids should also receive methadone first (level III evidence). If buprenorphine-naloxone is prescribed first, the patient should be promptly switched to methadone if withdrawal symptoms, cravings, or opioid use persist despite an optimal buprenorphine-naloxone dose (level II evidence). Buprenorphine-naloxone is recommended for socially stable prescription oral opioid users, particularly if their work or family commitments make it difficult for them to attend the pharmacy daily, if they have a medical or psychiatric condition requiring regular primary care (level IV evidence), or if their jobs require higher levels of cognitive functioning or psychomotor performance (level III evidence). Buprenorphine-naloxone is also recommended for patients at high risk of methadone toxicity, such as the elderly, those taking high doses of benzodiazepines or other sedating drugs, heavy drinkers, those with a lower level of opioid tolerance, and those at high risk of prolonged QT interval (level III evidence). Conclusion Individual patient characteristics and preferences should be taken into consideration when choosing a first-line opioid agonist treatment. For patients at high risk of dropout (such as adolescents and socially unstable patients), treatment retention should take precedence over other clinical considerations. For patients with high risk of toxicity (such as patients with heavy alcohol or benzodiazepine use), safety would likely be the first consideration. However, the most important factor to consider is that opioid agonist treatment is far more effective than abstinence-based treatment.

Screening for frailty in primary care Accuracy of gait speed and hand-grip strength

Abstract: Objective To examine the accuracy of individual Fried frailty phenotype measures in identifying the Fried frailty phenotype in primary care. Design Retrospective chart review. Setting A community-based primary care practice in Kitchener, Ont. Participants A total of 516 patients 75 years of age and older who underwent frailty screening. Main outcome measures Using modified Fried frailty phenotype measures, frailty criteria included gait speed, hand-grip strength as measured by a dynamometer, and self-reported exhaustion, low physical activity, and unintended weight loss. Sensitivity, specificity, accuracy, and precision were calculated for single-trait and dual-trait markers. Results Complete frailty screening data were available for 383 patients. The overall prevalence of frailty based on the presence of 3 or more frailty criteria was 6.5%. The overall prevalence of individual Fried frailty phenotype markers ranged from 2.1% to 19.6%. The individual criteria all showed sensitivity and specificity of more than 80%, with the exception of weight loss (8.3% and 97.4%, respectively). The positive predictive value of the single-item criteria in predicting the Fried frailty phenotype ranged from 12.5% to 52.5%. When gait speed and hand-grip strength were combined as a dual measure, the positive predictive value increased to 87.5%. Conclusion There is a need for frailty measures that are psychometrically sound and feasible to administer in primary care. While use of gait speed or grip strength alone was found to be sensitive and specific as a proxy for the Fried frailty phenotype, use of both measures together was found to be accurate, precise, specific, and more sensitive than other possible combinations. Assessing both measures is feasible within primary care.

Causes and outcomes of markedly elevated C-reactive protein levels.

Abstract: OBJECTIVE To characterize the causes of marked elevation of C-reactive protein (CRP) levels, investigate patient outcomes, and examine factors that might influence the CRP response. DESIGN Health records were used to retrospectively determine patient characteristics, diagnoses, and outcomes over a 2-year period (2012 to 2013). SETTING A large referral centre in Moncton, NB. PARTICIPANTS Adult inpatients and outpatients with a CRP level above 100 mg/L. MAIN OUTCOME MEASURES Differences among the CRP distributions of various diagnosis categories were examined using Kruskal-Wallis tests, and factors affecting outcomes were examined using Fisher exact tests. RESULTS Over the 2-year period, 1260 CRP levels (839 patients; 3.1% of all tests) were above 100 mg/L (range 100.1 to 576.0 mg/L). The mean age was 63 years (range 18 to 101) and 50.2% of patients were men. Infection was the most prevalent cause (55.1%), followed by rheumatologic diseases (7.5%), multiple causes (5.6%), other inflammatory conditions (5.4%), malignancy (5.1%), drug reactions (1.7%), and other conditions (2.0%). A diagnosis could not be established in 17.6% of cases. On average, infections caused higher peak CRP levels (W = 34 519, P < .001) and infection was present in 88.9% of cases with CRP levels greater than 350 mg/L. Rheumatologic causes were associated with only 5.6% of CRP levels above 250 mg/L. The overall mortality was 8.6% and was higher in patients with malignancy (37.0%), multiple diagnoses (21.0%), and leukopenia (20.7%, P = .002). CONCLUSION Most patients had infections and the proportion of patients with infections increased with the level of CRP, although many diagnoses were associated with markedly elevated CRP levels. These data could help guide health care professionals in the evaluation and management of these patients.

