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Healthspan describes the length of time an individual lives without disability or chronic disease. Characteristic to aging is the risk for the onset of both through a progressive accumulation of deficits in normal physiologic function. In the past, the declines associated with aging were simply accepted as inevitable. Today, longevity research has undergone a meteoric rise in popularity. This is due to several landmark studies demonstrating that what was once thought of as inevitable has potential to be delayed. This thesis aims to consolidate current theories of biochemical processes believed to underlie aging, and explore their interconnections. Furthermore, current pharmaceutical and lifestyle interventions being studied to promote longevity and target these specific pathways will be analyzed for safety and practicality for use in a primary care setting. Through a shift from symptom-based care to personalized preventative care, the goal is to maximize function into older age and empower individuals to live life to the fullest well beyond what was previously imagined.

Child overweight has reached an epidemic level throughout the United States. A total of 65 primary care providers in southern Appalachia were surveyed to understand current issues in addressing child overweight in rural primary care practice. The study shows that while providers realized the importance of child overweight intervention, many were not ready and did little to address child overweight in their practices. The providers' skill levels in addressing child overweight were generally less than sufficient. Common barriers to child overweight treatment included lack of parental motivation and involvement, lack of supportive services, and lack of clinician time. In conclusion, rural primary care is facing many challenges in addressing child overweight. However, with more training in behavioral intervention skills and through establishing a family-based intervention and a group visit approach, primary care providers could play a more active role in the fight against the epidemic of child overweight.

Cluster randomized trials (CRT) are comparative studies designed to evaluate interventions where the unit of analysis and randomization is the cluster but the unit of observation is individuals within clusters. Typically such designs involve a limited number of clusters and thus the variation between clusters is left uncontrolled. Experimental designs and analysis strategies that minimize this variance are required. In this work we focus on the CRT with pre-post intervention measures. By incorporating the baseline measure into the analysis, we can effectively reduce the variance of the treatment effect. Well known methods such as adjustment for baseline as a covariate and analysis of differences of pre and post measures are two ways to accomplish this. An alternate way of incorporating baseline measures in the data analysis is to order the clusters on baseline means and pairmatch the two clusters with the smallest means, pair-match the next two, and so on. Our results show that matching on baseline helps to control the between cluster variation when there is a high correlation between the pre-post measures. Six cases of designs and analysis are evaluated by comparing the variance of the treatment effect and the power of related hypothesis tests. We observed that - given our assumptions - the adjusted analysis for baseline as a covariate without pair-matching is the best choice in terms of variance. Future work may reveal that other matching schemes that reflect the natural clustering of experimental units could reduce the variance and increase the power over the standard methods.

Since 2008, physician-led primary care practices have decreased as physician's encounter sustainability challenges because of government regulations and the requirements of the Affordable Care Act. The problem is that some physician-led primary care practice leaders lack strategies to sustain a medical practice longer than 5 years. The purpose of this study was to explore strategies primary-care practice leaders use to sustain a practice longer than 5 years. This study followed a case study design, including a purposeful sampling of 3 physician-led primary care practice leaders in southern Indiana. Open-ended semistructured interviews were conducted and triangulated with company policies and procedures as well as government statistics. Coded data and themes were identified using the complex adaptive systems theory. Three sustainability themes emerged: (1) patient engagement, (2) relationship development and retention, and (3) adaptation and innovation. The recommended action is for physician leaders to apply the strategies to develop their primary care medical practices. Results from the study may contribute a positive social change by presenting strategies to develop and sustain physician-led primary care practices, which could lead to an increase of primary care medical practices, resulting in more patients having access to primary care physicians.

