Current models of cancer care delivery in Canada are unsustainable due to the rapidly increasing number of cancer survivors at a time when there is a shortage of human and financial resources. With improvements in early detection, diagnosis, and treatment; patients diagnosed with cancer are living longer. There is also growing recognition of the chronic nature of cancer. Provincial cancer agencies have introduced new models of post-treatment follow-up involving early transition of cancer survivors back to their primary care providers. There is limited research evidence about the role nurses working in primary care settings play in the delivery of post-treatment follow-up and cancer survivorship care (CSC). The purpose of this study was to identify and examine, from the perspective of registered nurses, the strengths, barriers, and opportunities for optimizing nursing roles in the delivery of CSC in primary care. A qualitative descriptive study was conducted. Participants were recruited through membership lists from the College of Nurses of Ontario and the Canadian Family Practice Nurses Association Ontario and snowball sampling. Purposeful and maximum variation sampling techniques were employed. Participants completed an oral demographic questionnaire and individual semi-structured in-depth telephone interviews. Data collection and data analysis were conducted concurrently. The final study sample included 18 primary care registered nurses from 9 of 14 Local Health Integration Networks across Ontario. Overall, participants’ involvement in CSC was quite limited. Registered nurse involvement in CSC was categorized into three relevant themes: care coordination and system navigation; emotional support, and facilitating access to community resources. Barriers and facilitators to optimizing nursing involvement in CSC related to individual participant, practice setting, and primary care team factors. Participants recommended multiple strategies for expanding the role of nurses in CSC. / Thesis / Candidate in Philosophy / The current approach to cancer survivorship care (CSC) in Canada is unsustainable due to the rapidly increasing number of cancer survivors at a time when there is a shortage of human and financial resources. Patients diagnosed with cancer are living longer and there is growing recognition of the chronic nature of cancer survivorship. Provincial cancer agencies have introduced new models of post-treatment follow-up involving earlier transition of cancer survivors from specialist care back to their primary care providers. Currently, there is a gap in research evidence regarding the role nurses working in primary care settings play in the delivery of CSC. This thesis will describe the results of a qualitative descriptive study that identified and examined the strengths, gaps, barriers, and opportunities for optimizing nursing roles in the delivery of CSC within primary care settings from the perspective of registered nurses practicing in primary care.

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Background Population aging has led to an increasing number of older adults living in the community with complex care needs such as functional limitations, cognitive impairment, and multimorbidity. These individuals may need help to remain in their homes, which has created a growing demand for home care. Strategies to manage complex older adults such as home care patients safely in the community typically emphasize robust and integrated primary care. The objective of this thesis is to explore how specific measures of quality in primary care are associated with emergency department use among home care patients in Ontario. Methods I conducted four studies on varying subsets of the same population-based retrospective cohort of long-stay home care patients assessed in Ontario from 2014-2016. The first study was a descriptive examination of the entire cohort that characterized their primary care and other health system use. The second was a case-crossover study among home nursing patients examining whether access to afterhours care modifies the association between home nursing visits and same-day emergency department visits. The third study looked at physician-level provision of primary care home visits and its association with emergency department visits among home care patients with extensive functional impairments. The final study examined and compared associations between continuity of primary and specialty physician care. Results Long-stay home care patients in Ontario are high users of both primary care and the emergency department. Better access to afterhours care reduced the likelihood of an emergency department visit on the same day as a home nursing visit. Patients with extensive functional impairments whose primary care physician who provided higher levels of home visits had lower rates of emergency department use. Finally, better continuity of both primary and specialty physician care were similarly associated with lower emergency department use. Conclusion Better quality primary care integrated with other sectors of the health system is crucial to enabling home care patients to age safety in the community. Access to care is particularly important and can be improved though enhancing the availability of afterhours care and increasing the provision of home visits for those who have difficulty reaching primary care offices. Improving continuity of specialty physician care should be a health system objective alongside improving continuity of primary care. / Thesis / Doctor of Philosophy (PhD) / Older adults receiving home care are a growing population of individuals with complex care needs and high rates of emergency department use. This thesis seeks to characterize the primary care use of home care patients in Ontario and examine to what degree better quality of primary care is associated with less use of the emergency department. My findings indicate that increased access to afterhours primary care, higher levels of primary care home visits, and better continuity of both primary and specialty physician care were associated fewer emergency department visits. In conjunction with other sectors, primary care plays a central role managing older adults with complex care needs in the community. Better quality of primary care, particularly advanced access, can help keep older adults safely at home and out of hospitals as they age.

No / This paper reports an evaluation of a counselling service that was introduced into 20 general practices within Bradford City Primary Care Trust. Clinical Outcomes in Routine Evaluation (CORE) Assessment and End of Therapy forms were used to record referral and attendance information along with problems identified and demographic information about clients. There was a large disparity in the number of referrals across practices illustrating a range of influences on take-up of the service. Levels of attrition from referral for counselling to commencing were relatively high (188 invitations: 89 took up counselling). A longitudinal evaluation of outcomes was conducted using the CORE outcome measure and the SF-36 Health Survey Questionnaire. Data was collected at the beginning of counselling, at six months and at 12 months follow-up. We found some indication of positive change relating to severity of problems and ability to engage in social activities. However, evaluators should be aware that high attrition rates can create problems in achieving statistical reliability in contexts where overall population numbers are relatively small and/or the time for data collection is relatively short. In light of the recent growth of counselling within primary care, and the need to evaluate these services, the issues encountered in setting up this counselling service, and in seeking to evaluate it, may be instructive to others. Focus groups with counsellors and practice staff explored the benefits and problems in providing the service within practices.

