Associations between characteristics of homeless clients and their return visits to a nurse-managed primary health care clinic were examined using a retrospective chart review of 1,467 records from clients seen between 1991 and 1994. Client characteristics examined included age, education, race, gender, sheltered status, report of chronic disease, and report of family living in the area. Only 47 percent of clients made return visits to the clinic. Logistic regression indicated that those with reported chronic disease, males, whites, and those living on the street were more likely to have returned to the clinic for care than those without chronic illness, females, nonwhites, and those living in some type of shelter. Results suggest the need for program planning and evaluation for this population, which particularly considers women, nonwhites, and those without chronic disease as target groups for services.

A ruptured abdominal aortic aneurysm (AAA) has a mortality of 80 percent. The majority of these cases present as medical emergencies, with 50 percent dying before they reach hospital. Twenty percent are not operated on because of an incorrect diagnosis and of the surviving 30 percent, there will be a peri-operative mortality of 40 percent. Thus only 20 percent of patients survive this condition. It is important to state that the long-term survival reported for patients undergoing AAA surgery approximates that of age-matched populations. This is in contrast to patients undergoing a coronary bypass procedure, where the long-term survival is affected by factors such as hypertension, angina and peripheral vascular disease. If the condition is diagnosed electively, the mortality rate is reduced to less than 5 percent. The researcher obtained the records of 18 patients who had presented to the vascular service at the New Kingsbury Hospital with a diagnosis of a ruptured or acute symptomatic AAA. He interviewed the referring family doctor and also obtained information from the case records to determine whether there were missed opportunities for the detection of such aneurysms. The results of the research showed that 12 general practitioners (GP's) out of a group of 13, were unaware that abdominal ultrasound is a highly specific and sensitive method for detecting AAA's. Only one of the group of 13 GP's regularly screens for AAA. The diagnosis of AAA was missed in 12 of the 18 patients. In this series the mean diameter of the aorta was 7,67 cm which is considered to be easily palpable. Five of the patients were referred to specialists for incidental reasons and they all failed to detect the AAA. The majority of patients with AAA's have at least 2 associated risk factors. The patients consulted their GP at least 5 times over the 24 month period. The GP's are not aware of the different modes of presentation, associated risk factors nor the value of screening for AAA's. Ten of the group of 13 GP's profess to engage in some form of Continuing Medical Education (CME). I have suggested a few guidelines to encourage family physicians to screen for AAA in all males over the age of 60, especially if they have risk factors, such as hypertension, a current or former cigarette smoker, coronary artery disease, peripheral vascular disease and a family history of AAA. The examination should include a thorough abdominal palpation and referral for an abdominal ultrasound examination to obtain the precise diameter of the AAA as treatment depends on the size of the AAA.

Tubal sterilization is the world's most popular contraceptive method. The possibility of subsequent menstrual dysfunction has been a cause for concern. This study was conducted to examine whether post-sterilisation menstrual dysfunction was measurable in a group of women attending a general practice, by means of a case-control study. Biopsychosocial factors, such as health status, social support, psychological and medical history, and reasons for sterilisation were investigated to see whether any of these factors could be predictive of post-sterilisation menstrual problems. Sterilised women attending a general practice over an eight-month period were invited to participate in the study. 143 out of 144 patients completed a highly structured interview (questionnaire) administered by two interviewers. Forty-nine cases were identified and compared to ninety-four controls. The results showed that women with menstrual dysfunction differed from a comparison group in that; those with menstrual dysfunction were generally less satisfied with their quality of life, had significantly more fears about sterilisation, felt that the quality of their social support was inferior, and suffered from depression and tension headaches more often than controls. Menstrual dysfunction was also more common during the first two years after tubal ligation. These results could point to factors other than biological factors involved in menstrual dysfunction following tubal ligation.

Includes bibliographical references. / Woman abuse is now well recognised as a local and international concern that has serious repercussions for women's health and well-being. Little however is known about what it feels like to be abused by someone you love. How does a woman make sense of a life of physical and psychological abuse? Why does she stay in the abusive relationship? To gain more understanding of this complex dynamic, a qualitative study of five women's experiences of violence by an intimate partner was performed. The first part of this paper, a literature review, examines women's accounts of their experiences in abusive relationships by looking at common themes across these studies. The second part details the research process. The knowledge uncovered by the women's stories, can provide family physicians with valuable insights for devising strategies to identify and intervene in domestic violence.

