Authors: Eric Mang, MPA; Artem Safarov, BSc, on behalf of CFPC Health Policy and Government Relations; Alan Katz, MBChB, CCFP, MSc, FCFP; Cheryl Levitt, MBBCh, CCFP, FCFP, on behalf of the CFPC Section of Researchers.

� The Author 2009. Published by Oxford University Press. All rights reserved.

For permissions, please e-mail: journals.permissions@oxfordjournals.org.

Family Practice 2010; 27:135–142

doi:10.1093/fampra/cmp094Advance Access published on 23 December 2009

A primary care pragmatic cluster randomized trialof the use of home blood pressure monitoring onblood pressure levels in hypertensive patients withabove target blood pressure

Marshall Godwina,*, Miu Lamb, Richard Birtwhistlec, Dianne Delvad,Rachelle Seguine, Ian Cassonc and Susan MacDonaldc

aFamily Medicine, Memorial University of Newfoundland, St. John’s, bDepartment of Community Health and Epidemiology,Kingston, cFamily Medicine, Queen’s University, Kingston, dFamily Medicine, Dalhousie University, Kingston, and eDepartmentof Family Medicine, Queen’s University, Kingston, Canada.*Correspondence to Marshall Godwin, Primary Healthcare Research Unit, Room 1776, 300 Prince Philip Drive, St. John’s, NL,Canada A1B 3V6; E-mail: godwinm@mun.ca

Received 9 March 2009; Revised 22 October 2009; Accepted 30 November 2009.

Background. The measurement of blood pressure (BP) at home by patients with hypertension isincreasingly used to assess and monitor BP. Evidence for its effectiveness in improving BPcontrol is mixed.

Methods. To determine if home BP monitoring improves BP a pragmatic cluster randomizedcontolled trial was carried out in family practices in southeastern Ontario, Canada. Family prac-tice patients with uncontrolled hypertension were recruited to the trail. Patients were divided in-to two groups: one with at least weekly measurements of BP at home, recording thosemeasurements and showing those to the family physician during office visits for hypertensionand the control group were given usual care. The primary outcome was mean awake BP on am-bulatory monitoring at 6- and 12-month follow-up and the secondary outcomes were mean BPon full 24-hour ambulatory blood pressure monitoring (ABPM), mean sleep BP on ABPM and BPon the BpTRU device, all at 6- and 12-month follow-up.

Results. Home BPmonitoring did not improve BP compared to usual care at 12-month follow-up:mean awake systolic BP on ABPM [141.1 versus 142.8 mmHg, mean difference 1.7 mmHg; 95%confidence interval (CI) –0.6 to 4.0, P = 0.314] andmean awake diastolic BP on ABPM (78.7 versus79.4 mmHg, mean difference 0.7 mmHg; 95% CI –7.7 to 9.1, P = 0.398). Similar negative resultswere obtained for men and women separately. However, outcomes using the full 24-hour ABPMand the BpTRU device showed a significantly lower diastolic BP at 12 months. When analysiswas done by sex, this effect was shown to be only in men.

Conclusion. Home BP monitoring may improve BP control in men with hypertension.

Keywords. Home blood pressure monitoring, hypertension, pragmatic randomized trials,primary care.

Introduction

The measurement of blood pressure (BP) at home bypatients with hypertension is being increasingly usedby physicians and patients to assess and monitor BPcontrol.1 If it is effective in increasing both awarenessof BP levels and adherence to medication, then thisapproach fits nicely into the concepts of self-care andchronic disease management and may result in moreeffective treatment of hypertension. In 2004, Cappuc-cio et al.2 published a meta-analysis of clinical trials

on home BP monitoring. The review included studiesthat had been conducted in hospital-based clinics, gen-eral practice and community settings up to the end of2002. The interventions all involved home BP moni-toring but varied as to how the information was usedby the physician to make treatment decisions. The re-view included studies with different measurements ofoutcome: office measurement by the physician, mea-surement by a trained technician and ambulatoryblood pressure monitoring (ABPM). They did not re-port the results by the type of outcome assessment.

135

by guest on October 20, 2014

http://fampra.oxfordjournals.org/

Dow

nloaded from

The 10 Most Notable Family Medicine Research Studies in Canada: a Retrospective

Objective: The College of Family Physicians of Canada (CFPC) in 2014 identified the 10 most notable family medicine research papers to promote the best of Canadian family medicine research.

Design: We focused on studies carried out since 2000, although studies carried out before were considered. We developed a framework for inclusion that included topics of interest, regional representation and quality of studies. We listed papers that had received awards for the CFPC Outstanding Family Medicine Research Article, the Canadian Family Physician Best Original Research Article and the Family Medicine Researcher of the Year. CFPC Section of Researchers' (SOR) Council members and the university departments’ Research Directors suggested additional studies.

Results: 31 studies were reviewed. A short list of 16 studies was developed. From this, we chose the “The Seven Wonders of Family Medicine Research” and with the help of SOR Council executive members the “Top 10 Family Medicine Research Studies” were decided.

Conclusions: “The Seven Wonders of Family Medicine Research” and “Top 10 Family Medicine Research Studies” represent the unique value that Canadian

family medicine research has had on health.

RESEARCH

Improving cardiovascular health at population level: 39communitycluster randomisedtrialofCardiovascularHealthAwareness Program (CHAP)

Janusz Kaczorowski, professor,1,2,3 LarryW Chambers, president and chief scientist,4 Lisa Dolovich, associateprofessor,2,5,6 J Michael Paterson, scientist,7 Tina Karwalajtys, assistant professor,2 Tracy Gierman, director,8

Barbara Farrell, scientist,4,9 Beatrice McDonough, public health nurse,10 Lehana Thabane, associateprofessor,5 Karen Tu, scientist,7 BrandonZagorski, analyst,7 RonGoeree, associate professor,5 Cheryl A Levitt,professor,2 William Hogg, professor,4,9,11 Stephanie Laryea, research assistant,2 Megan Ann Carter, researchassociate,11 Dana Cross, acting director,8 Rolf J Sabaldt, associate clinical professor6

ABSTRACT

Objective To evaluate the effectiveness of the community

based Cardiovascular Health Awareness Program (CHAP)

on morbidity from cardiovascular disease.