Community-associated methicillin-resistant Staphylococcus aureus infection: Literature review and clinical update.

Abstract: Objective To provide information on the prevalence and treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections and the distinction between community-associated MRSA and health care-associated MRSA. Quality of evidence The MEDLINE and EMBASE databases were searched from 2005 to 2016. Epidemiologic studies were summarized and the relevant treatment literature was based on level I evidence. Main message The incidence of community-associated MRSA infection is rising. Certain populations, including indigenous Canadians and homeless populations, are particularly affected. Community-associated MRSA can be distinguished from health care-associated MRSA based on genetic, epidemiologic, or microbiological profiles. It retains susceptibility to some oral agents including trimethoprim-sulfamethoxazole, clindamycin, and tetracyclines. Community-associated MRSA typically presents as purulent skin and soft tissue infection, but invasive infection occurs and can lead to severe, complicated disease. Treatment choices and the need for empiric MRSA coverage are influenced by the type and severity of infection. Conclusion Community-associated MRSA is a common cause of skin and soft tissue infections and might be common in populations where overcrowding and limited access to clean water exist.

Family medicine around the world: overview by region: The Besrour Papers: a series on the state of family medicine in the world.

Abstract: Objective To demonstrate how family medicine has been recognized and integrated into primary health care systems in contrasting contexts around the world and to provide an overview of how family physicians are trained and certified. Composition of the committee Since 2012, the College of Family Physicians of Canada has hosted the Besrour Conferences to reflect on its role in advancing the discipline of family medicine globally. The Besrour Papers Working Group, which was struck at the 2013 conference, was tasked with developing a series of papers to highlight the key issues, lessons learned, and outcomes emerging from the various activities of the Besrour collaboration. The working group comprised members of various academic departments of family medicine in Canada and abroad who attended the conferences. Methods An initial search was conducted in PubMed using a family medicine hedge of MeSH terms, text words, and family medicine journals, combined with text words and terms representing low- and middle-income countries and the concept of family medicine training programs. A second search was completed using only family medicine terms in the CAB Direct and World Bank databases. Subsequent PubMed searches were conducted to identify articles about specific conditions or services based on suggestions from the authors of the articles selected from the second search. Additional articles were identified through reference lists of key articles and through Google searches. We then attempted to verify and augment the information through colleagues and partners. Report The scope of family medicine and the nature of family medicine training vary considerably worldwide. Challenges include limited capacity, incomplete understanding of roles, and variability of standards and recognition. Opportunities for advancement might include technology, collaboration, changes in pedagogy, flexible training methods, and system-wide support.

Framework for building primary care capacity to address the social determinants of health.

Abstract: Problem addressed Family physicians have long understood that social factors influence the health of individuals and communities; however, most primary care organizations have yet to develop the capacity to specifically address these social determinants of health (SDOH). Objective of program To support SDOH interventions and foster an organizational culture in which addressing SDOH is considered part of high-quality primary care. Program description An academic family health team in Toronto, Ont, established a committee comprising a diverse group of health professionals focused on the SDOH. The committee analyzes how social factors affect patients and supports the development and implementation of interventions. The committee's current interventions include the following: collecting and analyzing detailed sociodemographic data to identify health inequities; launching an income security health promotion service; establishing a medical-legal partnership; implementing a child literacy program in its clinics; and developing an advocacy and service program to improve access to decent work. Each intervention includes a rigorous evaluation plan to assess implementation and effect. Next steps include developing tools to enable organizations to "move upstream" and adopt a health equity approach to all work, including joining in advocacy. Conclusion Primary care providers are well situated to address SDOH. This article provides a framework that can assist every large primary care organization in establishing a similar committee dedicated to SDOH, which could help build a network across Canada to share lessons learned and support joint advocacy.