Transgender individuals represent one of the most marginalized and underserved populations in healthcare. Issues such as discrimination, lack of practitioner experience and knowledge, and a deficiency of services have contributed to the healthcare barriers experienced by transgender individuals. There is a lack of literature demonstrating how primary care services are delivered to transgender individuals and a need for research that helps advance our knowledge about the delivery and implementation of primary care services for this population. This thesis explores how primary care services are delivered and implemented from a perspective that acknowledges the complexities of the healthcare needs of the transgender population. A multiple-case study design was used to explore the implementation and delivery of primary care for transgender individuals in Ontario within different delivery models of primary care and through diverse roles of primary care team members. Normalization Process Theory, an implementation theory and conceptual framework, was used in this study to understand and explain the dynamic processes that occur during implementation of interventions in healthcare, and guide data collection and analysis. Three cases representing different models of primary care delivery in Ontario were identified, all of which provide primary care services to transgender individuals. These models included a solo physician Fee-For-Service practice, a Family Health Team and a Community Health Centre. The multiple sources of data collection strategies used were interviews, a survey, documental evidence, and field notes. Participants included multiple members of the primary healthcare team, such as practitioners, clinical support staff and executive directors. This study helps to advance our knowledge of the delivery and implementation of primary care services for transgender individuals. Implications for nursing practice, including highlighting the need for curricula changes and understanding the nursing role, are discussed. / Thesis / Doctor of Philosophy (PhD) / Primary care, such as a family doctor, is where people get day-to-day healthcare. Worldwide, transgender individuals encounter barriers to appropriate healthcare, in particular access to practitioners who understand their health needs. This thesis aims to explore how primary care services are delivered to transgender individuals in Ontario, through a study that examined different ways services are provided, from a family doctor working alone in a clinic to a clinic with a team of practitioners (e.g., family doctors, nurse practitioners, nurses, counsellors). Interviews with practitioners, a survey, and clinic documents showed that primary care for transgender individuals is part of regular primary care services; whether delivered via a rapid access specialty clinic or embedded into regular primary care services, study participants were easily able to integrate primary care for transgender individuals into their routine work. However, evidence also highlighted the need for practitioners to obtain specialized knowledge of transgender needs.

Population health is concerned with analyzing the factors that determine the uneven distribution of health in a population and it also proposes interventions to narrow health inequalities. Kindig has proposed a population health management strategy that would engage the health and other sectors on population health improvement through a financial incentive linked to health outcomes. Proposed elements of a population health approach in health care at the patient encounter level include paying attention to health determinants for the patient and ensuring interprofessional collaboration; at the system level the approach includes developing and advocating for interventions that address health inequalities, such as delivering services to under-serviced areas and vulnerable populations. There has been virtually no research among frontline clinicians on the awareness and salience of a population health approach. In order to address this gap an exploratory study was conducted among family physicians in Primary Care Networks (PCNs) in Alberta, Canada. PCNs include capitation funding that is used to purchase services such as nursing, pharmacy and dietetics. The physicians were able to describe their patient populations in terms of a full range of social determinants and the health status inequalities they produce. They emphasized the importance of preventive screening and counseling in contributing to the health of their patients, and cited the key contributions of other team members to these activities, as well as the electronic medical record (EMR). They reported ambivalence toward the effectiveness of financial incentives for population health improvement, and while there was some collaboration with schools, inter-sectoral collaboration has yet to develop outside the health sector. This thesis has demonstrated the potential for primary care physicians to adopt a population health approach. However, there is a considerable distance to go in introducing an incentive approach for outcome-based population health management, as envisioned by Kindig.

Population health is concerned with analyzing the factors that determine the uneven distribution of health in a population and it also proposes interventions to narrow health inequalities. Kindig has proposed a population health management strategy that would engage the health and other sectors on population health improvement through a financial incentive linked to health outcomes. Proposed elements of a population health approach in health care at the patient encounter level include paying attention to health determinants for the patient and ensuring interprofessional collaboration; at the system level the approach includes developing and advocating for interventions that address health inequalities, such as delivering services to under-serviced areas and vulnerable populations. There has been virtually no research among frontline clinicians on the awareness and salience of a population health approach. In order to address this gap an exploratory study was conducted among family physicians in Primary Care Networks (PCNs) in Alberta, Canada. PCNs include capitation funding that is used to purchase services such as nursing, pharmacy and dietetics. The physicians were able to describe their patient populations in terms of a full range of social determinants and the health status inequalities they produce. They emphasized the importance of preventive screening and counseling in contributing to the health of their patients, and cited the key contributions of other team members to these activities, as well as the electronic medical record (EMR). They reported ambivalence toward the effectiveness of financial incentives for population health improvement, and while there was some collaboration with schools, inter-sectoral collaboration has yet to develop outside the health sector. This thesis has demonstrated the potential for primary care physicians to adopt a population health approach. However, there is a considerable distance to go in introducing an incentive approach for outcome-based population health management, as envisioned by Kindig.