Design Community cluster randomised trial.

Setting 39 mid-sized communities in Ontario, Canada,

stratified by location and population size.

Participants Community dwelling residents aged 65 years

or over, family physicians, pharmacists, volunteers,

community nurses, and local lead organisations.

Intervention Communities were randomised to receive

CHAP (n=20) or no intervention (n=19). In CHAP

communities, residents aged 65 or over were invited to

attend volunteer run cardiovascular risk assessment and

education sessions held in community based pharmacies

over a 10 week period; automated blood pressure

readings and self reported risk factor data were collected

and shared with participants and their family physicians

and pharmacists.

Main outcome measure Composite of hospital

admissions for acute myocardial infarction, stroke, and

congestive heart failure among all community residents

aged 65 and over in the year before compared with the

year after implementation of CHAP.

Results All 20 intervention communities successfully

implemented CHAP. A total of 1265 three hour long

sessions were held in 129/145 (89%) pharmacies during

the 10 week programme. 15889 unique participants had

a total of 27358 cardiovascular assessments with the

assistance of 577 peer volunteers. After adjustment for

hospital admission rates in the year before the

intervention, CHAP was associated with a 9% relative

reduction in the composite endpoint (rate ratio 0.91, 95%

confidence interval 0.86 to 0.97; P=0.002) or 3.02 fewer

annual hospital admissions for cardiovascular disease

per 1000 people aged 65 and over. Statistically

significant reductions favouring the intervention

communities were seen in hospital admissions for acute

myocardial infarction (rate ratio 0.87, 0.79 to 0.97;

P=0.008) and congestive heart failure (0.90, 0.81 to 0.99;P=0.029) but not for stroke (0.99, 0.88 to 1.12; P=0.89).Conclusions A collaborative, multi-pronged, community

based health promotion and prevention programme

targeted at older adults can reduce cardiovascular

morbidity at the population level.

Trial registration Current controlled trials

ISRCTN50550004.

INTRODUCTION

In 2002 theWorldHealthOrganization identified highblood pressure as the leading risk factor for death, fore-casting an epidemic of hypertension and identifyingcommunity programmes to prevent cardiovasculardisease as a priority.1 Worldwide, 30% of all deathsare due to cardiovascular disease, and more than 54%of deaths from stroke, 47% of those from ischaemicheart disease, and 14% of all deaths are attributable tohigh blood pressure.2 3 Effective population based stra-tegies for health promotion and disease prevention,both for peoplewith established cardiovascular diseaseand for those at risk of developing it, are seen as criticalto countering widespread and growing epidemics ofobesity, hypertension, diabetes, heart disease, andstroke.4-6 Both the incidence and the prevalence ofhypertension increase with age, and the lifetime resi-dual risk of developing hypertension for amiddle agedperson with normal blood pressure is 90%.7

A recent review of community programmes for pre-vention of cardiovascular disease included 36 commu-nity programmes that took place between 1970 and2008 and concluded that although generally favour-able changes in overall cardiovascular risk have beenshown, considerable uncertainties about their effec-tiveness remain.8 The review further concluded thatstudies of programmes better adapted to currentcircumstances need to be implemented and rigorouslyevaluated before widespread implementation ofsuch programmes can be recommended. Specific

1Department of Family Practice,University of British Columbia,320-5950 University Boulevard,Vancouver, BC, Canada V6T 1Z32Department of Family Medicine,McMaster University, Hamilton,ON, Canada3Child & Family ResearchInstitute, Vancouver4Institut de recherche Élisabeth-Bruyère Research Institute,Bruyère Continuing Care andUniversity of Ottawa, Ottawa, ON,Canada5Department of ClinicalEpidemiology and Biostatistics,McMaster University, Hamilton6Department of Medicine,McMaster University, Hamilton7Institute for Clinical EvaluativeSciences, Toronto, ON, Canada8Academic Health Council,University of Ottawa, Ottawa9Department of Family Medicine,University of Ottawa10Public Health Services, City ofHamilton, Hamilton11Institute of Population Health,University of Ottawa

Correspondence to: J KaczorowskiJanusz.kaczorowski@familymed.ubc.ca

Cite this as: BMJ 2011;342:d442doi:10.1136/bmj.d442

BMJ | ONLINE FIRST | bmj.com page 1 of 8

RESEARCH

Improving cardiovascular health at population level: 39communitycluster randomisedtrialofCardiovascularHealthAwareness Program (CHAP)

Janusz Kaczorowski, professor,1,2,3 LarryW Chambers, president and chief scientist,4 Lisa Dolovich, associateprofessor,2,5,6 J Michael Paterson, scientist,7 Tina Karwalajtys, assistant professor,2 Tracy Gierman, director,8

Barbara Farrell, scientist,4,9 Beatrice McDonough, public health nurse,10 Lehana Thabane, associateprofessor,5 Karen Tu, scientist,7 BrandonZagorski, analyst,7 RonGoeree, associate professor,5 Cheryl A Levitt,professor,2 William Hogg, professor,4,9,11 Stephanie Laryea, research assistant,2 Megan Ann Carter, researchassociate,11 Dana Cross, acting director,8 Rolf J Sabaldt, associate clinical professor6

ABSTRACT

Objective To evaluate the effectiveness of the community

based Cardiovascular Health Awareness Program (CHAP)

on morbidity from cardiovascular disease.

Design Community cluster randomised trial.

Setting 39 mid-sized communities in Ontario, Canada,

stratified by location and population size.

Participants Community dwelling residents aged 65 years

or over, family physicians, pharmacists, volunteers,

community nurses, and local lead organisations.

Intervention Communities were randomised to receive

CHAP (n=20) or no intervention (n=19). In CHAP

communities, residents aged 65 or over were invited to

attend volunteer run cardiovascular risk assessment and

education sessions held in community based pharmacies

over a 10 week period; automated blood pressure

readings and self reported risk factor data were collected

and shared with participants and their family physicians

and pharmacists.