Hand-arm vibration syndrome: What family physicians should know.

Abstract: Objective To provide family physicians with an understanding of the epidemiology, pathogenesis, symptoms, diagnosis, and management of hand-arm vibration syndrome (HAVS), an important and common occupational disease in Canada. Sources of information A MEDLINE search was conducted for research and review articles on HAVS. A Google search was conducted to obtain gray literature relevant to the Canadian context. Additional references were obtained from the articles identified. Main message Hand-arm vibration syndrome is a prevalent occupational disease affecting workers in multiple industries in which vibrating tools are used. However, it is underdiagnosed in Canada. It has 3 components—vascular, in the form of secondary Raynaud phenomenon; sensorineural; and musculoskeletal. Hand-arm vibration syndrome in its more advanced stages contributes to substantial disability and poor quality of life. Its diagnosis requires careful history taking, in particular occupational history, physical examination, laboratory tests to rule out alternative diagnoses, and referral to an occupational medicine specialist for additional investigations. Management involves reduction of vibration exposure, avoidance of cold conditions, smoking cessation, and medication. Conclusion To ensure timely diagnosis of HAVS and improve prognosis and quality of life, family physicians should be aware of this common occupational disease and be able to elicit the relevant occupational history, refer patients to occupational medicine clinics, and appropriately initiate compensation claims.

How do family physicians measure blood pressure in routine clinical practice? National survey of Canadian family physicians.

Abstract: Objective To describe the techniques currently used by family physicians in Canada to measure blood pressure (BP) for screening for, diagnosing, and treating hypertension. Design A Web-based cross-sectional survey distributed by e-mail. Setting Stratified random sample of family physicians in Canada. Participants Family physician members of the College of Family Physicians of Canada with valid e-mail addresses. Main outcome measures Physicians' self-reported routine methods for recording BP in their practices to screen for, diagnose, and manage hypertension. Results A total of 774 valid responses were received, for a response rate of 16.2%. Respondents were similar to nonrespondents except for underrepresentation of male physicians. Of 769 respondents, 417 (54.2%) indicated that they used manual office BP measurement with a mercury or aneroid device and stethoscope as the routine method to screen patients for high BP, while 42.9% (330 of 769) reported using automated office BP (AOBP) measurement. The method most frequently used to make a diagnosis of hypertension was AOBP measurement (31.1%, 240 of 771), followed by home BP measurement (22.4%, 173 of 771) and manual office BP measurement (21.4%, 165 of 771). Ambulatory BP monitoring (ABPM) was used for diagnosis by 14.4% (111 of 771) of respondents. The most frequently reported method for ongoing management was home BP monitoring (68.7%, 528 of 769), followed by manual office BP measurement (63.6%, 489 of 769) and AOBP measurement (59.2%, 455 of 769). More than three-quarters (77.8%, 598 of 769) of respondents indicated that ABPM was readily available for their patients. Conclusion Canadian family physicians exhibit overall high use of electronic devices for BP measurement, However, more efforts are needed to encourage practitioners to follow current Canadian guidelines, which advocate the use of AOBP measurement for hypertension screening, ABPM and home BP measurement for making a diagnosis, and both AOBP and home BP monitoring for ongoing management.