Introduction : La prévalence de l’obésité chez les adultes canadiens a atteint un niveau record en 2015 (28.1 %). Les professionnels de santé de première ligne (PPL) ont un rôle crucial dans le contrôle de cette épidémie. Bien que la littérature internationale suggère que la prise en charge de l’obésité en première ligne est sous optimale, aucune étude canadienne fondée sur l’analyse de dossiers médicaux ne s’est encore penchée sur la question. Ce manque d’information est problématique, car il est impossible de juger de l’étendue du problème au pays. De plus, puisque les aspects de la prise en charge qui représentent les plus grands défis pour les PPL canadiens restent à définir, il est difficile d’adapter les programmes de formation qui leur sont destinés. Objectifs du projet de maîtrise : Établir le premier portrait de la prise en charge de l’obésité au Québec et évaluer quels sont les déterminants de la prise en charge de l’obésité. Méthodologie : Une étude de cohorte rétrospective a été menée auprès de 439 adultes traités dans l’un des 10 groupes de médecine familiale (GMFs) participants. Des mesures anthropométriques ont été réalisées auprès des patients dans le cadre d’une visite initiale. Les notes des médecins et des infirmières présentes au dossier médical ont été révisées sur une période de 18 mois afin d’y déceler la présence d’interventions documentées liées à la prise en charge de l’obésité. Les interventions ont été extraites des lignes directrices canadiennes en matière de gestion de l’obésité. Des modèles de régression logistique mixtes généralisés ont été complétés afin d’identifier les déterminants de la prise en charge de l’obésité. Résultats : Le taux de dépistage de l’obésité était bas (31 %). Parmi les patients ayant un indice de masse corporelle (IMC) mesuré ≥30 (n=175), 52 % avaient un diagnostic d’obésité et 38 % avaient obtenu du counseling lié aux habitudes de vie au cours de la période de suivi. L’IMC et le nombre de comorbidités identifiées du patient étaient des déterminants indépendants associés à la présence d’un diagnostic au dossier médical. La présence du diagnostic de même que le nombre de visites avec une infirmière au cours des 18 mois de suivi étaient quant à eux des déterminants associés au counseling sur les habituds de vie. Quatre-vingts pour cent des dépistages et des diagnostics de l’obésité ont été réalisés par des médecins seulement. Les infirmières ont considérablement participé à la réalisation du counseling (65 % MDs/35 % infirmières). Conclusions : Les taux de dépistage, de diagnostic et de counseling liés à l’obésité dans les GMFs sont sous-optimaux. Des interventions devront être développées afin d’améliorer la qualité des soins. Ces dernières devraient explorer la promotion d’un meilleur accès à des infirmières spécialisées et l’adaptation des programmes de formation initiale et continue. / Abstract : Background : The prevalence of obesity among Canadian adults reached a record high in 2015 (28.1%). Primary care providers (PCPs) play a crucial role regarding the management of this epidemic. Although international literature suggests that the management of obesity in the primary care setting is suboptimal, no Canadian study based on medical record review has yet assessed this issue. The current lack of information is problematic because it makes it impossible to judge the extent of the problem in the country. Moreover, since the aspects of obesity management which represent the greatest challenges for Canadian PCPs remain unidentified, it is difficult to adapt PCPs’ education programs. Objectives of the project: Identify the rates of obesity screening, diagnosis and management in Quebec and evaluate the predictors of obesity management. Methodology: A retrospective cohort study was conducted among 439 adults treated in one of 10 participating family medicine groups (FMG). Anthropometric measurements were performed from each patient as part of an initial visit. The clinical encounter notes of physicians and nurses from every patient medical record were reviewed over an 18 months period in order to detect the presence of documented obesity management interventions. The looked-for interventions were extracted from the Canadian guidelines for the management of obesity. Mixed-effects regression models were used to identify the predictors of obesity management. Results: The rate of obesity screening was low (31%). Among patients with a measured body mass index (BMI) ≥30 (n = 175), 52% had an obesity diagnosis and 38% received physical activity or nutritional counseling during the follow-up period. Patient’s BMI and number of identified comorbidities were independant predictors of obesity diagnosis. The presence of an obesity diagnosis in the medical record and the number of clinical encounters with a nurse during the 18-months period were independent predictors of lifestyle counseling. Eighty percent of screening and diagnoses were performed by physicians. Nurses were considerably more involved in the provision of lifestyle counselling (65 % GPs/35 % nurses). Conclusions : The rates of obesity screening, diagnosis and counselling in Quebec FMGs are suboptimal. Interventions have to be deployed in order to increase the quality of care. Future researches should explore the impact of an enhanced access to specialized nurses and the adaptation of the current initial and continuous education programs on the rates of obesity management.

Parents do not always receive accurate, timely and comprehensive information regarding a positive newborn screening from their infants’ primary care providers. The dissertation outlines the investigation of this problem. The methodology of the study is discussed including the survey of parents and primary care providers using the past system, the development of a web portal with a focus on plain language and action focused handouts. Without a simple to understand parent handout the newborn screening process is more stressful to families. Review of the literature is detailed including newborn screening, patient education, health literacy, Internet usage, online health education, design of patient education websites and the evaluative process of learning tools. Surveys informed the content of the web-based patient portal for both parents and PCP. Abbreviated parental stress scores did not identify elevated stress in parents during the initial PCP visit when the NBS results and plan of care were discussed. Evaluation of the planned web portal was permanently delayed related to change in statewide policies; thus, a standalone website was developed using Agency for Health Care Research and Quality’s patient education material tool for understandability and actionability of both patient handouts and web portals. Physician actionable NBS handouts were also developed. Formative evaluation using experts’ input, one-to-one trials and small group trials of the handouts for the site were completed with minor revisions made to the portal. The formative evaluation using the simple survey tool would have provided any additional portal changes required. Strengths of the study to include survey response rates, rigor of the comments by both parents and PCPs as well as constructive feedback from NBS experts are highlighted. The weakness is the lack of having a final participant group identified or available related to local NBS policies. Recommendations for future research are highlighted as well as discussion of changes in federal policy that will now allow further NBS research without the limitations once imposed.