Main outcome measure Composite of hospital

admissions for acute myocardial infarction, stroke, and

congestive heart failure among all community residents

aged 65 and over in the year before compared with the

year after implementation of CHAP.

Results All 20 intervention communities successfully

implemented CHAP. A total of 1265 three hour long

sessions were held in 129/145 (89%) pharmacies during

the 10 week programme. 15889 unique participants had

a total of 27358 cardiovascular assessments with the

assistance of 577 peer volunteers. After adjustment for

hospital admission rates in the year before the

intervention, CHAP was associated with a 9% relative

reduction in the composite endpoint (rate ratio 0.91, 95%

confidence interval 0.86 to 0.97; P=0.002) or 3.02 fewer

annual hospital admissions for cardiovascular disease

per 1000 people aged 65 and over. Statistically

significant reductions favouring the intervention

communities were seen in hospital admissions for acute

myocardial infarction (rate ratio 0.87, 0.79 to 0.97;

P=0.008) and congestive heart failure (0.90, 0.81 to 0.99;P=0.029) but not for stroke (0.99, 0.88 to 1.12; P=0.89).Conclusions A collaborative, multi-pronged, community

based health promotion and prevention programme

targeted at older adults can reduce cardiovascular

morbidity at the population level.

Trial registration Current controlled trials

ISRCTN50550004.

INTRODUCTION

In 2002 theWorldHealthOrganization identified highblood pressure as the leading risk factor for death, fore-casting an epidemic of hypertension and identifyingcommunity programmes to prevent cardiovasculardisease as a priority.1 Worldwide, 30% of all deathsare due to cardiovascular disease, and more than 54%of deaths from stroke, 47% of those from ischaemicheart disease, and 14% of all deaths are attributable tohigh blood pressure.2 3 Effective population based stra-tegies for health promotion and disease prevention,both for peoplewith established cardiovascular diseaseand for those at risk of developing it, are seen as criticalto countering widespread and growing epidemics ofobesity, hypertension, diabetes, heart disease, andstroke.4-6 Both the incidence and the prevalence ofhypertension increase with age, and the lifetime resi-dual risk of developing hypertension for amiddle agedperson with normal blood pressure is 90%.7

A recent review of community programmes for pre-vention of cardiovascular disease included 36 commu-nity programmes that took place between 1970 and2008 and concluded that although generally favour-able changes in overall cardiovascular risk have beenshown, considerable uncertainties about their effec-tiveness remain.8 The review further concluded thatstudies of programmes better adapted to currentcircumstances need to be implemented and rigorouslyevaluated before widespread implementation ofsuch programmes can be recommended. Specific

1Department of Family Practice,University of British Columbia,320-5950 University Boulevard,Vancouver, BC, Canada V6T 1Z32Department of Family Medicine,McMaster University, Hamilton,ON, Canada3Child & Family ResearchInstitute, Vancouver4Institut de recherche Élisabeth-Bruyère Research Institute,Bruyère Continuing Care andUniversity of Ottawa, Ottawa, ON,Canada5Department of ClinicalEpidemiology and Biostatistics,McMaster University, Hamilton6Department of Medicine,McMaster University, Hamilton7Institute for Clinical EvaluativeSciences, Toronto, ON, Canada8Academic Health Council,University of Ottawa, Ottawa9Department of Family Medicine,University of Ottawa10Public Health Services, City ofHamilton, Hamilton11Institute of Population Health,University of Ottawa

Correspondence to: J KaczorowskiJanusz.kaczorowski@familymed.ubc.ca

Cite this as: BMJ 2011;342:d442doi:10.1136/bmj.d442

BMJ | ONLINE FIRST | bmj.com page 1 of 8

RESEARCH

Improving cardiovascular health at population level: 39communitycluster randomisedtrialofCardiovascularHealthAwareness Program (CHAP)

Janusz Kaczorowski, professor,1,2,3 LarryW Chambers, president and chief scientist,4 Lisa Dolovich, associateprofessor,2,5,6 J Michael Paterson, scientist,7 Tina Karwalajtys, assistant professor,2 Tracy Gierman, director,8

Barbara Farrell, scientist,4,9 Beatrice McDonough, public health nurse,10 Lehana Thabane, associateprofessor,5 Karen Tu, scientist,7 BrandonZagorski, analyst,7 RonGoeree, associate professor,5 Cheryl A Levitt,professor,2 William Hogg, professor,4,9,11 Stephanie Laryea, research assistant,2 Megan Ann Carter, researchassociate,11 Dana Cross, acting director,8 Rolf J Sabaldt, associate clinical professor6

ABSTRACT

Objective To evaluate the effectiveness of the community

based Cardiovascular Health Awareness Program (CHAP)

on morbidity from cardiovascular disease.

Design Community cluster randomised trial.

Setting 39 mid-sized communities in Ontario, Canada,

stratified by location and population size.

Participants Community dwelling residents aged 65 years

or over, family physicians, pharmacists, volunteers,

community nurses, and local lead organisations.

Intervention Communities were randomised to receive

CHAP (n=20) or no intervention (n=19). In CHAP

communities, residents aged 65 or over were invited to

attend volunteer run cardiovascular risk assessment and

education sessions held in community based pharmacies

over a 10 week period; automated blood pressure

readings and self reported risk factor data were collected

and shared with participants and their family physicians

and pharmacists.

Main outcome measure Composite of hospital

admissions for acute myocardial infarction, stroke, and

congestive heart failure among all community residents

aged 65 and over in the year before compared with the

year after implementation of CHAP.

Results All 20 intervention communities successfully

implemented CHAP. A total of 1265 three hour long

sessions were held in 129/145 (89%) pharmacies during

the 10 week programme. 15889 unique participants had

a total of 27358 cardiovascular assessments with the

assistance of 577 peer volunteers. After adjustment for

hospital admission rates in the year before the

intervention, CHAP was associated with a 9% relative

reduction in the composite endpoint (rate ratio 0.91, 95%

confidence interval 0.86 to 0.97; P=0.002) or 3.02 fewer

annual hospital admissions for cardiovascular disease

per 1000 people aged 65 and over. Statistically

significant reductions favouring the intervention

communities were seen in hospital admissions for acute

myocardial infarction (rate ratio 0.87, 0.79 to 0.97;

P=0.008) and congestive heart failure (0.90, 0.81 to 0.99;P=0.029) but not for stroke (0.99, 0.88 to 1.12; P=0.89).Conclusions A collaborative, multi-pronged, community

based health promotion and prevention programme

targeted at older adults can reduce cardiovascular

morbidity at the population level.