What is hidradenitis suppurativa

Abstract: Objective To provide family physicians with an understanding of the epidemiology, clinical features, diagnosis, and management of hidradenitis suppurativa (HS). Sources of information A PubMed literature search was performed using the MeSH term hidradenitis suppurativa . Main message Hidradenitis suppurativa is a chronic, recurrent, and debilitating skin condition. It is an inflammatory disorder of the follicular epithelium, but secondary bacterial infection can often occur. The diagnosis is made clinically based on typical lesions (nodules, abscesses, sinus tracts), locations (skin folds), and nature of relapses and chronicity. Multiple comorbidities are associated with HS, including obesity, metabolic syndrome, inflammatory bowel disease, and spondyloarthropathy. Although the lack of curative therapy and the recurrent nature makes HS treatment challenging, there are effective symptomatic management options. Conclusion Family physicians should be suspicious of HS in patients presenting with recurrent skin abscesses at the skin folds. Family physicians play an important role in early diagnosis, initiation of treatment, and referral to a dermatologist before HS progresses to debilitating end-stage disease.

Evaluation of 6 remote First Nations community-based buprenorphine programs in northwestern Ontario: Retrospective study.

Abstract: Objective To evaluate established opioid addiction treatment programs that use traditional healing in combination with buprenorphine-naloxone maintenance treatment in 6 First Nations communities in the Sioux Lookout region of northwestern Ontario. Design Retrospective cohort study. Setting Six First Nations communities in northwestern Ontario. Participants A total of 526 First Nations participants in opioid-dependence treatment programs. Intervention Buprenorphine-naloxone substitution therapy and First Nations healing programming. Main outcome measures Retention rates and urine drug screening (UDS) results. Results Treatment retention rates at 6, 12, and 18 months were 84%, 78%, and 72%, respectively. We estimate that the rate at 24 months will also be more than 70%. The UDS programming varied and was implemented in only 1 community. Initially urine testing was voluntary and it then became mandatory. Screening with either method found the proportion of urine samples with negative results for illicit opioids ranged between 84% and 95%. Conclusion The program’s treatment retention rates and negative UDS results were higher than those reported for most methadone and buprenorphine-naloxone programs, despite a patient population where severe posttraumatic stress disorder is endemic, and despite the programs’ lack of resources and addiction expertise. Community-based programs like these overcome the initial challenge of cultural competence. First Nations communities in other provinces should establish their own buprenorphinenaloxone programs, using local primary care physicians as prescribers. Sustainable core funding is needed for programming, long-term aftercare, and trauma recovery for such initiatives.

Better decision making in preventive health screening: Balancing benefits and harms.

Abstract: Decision making around preventive health screening by family physicians, other health care practitioners, and patients has become increasingly complex and controversial in recent years. Preventive health screening has long been advocated as one of the most important health care strategies to

Choosing Wisely Canada.

Abstract: 1. Imaging for low back pain is only indicated where red flags are present.1 4 5 The Canadian Association of Radiologists’ lower back pain guideline released in 2012 states that imaging is only 6 indicated if there are the following “red flag” indications: 7 8 Suspected epidural abscess or hematoma which may present with acute pain but no neurological 9 symptoms, urgent imaging is required 10 Suspected cancer 11 Suspected infection 12 Cauda equina syndrome 13 Severe/progressive neurologic deficit 14 Suspected compression fracture 15 16 In patients with suspected uncomplicated herniated disc or spinal stenosis imaging is only indicated after at least 17 a six week trial of conservative management and if symptoms are severe enough that surgery is being considered. 18

Competing demands and opportunities in primary care

Abstract: Historically, preventive interventions have yielded dramatic improvements in population health, with substantial benefits in patient-oriented outcomes including death from infectious disease and infant mortality. As medicine evolves, greater numbers of preventive and screening recommendations are

Concussion diagnosis and management: Knowledge and attitudes of family medicine residents.