Contexte : L’engagement des patients dans les soins de santé et en gouvernance a fait l’objet de plusieurs études au cours de la dernière décennie, mais aucune ne s’est intéressée à leur engagement au niveau stratégique d’un Groupe de médecine de famille universitaire (GMF-U). En 2017, les gestionnaires du GMF-U de Verdun, situé à Montréal, au Canada, ont décidé de mettre en place une approche de co-construction avec des patients ressources au sein de leur comité de gouvernance, afin d’améliorer la qualité et la pertinence des soins et des services, de l’enseignement et de la recherche au sein de l’organisation. Objectifs : 1) Évaluer le rôle et l’influence des patients ressources sur la prise de décision au sein d’un comité de gestion dans un GMF-U ; 2) déterminer les facteurs favorables et les obstacles à l’engagement de patients ressources sur un comité de gestion dans un GMF-U ; 3) évaluer l’impact de cette innovation sur la promotion d’une culture de partenariat à travers l’organisation. Méthodes : À partir d’une étude de cas unique, à trois niveaux d’analyse, les données ont été collectées au niveau du 1) CIUSSS ; 2) comité de gouvernance du GMF-U ; 3) GMF-U. De juin 2017 à mai 2019, des données qualitatives ont été collectées via deux groupes de discussion de quatre et quatorze personnes, quatre entretiens semi-dirigés, des documents et un journal de bord. Des données quantitatives ont également été collectées à partir de questionnaires. Résultats : La mise en valeur du rôle des patients ressources, soit le partage de leur savoir expérientiel, repose sur une démarche d’engagement structurée qui inclut un processus de recrutement rigoureux, la formation et le coaching de l’ensemble des membres du comité et l’élaboration de modalités de travail qui répondent aux conditions de participation des patients. Un leadership aux multiples niveaux organisationnels est également essentiel afin de soutenir la culture de partenariat et la démarche de co-construction en gouvernance. Conclusion : Les résultats de cette étude illustrent les possibilités et les défis liés à la participation de patients au niveau de la gouvernance d’un GMF-U et permettront de guider d’autres GMF-U ou GMF intéressés en ce sens. / Background: Patient engagement in primary care has been the focus of many studies in the past decade, however little research has evaluated its added value to organisational management in an academic community-based primary care practice (ACBPCP). In 2017, managers of an ACBPCP in Montreal, Canada, decided to integrate patients into the organization’s management committee to enhance the quality and relevance of decision-making for clinical services, education and research. Objectives: 1) Assess patient advisors’ role and influence on an ACBPCP management committee’s decision-making process; 2) identify the facilitators of and obstacles to patient engagement in this context; and 3) evaluate the impact of this innovative approach in promoting a patient-partnership culture throughout the organization. Design: Using a single case study, data was collected from three levels: 1) the professionals in charge of patient partnership within the territorial health care organization’s quality division; 2) the management committee; and 3) the ACBPCP’s staff outside the committee. From June 2017 to May 2019, qualitative data was collected through two focus groups, four interviews, documents and a logbook, and quantitative data was collected through questionnaires. Results: Patient advisors’ role on the strategic committee is to share their perspective based on experiential knowledge. Successful patient governance relies on a structured engagement approach, including a rigorous recruitment process of patient advisors, training and coaching of all committee members and the development of work modalities that meet the conditions of patient participation. Multilevel leadership is also fundamental to support a partnership culture throughout the organisation, including at the governance level. Conclusion: The results of this study illustrate opportunities and challenges related to patient involvement at an ACBPCP’s organizational level. They can guide other community-based primary care practices interested in involving patients in their management activities.

Service provision in veterinary oncology in Ontario was examined using a mixed methods approach. First, an interview-based qualitative study explored the service expectations of oncology clients at a tertiary referral centre. Next, a survey-based quantitative study established an understanding of oncology service in primary care practice and investigated the treatment recommendations of practitioners for dogs diagnosed with cancer. The first study, which involved 30 individual and dyadic interviews, identified “uncertainty” (attributable to the unpredictable nature of cancer and its treatment) as an overarching psychological feature of clients’ experience. Consequently, “the communication of information” (both content and process) was the foremost service expectation. For clients, it enabled confidence in the service, the ability to make informed patient care decisions, and preparedness for the potential outcomes of those decisions; it also contributed to creating a humanistic environment, which enhanced client resiliency. Findings suggest that services can support client efforts to manage uncertainty through strategic design and delivery of service, and incorporate intentional communication strategies to support clients’ psychological fortitude in managing the cancer journey. The second study, a vignette-based survey of primary care practitioners across Ontario (N=1071) which investigated veterinarian decision-making in relation to oncology care, determined that 56% of practitioners recommended referral as their first choice of intervention, while 28% recommended palliative care, 13% in-clinic treatment, and 3% euthanasia. Recommendations were associated with patient, client and veterinarian factors. Specifically, referral and treatment were recommended for younger dogs, healthier dogs, and dogs with lymphoma versus osteosarcoma; for strongly bonded clients, and financially secure clients; and by veterinarians who graduated from a North American college, had experience with treating cancer, felt confident in the referral centre, and believed treatment was worthwhile, with variation in relation to practitioner gender and the type of medicine practiced. The human-animal bond appeared to be the primary factor associated with practitioners’ advocacy for quality of medical care for patients. Through a blend of qualitative and quantitative methodologies, this thesis contributes to the evidence upon which best practices may be built so as to enhance the quality of patient and client care in veterinary oncology. / Ontario Veterinary College Pet Trust Fund 049406 and 049854