Trial registration Current controlled trials

ISRCTN50550004.

INTRODUCTION

In 2002 theWorldHealthOrganization identified highblood pressure as the leading risk factor for death, fore-casting an epidemic of hypertension and identifyingcommunity programmes to prevent cardiovasculardisease as a priority.1 Worldwide, 30% of all deathsare due to cardiovascular disease, and more than 54%of deaths from stroke, 47% of those from ischaemicheart disease, and 14% of all deaths are attributable tohigh blood pressure.2 3 Effective population based stra-tegies for health promotion and disease prevention,both for peoplewith established cardiovascular diseaseand for those at risk of developing it, are seen as criticalto countering widespread and growing epidemics ofobesity, hypertension, diabetes, heart disease, andstroke.4-6 Both the incidence and the prevalence ofhypertension increase with age, and the lifetime resi-dual risk of developing hypertension for amiddle agedperson with normal blood pressure is 90%.7

A recent review of community programmes for pre-vention of cardiovascular disease included 36 commu-nity programmes that took place between 1970 and2008 and concluded that although generally favour-able changes in overall cardiovascular risk have beenshown, considerable uncertainties about their effec-tiveness remain.8 The review further concluded thatstudies of programmes better adapted to currentcircumstances need to be implemented and rigorouslyevaluated before widespread implementation ofsuch programmes can be recommended. Specific

1Department of Family Practice,University of British Columbia,320-5950 University Boulevard,Vancouver, BC, Canada V6T 1Z32Department of Family Medicine,McMaster University, Hamilton,ON, Canada3Child & Family ResearchInstitute, Vancouver4Institut de recherche Élisabeth-Bruyère Research Institute,Bruyère Continuing Care andUniversity of Ottawa, Ottawa, ON,Canada5Department of ClinicalEpidemiology and Biostatistics,McMaster University, Hamilton6Department of Medicine,McMaster University, Hamilton7Institute for Clinical EvaluativeSciences, Toronto, ON, Canada8Academic Health Council,University of Ottawa, Ottawa9Department of Family Medicine,University of Ottawa10Public Health Services, City ofHamilton, Hamilton11Institute of Population Health,University of Ottawa

Correspondence to: J KaczorowskiJanusz.kaczorowski@familymed.ubc.ca

Cite this as: BMJ 2011;342:d442doi:10.1136/bmj.d442

BMJ | ONLINE FIRST | bmj.com page 1 of 8

RESEARCH

Improving cardiovascular health at population level: 39communitycluster randomisedtrialofCardiovascularHealthAwareness Program (CHAP)

Janusz Kaczorowski, professor,1,2,3 LarryW Chambers, president and chief scientist,4 Lisa Dolovich, associateprofessor,2,5,6 J Michael Paterson, scientist,7 Tina Karwalajtys, assistant professor,2 Tracy Gierman, director,8

Barbara Farrell, scientist,4,9 Beatrice McDonough, public health nurse,10 Lehana Thabane, associateprofessor,5 Karen Tu, scientist,7 BrandonZagorski, analyst,7 RonGoeree, associate professor,5 Cheryl A Levitt,professor,2 William Hogg, professor,4,9,11 Stephanie Laryea, research assistant,2 Megan Ann Carter, researchassociate,11 Dana Cross, acting director,8 Rolf J Sabaldt, associate clinical professor6

ABSTRACT

Objective To evaluate the effectiveness of the community

based Cardiovascular Health Awareness Program (CHAP)

on morbidity from cardiovascular disease.

Design Community cluster randomised trial.

Setting 39 mid-sized communities in Ontario, Canada,

stratified by location and population size.

Participants Community dwelling residents aged 65 years

or over, family physicians, pharmacists, volunteers,

community nurses, and local lead organisations.

Intervention Communities were randomised to receive

CHAP (n=20) or no intervention (n=19). In CHAP

communities, residents aged 65 or over were invited to

attend volunteer run cardiovascular risk assessment and

education sessions held in community based pharmacies

over a 10 week period; automated blood pressure

readings and self reported risk factor data were collected

and shared with participants and their family physicians

and pharmacists.

Main outcome measure Composite of hospital

admissions for acute myocardial infarction, stroke, and

congestive heart failure among all community residents

aged 65 and over in the year before compared with the

year after implementation of CHAP.

Results All 20 intervention communities successfully

implemented CHAP. A total of 1265 three hour long

sessions were held in 129/145 (89%) pharmacies during

the 10 week programme. 15889 unique participants had

a total of 27358 cardiovascular assessments with the

assistance of 577 peer volunteers. After adjustment for

hospital admission rates in the year before the

intervention, CHAP was associated with a 9% relative

reduction in the composite endpoint (rate ratio 0.91, 95%

confidence interval 0.86 to 0.97; P=0.002) or 3.02 fewer

annual hospital admissions for cardiovascular disease

per 1000 people aged 65 and over. Statistically

significant reductions favouring the intervention

communities were seen in hospital admissions for acute

myocardial infarction (rate ratio 0.87, 0.79 to 0.97;

P=0.008) and congestive heart failure (0.90, 0.81 to 0.99;P=0.029) but not for stroke (0.99, 0.88 to 1.12; P=0.89).Conclusions A collaborative, multi-pronged, community

based health promotion and prevention programme

targeted at older adults can reduce cardiovascular

morbidity at the population level.

Trial registration Current controlled trials

ISRCTN50550004.