Abstract: Objective To assess the knowledge of, attitudes toward, and learning needs for concussion diagnosis and management among family medicine residents. Design E-mail survey. Setting University of Toronto in Ontario. Participants Family medicine residents (N = 348). Main outcome measures To describe relationships between awareness of concussion management and lifestyle, education background, and residency placement, t tests and 2 tests were used as appropriate. Linear regression was used to compare self-reported concussion knowledge with knowledge scores. Thematic analysis was used to interpret answers to the qualitative question asking residents to describe challenges they foresee physicians facing when diagnosing and managing concussion. Results The residents who responded (n = 73, response rate 21%) correctly answered an average of 5.2 questions out of 9 (58%) regarding the diagnosis and management of concussion. Postgraduate year, sex, personal history of concussion, and clinical exposure to concussion were not significant factors in predicting the number of correct answers. Several misconceptions and knowledge gaps were revealed. Of residents who responded, 71% did not recognize chronic traumatic encephalopathy and only 63% recognized second-impact syndrome as consequences of repetitive concussions. Moreover, 32% of residents did not think that every individual with a concussion should see a physician as part of management. Knowledge scores did not predict self-reported concussion knowledge. Thematic analysis revealed 4 themes related to the challenges of concussion diagnosis and management: the nonspecificity and vagueness of symptoms, lack of formal diagnostic criteria, patient compliance with management, and counseling patients with respect to return to play, work, or learning. Conclusion We found substantial gaps in knowledge surrounding concussion diagnosis and management among family medicine residents. This lack of knowledge should be addressed at both the undergraduate medical education level and the residency training level to improve concussion-related care and patient outcomes.

Predictors of job satisfaction among academic family medicine faculty

Abstract: Objective To identify predictors of job satisfaction among academic family medicine faculty members. Design A comprehensive Web-based survey of all faculty members in an academic department of family medicine. Bivariate and multivariable analyses (logistic regression) were used to identify variables associated with job satisfaction. Setting The Department of Family and Community Medicine at the University of Toronto in Ontario and its 15 affiliated community teaching hospitals and community-based teaching practices. Participants All 1029 faculty members in the Department of Family and Community Medicine were invited to complete the survey. Main outcome measures Faculty members’ demographic and practice information; teaching, clinical, administration, and research activities; leadership roles; training needs and preferences; mentorship experiences; health status; stress levels; burnout levels; and job satisfaction. Faculty members’ perceptions about supports provided, recognition, communication, retention, workload, teamwork, respect, resource distribution, remuneration, and infrastructure support. Faculty members’ job satisfaction, which was the main outcome variable, was obtained from the question, “Overall, how satisfied are you with your job?” Results Of the 1029 faculty members, 687 (66.8%) responded to the survey. Bivariate analyses revealed 26 predictors as being statistically significantly associated with job satisfaction, including faculty members’ ratings of their local department and main practice setting, their ratings of leadership and mentorship experiences, health status variables, and demographic variables. The multivariable analyses identified the following 5 predictors of job satisfaction: the Maslach Burnout Inventory subscales of emotional exhaustion and personal accomplishment; being born in Canada; the overall quality of mentorship that was received being rated as very good or excellent; and teamwork being rated as very good or excellent. Conclusion The findings from this study show that job satisfaction among academic family medicine faculty members is a multi-dimensional construct. Future improvement in overall level of job satisfaction will therefore require multiple strategies.

Periodic preventive health visits: a more appropriate approach to delivering preventive services: From the Canadian Task Force on Preventive Health Care.

Abstract: T he annual checkup is a long-established tradition in North America. Typically this visit entails a review of the patient’s health history, medications, allergies, and organ systems, as well as a “complete” physical examination that is sometimes followed by laboratory testing and discussion of health risks, lifestyle behaviour, and social situation. These visits consume substantial time and resources. Whether or not they provide health benefts that justify this effort has been much debated.1-6 The Canadian Task Force on the Periodic Health Examination, established in 1976, was one of the first groups to use systematic methods to assess what services should be included in periodic health examinations. The frst report recommended abandoning the annual checkup7 and replacing it with age-specifc “health protection packages” that focused on the identifcation and early management of potentially preventable conditions. The role of the physical examination in preventive care was de-emphasized in favour of activities such as risk factor assessment. More recently, the College of Family Physicians of Canada in association with Choosing Wisely Canada similarly recommended that family physicians not do annual physical examinations but instead provide periodic preventive health checks.8