Yes / Objectives: Increasing diagnostic rates of dementia is a national health priority; to meet this priority, improvement needs to be made to diagnostic services. It has been increasingly recognized that primary can play a significant role in the diagnostic journey for people with dementia, with some diagnostic services entirely located in primary care. This article reviews the extent of the involvement of primary care in diagnostic care pathways for people presenting with memory complaints within England, and presents examples of innovative approaches, which may be of interest to practitioners. Method: A rapid review was undertaken to identify articles outlining diagnostic care pathways for dementia involving primary care in England. Results: Six articles relating to pathway evaluations and innovative approaches involving primary care were deemed suitable for inclusion in the review. Conclusions: The review found examples of diagnostic pathways and innovative practices being implemented in in primary care. These practices aligned to the strategic ambitions of the National Dementia Strategy. However, it was widely acknowledged that there is a need to improve postdiagnostic pathways; in particular, access to postdiagnostic support. This issue is being reflected in contemporary policy initiatives such as the Department of Health’s 2016 Joint Declaration on postdiagnostic dementia care and support.

Yes / Congenital anomalies (CAs) are a common cause of infant death and disability. We linked children from a large birth cohort to a routine primary care database to detect CA diagnoses from birth to age 5 years. There could be evidence of underreporting by CA registries as they estimate that only 2% of CA registrations occur after age 1 year. Methods CA cases were identified by linking children from a prospective birth cohort to primary care records. CAs were classified according to the European Surveillance of CA guidelines. We calculated rates of CAs by using a bodily system group for children aged 0 to <5 years, together with risk ratios (RRs) with 95% CIs for maternal risk factors. Results Routinely collected primary care data increased the ascertainment of children with CAs from 432.9 per 10 000 live births under 1 year to 620.6 per 10 000 live births under 5 years. Consanguinity was a risk factor for Pakistani mothers (multivariable RR 1.87, 95% CI 1.46 to 2.83), and maternal age >34 years was a risk factor for mothers of other ethnicities (multivariable RR 2.19, 95% CI 1.36 to 3.54). Education was associated with a lower risk (multivariable RR 0.78, 95% CI 0.62 to 0.98). Conclusion 98% of UK CA registrations relate to diagnoses made in the first year of life. Our data suggest that this leads to incomplete case ascertainment with a further 30% identified after age 1 year in our study. Risk factors for CAs identified up to age 1 year persist up to 5 years. National registries should consider using routine data linkage to provide more complete case ascertainment after infancy. / Collaboration for Leadership in Applied Health Research and Care Yorkshire and Humber programme ‘Healthy Children Healthy Families Theme’ (IS-CLA-0113–10020).

No / The National Audit Office (NAO) has produced prescribing indicators that Primary Care Trusts (PCTs) can use to judge their performance. One of the indicators is for the antiplatelet clopidogrel, measured as defined daily dose (DDD) per cardiovascular Specific Therapeutic Age Related Prescribing Unit (STAR-PU). Clopidogrel is used as an indicator because it is a more expensive medicine than the alternative (aspirin) and there may be scope for cost reduction. We aimed to establish if the NAO indicator for clopidogrel prescribing is a valid measure of prescribing performance. Methods Prescribing data for 152 PCTs and a range of explanatory variables were obtained. Correlation between variables was determined. A regression analysis was conducted to compare the dependent variable (prescribing) with the explanatory variables identified. Results The percentage of patients on the coronary heart disease register and Index of Multiple Deprivation explained 30% of the variation in prescribing (DDD/STAR-PU) between PCTs. Even though DDD/STAR-PU is adjusted for age and sex other measures of need still have an impact on prescribing. Conclusions Using DDD/STAR-PU alone as a prescribing indicator might misidentify some PCTs, which are under- and over-using clopidogrel. Poor ranking against other PCTs using the NAO indicator should be fully explored taking into account other variables (cardiovascular morbidity and deprivation) before any corrective action is taken.

Yes / Purpose: The purpose of this paper is to investigate the potential of using primary care optometry data to support ophthalmic public health, research and policy making. Methods: Suppliers of optometric electronic patient record systems (EPRs) were interviewed to gather information about the data present in commercial software programmes and the feasibility of data extraction. Researchers were presented with a list of metrics that might be included in an optometric practice dataset via a survey circulated by email to 102 researchers known to have an interest in eye health. Respondents rated the importance of each metric for research. A further survey presented the list of metrics to 2000 randomly selected members of the College of Optometrists. The optometrists were asked to specify how likely they were to enter information about each metric in a routine sight test consultation. They were also asked if data were entered as free text, menus or a combination of these. Results: Current EPRs allowed the input of data relating to the metrics of interest. Most data entry was free text. There was a good match between high priority metrics for research and those commonly recorded in optometric practice. Conclusions: Although there were plenty of electronic data in optometric practice, this was highly variable and often not in an easily analysed format. To facilitate analysis of the evidence for public health purposes a UK based minimum dataset containing standardised clinical information is recommended. Further research would be required to develop suitable coding for the individual metrics included. The dataset would need to capture information from all sectors of the population to ensure effective planning of any future interventions.

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