INTRODUCTION

In 2002 theWorldHealthOrganization identified highblood pressure as the leading risk factor for death, fore-casting an epidemic of hypertension and identifyingcommunity programmes to prevent cardiovasculardisease as a priority.1 Worldwide, 30% of all deathsare due to cardiovascular disease, and more than 54%of deaths from stroke, 47% of those from ischaemicheart disease, and 14% of all deaths are attributable tohigh blood pressure.2 3 Effective population based stra-tegies for health promotion and disease prevention,both for peoplewith established cardiovascular diseaseand for those at risk of developing it, are seen as criticalto countering widespread and growing epidemics ofobesity, hypertension, diabetes, heart disease, andstroke.4-6 Both the incidence and the prevalence ofhypertension increase with age, and the lifetime resi-dual risk of developing hypertension for amiddle agedperson with normal blood pressure is 90%.7

A recent review of community programmes for pre-vention of cardiovascular disease included 36 commu-nity programmes that took place between 1970 and2008 and concluded that although generally favour-able changes in overall cardiovascular risk have beenshown, considerable uncertainties about their effec-tiveness remain.8 The review further concluded thatstudies of programmes better adapted to currentcircumstances need to be implemented and rigorouslyevaluated before widespread implementation ofsuch programmes can be recommended. Specific

1Department of Family Practice,University of British Columbia,320-5950 University Boulevard,Vancouver, BC, Canada V6T 1Z32Department of Family Medicine,McMaster University, Hamilton,ON, Canada3Child & Family ResearchInstitute, Vancouver4Institut de recherche Élisabeth-Bruyère Research Institute,Bruyère Continuing Care andUniversity of Ottawa, Ottawa, ON,Canada5Department of ClinicalEpidemiology and Biostatistics,McMaster University, Hamilton6Department of Medicine,McMaster University, Hamilton7Institute for Clinical EvaluativeSciences, Toronto, ON, Canada8Academic Health Council,University of Ottawa, Ottawa9Department of Family Medicine,University of Ottawa10Public Health Services, City ofHamilton, Hamilton11Institute of Population Health,University of Ottawa

Correspondence to: J KaczorowskiJanusz.kaczorowski@familymed.ubc.ca

Cite this as: BMJ 2011;342:d442doi:10.1136/bmj.d442

BMJ | ONLINE FIRST | bmj.com page 1 of 8

Prevalence of Multimorbidity Among Adults Seen in Family Practice

ABSTRACTPURPOSE There are few valid data that describe the extent of multimorbidity in primary care patients. The purpose of this study was to estimate its prevalence in family practice patients by counting the number of chronic medical conditions and using a measure that considers the severity of these conditions, the Cumula-tive Illness Rating Scale (CIRS).

METHODS The study was carried out in the Saguenay region (Québec, Canada) in 2003. The participation of adult patients from 21 family physicians was solicited during consecutive consultation periods. A research nurse reviewed medical records and extracted the data regarding chronic illnesses. For each chronic condition, a severity rating was determined in accordance with the CIRS scoring guidelines.

RESULTS The sample consisted of 320 men and 660 women. Overall, 9 of 10 patients had more than 1 chronic condition. The prevalence of having 2 or more medical conditions in the 18- to 44-year, 45- to 64-year, and 65-year and older age-groups was, respectively, 68%, 95%, and 99% among women and 72%, 89%, and 97% among men. The mean number of conditions and mean CIRS score also increased signifi cantly with age.

CONCLUSIONS Whether measured by simply counting the number of conditions or using the CIRS, the prevalence of multimorbidity is quite high and increases signifi cantly with age in both men and women. Patients with multimorbidity seen in family practice represent the rule rather than the exception.

Ann Fam Med 2005;3:223-228. DOI: 10.1370/afm.272.

INTRODUCTION

Multimorbidity may be defi ned as the simultaneous occurrence of several medical conditions in the same person.1 Although family physicians care for such patients on a daily basis, there are few

valid data that describe the extent of the multimorbidity phenomenon.2 It is estimated that 57 million Americans had multiple chronic conditions in 2000 and that this number will rise to 81 million by 2020.3

A few studies have estimated the prevalence of multimorbidity in Europe,4,5 the Middle East,6 the United States,7-9 and Canada.10 Table 1 summarizes the prevalence data found in the literature. There are, however major differences in the sources and results of these studies.4-10 The data were obtained from various surveys,8-10 administrative databases,7 or com-puterized networks of family practices.4,5 None of these reports includes prevalence data obtained from a review of medical records, although some have suggested that this strategy is the best way to collect information about medical diagnoses. Furthermore, almost one half the studies were limited to elderly populations. In these studies, multimorbidity was defi ned as 2 or more chronic medical conditions, and the measure was a simple count of such conditions. As the diagnoses taken into account differed, the total number of chronic conditions reported widely varied.

When addressing the problem of multimorbidity, the fi rst diffi culty that arises is the lack of a clear defi nition that also captures the clinical burden.

Martin Fortin, MD, MSc, CMFC1

Gina Bravo, PhD2

Catherine Hudon, MD, CMFC1

Alain Vanasse, MD, PhD, CMFC1

Lise Lapointe, MA1

1Department of Family Medicine, Sherbrooke University, Québec, Canada

2Department of Community Health Sciences, Sherbrooke University, Québec, Canada

Confl icts of interest: none reported

CORRESPONDING AUTHOR

Martin Fortin, MD, MSc, CMFCUnité de Médecine de Famille305 St-VallierChicoutimi, QuébecG7H 5H6martinfortin@videotron.ca

ANNALS OF FAMILY MEDICINE � WWW.ANNFAMMED.ORG � VOL. 3, NO. 3 � MAY/JUNE 2005

223

Prevalence of Multimorbidity Among Adults Seen in Family Practice

ABSTRACTPURPOSE There are few valid data that describe the extent of multimorbidity in primary care patients. The purpose of this study was to estimate its prevalence in family practice patients by counting the number of chronic medical conditions and using a measure that considers the severity of these conditions, the Cumula-tive Illness Rating Scale (CIRS).

METHODS The study was carried out in the Saguenay region (Québec, Canada) in 2003. The participation of adult patients from 21 family physicians was solicited during consecutive consultation periods. A research nurse reviewed medical records and extracted the data regarding chronic illnesses. For each chronic condition, a severity rating was determined in accordance with the CIRS scoring guidelines.