Patients’ experiences of diabetes education teams integrated into primary care

Abstract: Objective To explore patients’ perspectives on care received from diabetes education teams (a registered nurse and a registered dietitian) integrated into primary care. Design Qualitative study using semistructured, one-on-one interviews. Setting Three diabetes education programs operating in 11 primary care sites in one region of Ontario. Participants Twenty-three patients with diabetes. Methods Purposeful sampling was used to recruit participants from each site for interviews. Educator teams invited patients with whom they had met at least once to participate in semistructured interviews. Data were analyzed using thematic analysis with NVivo 11 software. Main findings The diabetes education teams integrated into primary care exhibited many of the principles of person-centred care, as evidenced by the 2 overarching themes. The first is personalized care, with the subthemes care environment, shared decision making, and patient preference for one-on-one care. Participants described feeling included in partnerships with their health care providers, as they collaborated with physicians and diabetes educators to develop knowledge and set goals in the convenience and comfort of their usual primary care settings. Many participants also expressed a preference for one-on-one sessions. The second theme is patient-provider relationship, with the subthemes respect, supportive interaction, and facilitating patient engagement. Supportive environments created by the educators built trusting relationships, where patients expressed enhanced motivation to improve their self-care. Conclusion Diabetes educators integrated into primary care can serve to enrich the experience of patients, provide key education to improve patient understanding, and support primary care physicians in providing timely and comprehensive clinical care. Diabetes patients appear to benefit from convenient access to interprofessional teams of educators in primary care to support diabetes self-management.

Referral processes and wait times in primary care.

Abstract: Objective To evaluate the response times to requests for consultations from FPs and the wait times for patient appointments. Design Mailed invitation to participate in a survey about non-FP specialist consultation requests from April 28 to May 9, 2014. Setting Hamilton, Ont. Participants All active physicians with community practices from the Department of Family Medicine at St Joseph's Healthcare Hamilton and Hamilton Health Sciences. Main outcome measures All non-FP specialist consultation requests for a 2-week period. Results Thirty-four practices (9.6% response rate) collected data on 816 consultation requests. Requests for referrals were most commonly made to the following 5 specialties: dermatology, surgery, gastroenterology, orthopedics, and obstetrics and gynecology. Overall, 36.4% of the requests for consultation received no response from the non-FP specialist's office by the end of the follow-up period. The mean wait time for a patient appointment was 60.1 days (range 23.3 to 168.5 days). Five specialties had particularly lengthy wait times of 105.9 to 168.5 days. Conclusion Allowing 5 to 7 weeks for a response from a non-FP specialist, there was still a 36.4% nonresponse rate (similar to a pilot survey administered in 2010). Patient and physician frustration is certainly heightened and more office time and energy is expended when no acknowledgment of a referral is received within 7 weeks. This gives our community wait times much longer than those reported by any of the national bodies.

Primary care specialty career choice among Canadian medical students: Understanding the factors that influence their decisions.

Abstract: OBJECTIVE To identify which factors influence medical students' decision to choose a career in family medicine and pediatrics, and which factors influence their decision to choose careers in non-front-line specialties. DESIGN Survey that was created based on a comprehensive literature review to determine which factors are considered important when choosing practice specialty. SETTING Ontario medical school. PARTICIPANTS An open cohort of medical students in the graduating classes of 2008 to 2011 (inclusive). MAIN OUTCOME MEASURES The main factors that influenced participants' decision to choose a career in primary care or pediatrics, and the main factors that influenced participants' decision to choose a career in a non-front-line specialty. RESULTS A total of 323 participants were included in this study. Factors that significantly influenced participants' career choice in family medicine or pediatrics involved work-life balance (acceptable hours of practice [P = .005], acceptable on-call demands [P = .012], and lifestyle flexibility [P = .006]); a robust physician-patient relationship (ability to promote individual health promotion [P = .014] and the opportunity to form long-term relationships [P < .001], provide comprehensive care [P = .001], and treat patients and their families [P = .006]); and duration of residency program (P = .001). The career-related factors that significantly influenced participants' decision to choose a non-front-line specialty were as follows: becoming an expert (P < .001), maintaining a focused scope of practice (P < .001), having a procedure-focused practice (P = .001), seeing immediate results from one's actions (P < .001), potentially earning a high income (P < .001), and having a perceived status among colleagues (P < .001). CONCLUSION In this study, 8 factors were found to positively influence medical students' career choice in family medicine and pediatrics, and 6 factors influenced the decision to choose a career in a non-front-line specialty. Medical students can be encouraged to explore a career in family medicine or pediatrics by addressing misinformation, by encouraging realistic expectations of career outcomes in the various specialties, and by demonstrating the capacity of primary care fields to incorporate specific motivating factors.