Over two thirds of adults in the United States are affected by overweight or obesity. Weight management, which requires multi-component, intensive interventions targeting dietary and physical activity behaviors, should be offered as part of routine primary care services. Unfortunately, there is a paucity of evidence to guide the implementation of feasible and effective strategies within primary care settings. This DNP Project utilized a cross-sectional descriptive needs-assessment to survey obese patients' perceptions and preferences regarding weight and the primary care provider role in weight management. The findings from the needs assessment were used to inform the development of a feasible, patient-centered, weight management program.

Background: Work-related asthma (WRA) is under-recognized and early detection is associated with improved outcomes. The Work-related Asthma Screening Questionnaire (Long-version) (WRASQ(L)) is a 14-item tool designed to increase the detection of WRA in primary care. Purpose: The purpose of this study was to assess whether the WRASQ(L) provided additional and reliable information on a patient’s likelihood of WRA, beyond what is collected in standard care, to explore the relationship of WRASQ(L) responses to clinical actions and to assess the use of the WRASQ(L) in the primary care setting. Methods: This was an intervention study involving two Ontario Primary Care Asthma Program (PCAP) sites assigned the WRASQ(L). Standard care for asthma patients in PCAP sites involved completing the Asthma Care Map (ACM), a clinical pathway which included seven WRA screening items. Consent to participate in this study involved completing an electronic WRASQ(L) at each visit for participants and prompted care providers to record details related to WRA investigations. Results: The study sample (N=37) was predominantly female (73.0%), with a mean age of 46.3 years (SD, 10.9). Use of the WRASQ(L) identified work-related symptoms, exposures and high- risk past occupations in 38% and 60% and 47% of participants, respectively, that were not identified in standard care. Two participants were newly-suspected cases of WRA during this study period. WRASQ(L) items demonstrated fair to moderate reproducibility, but estimates may have been subject to measurement error. Incorporation of the electronic WRASQ(L) in clinical care was limited by time constraints and technical factors, such as ease of use and flexibility of the application. Conclusions: The WRASQ(L) provided added information about possible WRA over standard care. Use of the questionnaire’s results by care providers in this study was limited due to barriers encountered in incorporating the use of the WRASQ(L) in clinical practice. Future directions include the validation of this tool in relation to WRA diagnosis. The WRASQ(L) has the potential to increase recognition of WRA, improving long-term health outcomes for those with WRA. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-09-27 21:16:28.59

Introduction: The Family Health Team (FHT) is an Ontario-based initiative that aims to provide primary care through multidisciplinary teams of healthcare professionals. Little is known about variability between and within teams, and whether certain organizational characteristics are associated with quality of patient care. Objectives: (1) To describe FHT-level organizational characteristics for seven FHTs in Southeastern Ontario. (2) To examine the role of physician-level organizational characteristics in predicting: (a) Up-to-date colorectal cancer screening and (b) episodic patient-centredness for patients within seven FHTs in Southeastern Ontario. Methods: This study employed linked datasets obtained from surveys of seven FHTs, 115 health care providers (including 41 family physicians) and 998 patients, as well as a chart abstraction. Statistical analyses included performing subject-specific multilevel multivariate modeling. Results: (1) FHTs varied on characteristics including length of time of practice operation, number of patients, existence of personnel policies, team makeup and team climate. (2) (a) Patient uptake of colorectal cancer screening was associated with average duration of regular routine visit OR=0.88 per minute (95% CI 0.83-0.94), patient gender male OR=2.00 (95% CI 1.22-3.28), general checkup in past 2 years OR=9.03 (95% CI 5.18-15.73), travel time less than or equal to 20 minutes OR=1.53 (95% CI 0.94-2.48), and usually see regular provider OR=0.40 (95% CI 0.19–0.87). Patient uptake or physician recommendation of colorectal cancer screening demonstrated similar associations, with the absence of travel time and the addition of team climate (family physician and nurses) OR=5.88 (95% CI 0.98-35.24), patient occupational status employed vs. retired OR=0.49 (95% CI 0.23–1.02), patient occupational status not employed vs. retired OR=0.42 (95% CI 0.16–1.13), and patient smoking status never vs. ever OR=0.59 (95% CI 0.37–0.96). (b) Episodic patient-centredness was associated with patient born in Canada 0.1119 (95% CI -0.0040-0.2278), seeing regular healthcare provider today 0.1449 (95% CI 0.0426-0.2472), physician-patient gender concordance 0.1019 (95% CI 0.0128-0.1910), and appointment length 0.006929 (95% CI 0.003554-0.010304). Discussion: Further research is needed to examine predictors of the quality of patient care at the practice, physician and patient levels. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-09-27 15:21:12.794