RESULTS The sample consisted of 320 men and 660 women. Overall, 9 of 10 patients had more than 1 chronic condition. The prevalence of having 2 or more medical conditions in the 18- to 44-year, 45- to 64-year, and 65-year and older age-groups was, respectively, 68%, 95%, and 99% among women and 72%, 89%, and 97% among men. The mean number of conditions and mean CIRS score also increased signifi cantly with age.

CONCLUSIONS Whether measured by simply counting the number of conditions or using the CIRS, the prevalence of multimorbidity is quite high and increases signifi cantly with age in both men and women. Patients with multimorbidity seen in family practice represent the rule rather than the exception.

Ann Fam Med 2005;3:223-228. DOI: 10.1370/afm.272.

INTRODUCTION

Multimorbidity may be defi ned as the simultaneous occurrence of several medical conditions in the same person.1 Although family physicians care for such patients on a daily basis, there are few

valid data that describe the extent of the multimorbidity phenomenon.2 It is estimated that 57 million Americans had multiple chronic conditions in 2000 and that this number will rise to 81 million by 2020.3

A few studies have estimated the prevalence of multimorbidity in Europe,4,5 the Middle East,6 the United States,7-9 and Canada.10 Table 1 summarizes the prevalence data found in the literature. There are, however major differences in the sources and results of these studies.4-10 The data were obtained from various surveys,8-10 administrative databases,7 or com-puterized networks of family practices.4,5 None of these reports includes prevalence data obtained from a review of medical records, although some have suggested that this strategy is the best way to collect information about medical diagnoses. Furthermore, almost one half the studies were limited to elderly populations. In these studies, multimorbidity was defi ned as 2 or more chronic medical conditions, and the measure was a simple count of such conditions. As the diagnoses taken into account differed, the total number of chronic conditions reported widely varied.

When addressing the problem of multimorbidity, the fi rst diffi culty that arises is the lack of a clear defi nition that also captures the clinical burden.

Martin Fortin, MD, MSc, CMFC1

Gina Bravo, PhD2

Catherine Hudon, MD, CMFC1

Alain Vanasse, MD, PhD, CMFC1

Lise Lapointe, MA1

1Department of Family Medicine, Sherbrooke University, Québec, Canada

2Department of Community Health Sciences, Sherbrooke University, Québec, Canada

Confl icts of interest: none reported

CORRESPONDING AUTHOR

Martin Fortin, MD, MSc, CMFCUnité de Médecine de Famille305 St-VallierChicoutimi, QuébecG7H 5H6martinfortin@videotron.ca

ANNALS OF FAMILY MEDICINE � WWW.ANNFAMMED.ORG � VOL. 3, NO. 3 � MAY/JUNE 2005

223

Research

Recherche

Dr. Lemelin is AssociateProfessor, Dr. Hogg isProfessor, and Mr. Baskervilleis Assistant Professor with theDepartment of FamilyMedicine, University ofOttawa, Ottawa, Ont.

This article has been peer reviewed.

CMAJ 2001;164(6):757-63

ß See related article page 790

Abstract

Background: Although there is much room for improvement in the performance

of recommended preventive manoeuvres, many inappropriate preventive in-

terventions are being done. We evaluated a multifaceted intervention, deliv-

ered by nurses trained in prevention facilitation, to improve prevention in pri-

mary care.Methods: Forty-six health service organizations (HSOs) were recruited from 100

sites in Ontario. After baseline data were collected, we randomly assigned the

practices to either an 18-month (July 1997 to December 1998) multifaceted in-

tervention delivered by 1 of 3 nurse facilitators (23 practices) or no intervention

(23 practices). The unit of intervention and analysis was the medical practice.

The outcome measure was an overall index of preventive performance, which

was calculated as the proportion of eligible patients who received 8 recom-

mended preventive manoeuvres less the proportion of eligible patients who re-

ceived 5 inappropriate preventive manoeuvres.

Results: One HSO, in the intervention group, was lost to follow-up. Before the in-

tervention, the index of preventive performance was similar for the intervention

and control groups (31.9% [95% confidence interval (CI) 27.3%–36.5%] and

32.1% [95% CI 27.2%–37.0%] respectively). At follow-up the corresponding

values were 43.2% (95% CI 38.4%–48.0%) and 31.9% (95% CI 26.8%–

37.0%), for an absolute improvement in the intervention group of 11.5% (p <

0.001). The mean proportion of eligible patients who received the recom-

mended manoeuvres was 62.3% (95% CI 58.2%–66.4%) in the intervention

group, as compared with 57.4% (95% CI 54.1%–60.7%) in the control group,

for an absolute improvement of 7.2% (p = 0.008). The corresponding values for

the inappropriate manoeuvres were 19.1% (95% CI 15.6%–22.6%) and 25.5%

(95% CI 20.0%–31.0%), for an absolute improvement of 4.4% (p = 0.019).

Interpretation: The tailored multifaceted intervention delivered by nurse facilitators

was effective in modifying physician practice patterns and significantly im-

proved preventive care performance.

The Canadian Task Force on Preventive Health Care (formerly the Can-

adian Task Force on the Periodic Health Examination) has established

guidelines for the delivery of preventive care1,2 that are supported by clini-

cal evidence as effective. Evidence-based guidelines are not self-implementing.3–5

Changing physicians’ long-held patterns of behaviour and the environments in

which they work is complex and difficult. Unless the barriers to change can be

overcome and action taken to improve compliance, efforts to develop evidence-

based guidelines will be wasted.6

Programs that address physician knowledge alone, such as traditional continu-

ing medical education and dissemination of guidelines, are insufficient to change

practice behaviour.3,4,7,8 In addition, single interventions are less likely to result in

Evidence to action: a tailoredmultifaceted approach to changingfamily physician practice patternsand improving preventive care

Jacques Lemelin, William Hogg, Neill Baskerville

CMAJ • MAR. 20, 2001; 164 (6) 757

© 2001 Canadian Medical Association or its licensors

Research

Recherche

Dr. Lemelin is AssociateProfessor, Dr. Hogg isProfessor, and Mr. Baskervilleis Assistant Professor with theDepartment of FamilyMedicine, University ofOttawa, Ottawa, Ont.