Time in therapeutic range: Warfarin anticoagulation for atrial fibrillation in a community-based practice.

Abstract: Objective To evaluate the effectiveness of an outpatient, nurse-administered warfarin anticoagulation protocol for the treatment of atrial fibrillation, and to identify clinical or biographical data that predict poor international normalized ratio control. Design Retrospective cohort study. Setting St Paul Family Health Network in Brantford, Ont. Participants A total of 150 patients with nonvalvular atrial fibrillation. Main outcome measures Time in therapeutic range (TTR) for each patient and for the clinic overall. The groups of patients above and below a target TTR of 60% were compared by stepwise binomial logistic regression. Results A time-weighted average TTR for the clinic was determined to be 58.76%, based on 183 452 patient-days taking warfarin. The regression analysis did not find a statistically significant association between TTR and any predictors. A trend indicating a 5-fold increase in the odds of inadequate anticoagulation was observed in current smokers (odds ratio of 4.71; 95% CI 0.97 to 22.93). Conclusion Compared with data from prospective randomized trials and meta-analysis, the anticoagulation protocol employed at the St Paul Family Health Network produced an average TTR near the lower end of the target threshold. Current smokers might be at greater risk of being below this target.

Diagnosis and treatment of pruritus.

Abstract: Objective To describe an approach that allows for a streamlined assessment and accurate differentiation of most patients with itch in primary care and to provide an update on the available nonpharmacologic, topical, and systemic therapies. Sources of information MEDLINE (Ovid) and PubMed were searched for the key words itch or pruritus. Searches were refined for each cause and treatment by adding appropriate key words, and subsequent hand searches of the references of retrieved literature were performed. Main message A good body of evidence from high-quality trials does not exist for treatment of pruritus, and the treatments that do exist are inconsistent in their success. The dominant causes of generalized itch are xerosis and eczema. Most patients will improve with nonpharmacologic therapy including frequent moisturization. If this avenue fails, further investigations are warranted to help guide subsequent treatment with any of the many cause-specific topical and systemic approaches available. Conclusion Chronic itch can be debilitating for patients. The approach described allows for a streamlined assessment and accurate differentiation of most patients with itch in primary care.

Driving and dementia: Efficient approach to driving safety concerns in family practice.

Abstract: Objective To provide primary care physicians with an approach to driving safety concerns when older persons present with memory difficulties. Sources of information The approach is based on an accredited memory clinic training program developed by the Centre for Family Medicine Primary Care Collaborative Memory Clinic. Main message One of the most challenging aspects of dementia care is the assessment of driving safety. Drivers with dementia are at higher risk of motor vehicle collisions, yet many drivers with mild dementia might be safely able to continue driving for several years. Because safe driving is dependent on multiple cognitive and functional skills, clinicians should carefully consider many factors when determining if cognitive concerns affect driving safety. Specific findings on corroborated history and office-based cognitive testing might aid in the physician’s decisions to refer for comprehensive on-road driving evaluation and whether to notify transportation authorities in accordance with provincial reporting requirements. Sensitive communication and a person-centred approach are essential. Conclusion Primary care physicians must consider many factors when determining if cognitive concerns might affect driving safety in older drivers.