This article has been peer reviewed.

CMAJ 2001;164(6):757-63

ß See related article page 790

Abstract

Background: Although there is much room for improvement in the performance

of recommended preventive manoeuvres, many inappropriate preventive in-

terventions are being done. We evaluated a multifaceted intervention, deliv-

ered by nurses trained in prevention facilitation, to improve prevention in pri-

mary care.Methods: Forty-six health service organizations (HSOs) were recruited from 100

sites in Ontario. After baseline data were collected, we randomly assigned the

practices to either an 18-month (July 1997 to December 1998) multifaceted in-

tervention delivered by 1 of 3 nurse facilitators (23 practices) or no intervention

(23 practices). The unit of intervention and analysis was the medical practice.

The outcome measure was an overall index of preventive performance, which

was calculated as the proportion of eligible patients who received 8 recom-

mended preventive manoeuvres less the proportion of eligible patients who re-

ceived 5 inappropriate preventive manoeuvres.

Results: One HSO, in the intervention group, was lost to follow-up. Before the in-

tervention, the index of preventive performance was similar for the intervention

and control groups (31.9% [95% confidence interval (CI) 27.3%–36.5%] and

32.1% [95% CI 27.2%–37.0%] respectively). At follow-up the corresponding

values were 43.2% (95% CI 38.4%–48.0%) and 31.9% (95% CI 26.8%–

37.0%), for an absolute improvement in the intervention group of 11.5% (p <

0.001). The mean proportion of eligible patients who received the recom-

mended manoeuvres was 62.3% (95% CI 58.2%–66.4%) in the intervention

group, as compared with 57.4% (95% CI 54.1%–60.7%) in the control group,

for an absolute improvement of 7.2% (p = 0.008). The corresponding values for

the inappropriate manoeuvres were 19.1% (95% CI 15.6%–22.6%) and 25.5%

(95% CI 20.0%–31.0%), for an absolute improvement of 4.4% (p = 0.019).

Interpretation: The tailored multifaceted intervention delivered by nurse facilitators

was effective in modifying physician practice patterns and significantly im-

proved preventive care performance.

The Canadian Task Force on Preventive Health Care (formerly the Can-

adian Task Force on the Periodic Health Examination) has established

guidelines for the delivery of preventive care1,2 that are supported by clini-

cal evidence as effective. Evidence-based guidelines are not self-implementing.3–5

Changing physicians’ long-held patterns of behaviour and the environments in

which they work is complex and difficult. Unless the barriers to change can be

overcome and action taken to improve compliance, efforts to develop evidence-

based guidelines will be wasted.6

Programs that address physician knowledge alone, such as traditional continu-

ing medical education and dissemination of guidelines, are insufficient to change

practice behaviour.3,4,7,8 In addition, single interventions are less likely to result in

Evidence to action: a tailoredmultifaceted approach to changingfamily physician practice patternsand improving preventive care

Jacques Lemelin, William Hogg, Neill Baskerville

CMAJ • MAR. 20, 2001; 164 (6) 757

© 2001 Canadian Medical Association or its licensors

Principles for the Justification ofPublic Health InterventionR.E.G. Upshur, MA, MD, MSc, FRCPC

ABSTRACT

Objectives: The objective of this paper is to discuss principles relevant to ethicaldeliberation in public health.

Methods: Conceptual analysis and literature review.

Results: Four principles are identified: The Harm Principle, The Principle of LeastRestrictive Means, The Reciprocity Principle, and The Transparency Principle. Twoexamples of how the principles are applied in practice are provided.

Interpretation: The paper illustrates how clinical ethics is not an appropriate model forpublic health ethics and argues that the type of reasoning involved in public health ethicsmay be at potential variance from that of empirical science. Further research and debateon the appropriate ethics for public health are required.

The framework of principalism hasproven to be robust and useful as ameans of assisting practicing clini-

cians to organize their thinking about ethicalissues in clinical medicine. Surveys done byCoughlin and others have pointed out therelative lack of systematic instruction inethics in both public health and epidemiolo-gy.1,2 Thus, there is a need for ethics instruc-tion in both epidemiology and in schools ofpublic health. Conceptual research on frame-works for ethical reasoning, recognizing theessential differences between public healthpractice and clinical medicine, is necessary.The focus of public health is directed to pop-ulations, communities and the broader socialand environmental influences of health. Aswell, there is a greater focus on preventionthan on treatment or cure. It is not clear thatsimply importing conceptual models fromclinical ethics will suffice for public health asthe philosophy that underlies public healthdiffers from that of clinical medicine.3

Public health practice differs substantiallyfrom clinical practice. The context, mandateand range of activities carried out by publichealth practitioners encompass a wide set ofconsiderations. Most public health depart-ments are part of state, provincial or federalgovernments. The overarching concern forthe individual patient found in clinicalethics is not neatly analogous to a concernfor the health of a population. As well, thereis no clear analogy to the fiduciary roleplayed by physicians. Simply put, popula-tions are constituted by diverse communitiesof heterogeneous beliefs and practices. Thesemay at times come into conflict. Individualversus community rights and conflicts with-in and between communities are the morelikely locus of ethical reflection in publichealth practice. Hence, public health ethicsmust recognize and be able to reasonthrough issues relating to social, political andcultural contexts; the existence of competingvalues and perspectives and perhaps, incom-mensurable world views. Given these con-siderations, it is clear that the straight-forward application of the principles of auto-nomy, beneficence, non-malfeasance and jus-tice in public health practice is problematic.

The principalist framework has comeunder heavy criticism in clinical ethics.4

Modern bioethics, which concerns itselfwith ethical issues both within and beyondclinical medicine, consists of a wide range oftheories including virtue ethics, feministethics, and utilitarianism (to name a few), all

The translation of the Abstract appears at the end of the article.

Department of Family and Community Medicine, Public Health Sciences and The Joint Centre forBioethics, University of Toronto, Primary Care Research Unit, Sunnybrook and Women’s CollegeHealth Sciences Centre, Toronto, ONCorrespondence: Dr. R.E.G. Upshur, Primary Care Research Unit Room E349B, Department of Familyand Community Medicine, Sunnybrook and Women’s College Health Science Centre, 2075 BayviewAvenue, Toronto, ON M4N 3M5, Tel: 416-480-4753, Fax: 416-480-4536, E-mail:rupshur@idirect.comAcknowledgements: Dr. Upshur is supported by a Canadian Institutes of Health Research NewInvestigator Award and a Research Scholarship from the Department of Family and CommunityMedicine, University of Toronto. The author thanks Shari Gruman for her assistance in preparing themanuscript.

MARCH – APRIL 2002 CANADIAN JOURNAL OF PUBLIC HEALTH 101

Principles for the Justification ofPublic Health InterventionR.E.G. Upshur, MA, MD, MSc, FRCPC

ABSTRACT

Objectives: The objective of this paper is to discuss principles relevant to ethicaldeliberation in public health.

Methods: Conceptual analysis and literature review.

Results: Four principles are identified: The Harm Principle, The Principle of LeastRestrictive Means, The Reciprocity Principle, and The Transparency Principle. Twoexamples of how the principles are applied in practice are provided.

Interpretation: The paper illustrates how clinical ethics is not an appropriate model forpublic health ethics and argues that the type of reasoning involved in public health ethicsmay be at potential variance from that of empirical science. Further research and debateon the appropriate ethics for public health are required.

The framework of principalism hasproven to be robust and useful as ameans of assisting practicing clini-

cians to organize their thinking about ethicalissues in clinical medicine. Surveys done byCoughlin and others have pointed out therelative lack of systematic instruction inethics in both public health and epidemiolo-gy.1,2 Thus, there is a need for ethics instruc-tion in both epidemiology and in schools ofpublic health. Conceptual research on frame-works for ethical reasoning, recognizing theessential differences between public healthpractice and clinical medicine, is necessary.The focus of public health is directed to pop-ulations, communities and the broader socialand environmental influences of health. Aswell, there is a greater focus on preventionthan on treatment or cure. It is not clear thatsimply importing conceptual models fromclinical ethics will suffice for public health asthe philosophy that underlies public healthdiffers from that of clinical medicine.3

Public health practice differs substantiallyfrom clinical practice. The context, mandateand range of activities carried out by publichealth practitioners encompass a wide set ofconsiderations. Most public health depart-ments are part of state, provincial or federalgovernments. The overarching concern forthe individual patient found in clinicalethics is not neatly analogous to a concernfor the health of a population. As well, thereis no clear analogy to the fiduciary roleplayed by physicians. Simply put, popula-tions are constituted by diverse communitiesof heterogeneous beliefs and practices. Thesemay at times come into conflict. Individualversus community rights and conflicts with-in and between communities are the morelikely locus of ethical reflection in publichealth practice. Hence, public health ethicsmust recognize and be able to reasonthrough issues relating to social, political andcultural contexts; the existence of competingvalues and perspectives and perhaps, incom-mensurable world views. Given these con-siderations, it is clear that the straight-forward application of the principles of auto-nomy, beneficence, non-malfeasance and jus-tice in public health practice is problematic.

The principalist framework has comeunder heavy criticism in clinical ethics.4

Modern bioethics, which concerns itselfwith ethical issues both within and beyondclinical medicine, consists of a wide range oftheories including virtue ethics, feministethics, and utilitarianism (to name a few), all

The translation of the Abstract appears at the end of the article.

Department of Family and Community Medicine, Public Health Sciences and The Joint Centre forBioethics, University of Toronto, Primary Care Research Unit, Sunnybrook and Women’s CollegeHealth Sciences Centre, Toronto, ONCorrespondence: Dr. R.E.G. Upshur, Primary Care Research Unit Room E349B, Department of Familyand Community Medicine, Sunnybrook and Women’s College Health Science Centre, 2075 BayviewAvenue, Toronto, ON M4N 3M5, Tel: 416-480-4753, Fax: 416-480-4536, E-mail:rupshur@idirect.comAcknowledgements: Dr. Upshur is supported by a Canadian Institutes of Health Research NewInvestigator Award and a Research Scholarship from the Department of Family and CommunityMedicine, University of Toronto. The author thanks Shari Gruman for her assistance in preparing themanuscript.

MARCH – APRIL 2002 CANADIAN JOURNAL OF PUBLIC HEALTH 101

Principles for the Justification ofPublic Health InterventionR.E.G. Upshur, MA, MD, MSc, FRCPC

ABSTRACT

Objectives: The objective of this paper is to discuss principles relevant to ethicaldeliberation in public health.

Methods: Conceptual analysis and literature review.

Results: Four principles are identified: The Harm Principle, The Principle of LeastRestrictive Means, The Reciprocity Principle, and The Transparency Principle. Twoexamples of how the principles are applied in practice are provided.

Interpretation: The paper illustrates how clinical ethics is not an appropriate model forpublic health ethics and argues that the type of reasoning involved in public health ethicsmay be at potential variance from that of empirical science. Further research and debateon the appropriate ethics for public health are required.

The framework of principalism hasproven to be robust and useful as ameans of assisting practicing clini-

cians to organize their thinking about ethicalissues in clinical medicine. Surveys done byCoughlin and others have pointed out therelative lack of systematic instruction inethics in both public health and epidemiolo-gy.1,2 Thus, there is a need for ethics instruc-tion in both epidemiology and in schools ofpublic health. Conceptual research on frame-works for ethical reasoning, recognizing theessential differences between public healthpractice and clinical medicine, is necessary.The focus of public health is directed to pop-ulations, communities and the broader socialand environmental influences of health. Aswell, there is a greater focus on preventionthan on treatment or cure. It is not clear thatsimply importing conceptual models fromclinical ethics will suffice for public health asthe philosophy that underlies public healthdiffers from that of clinical medicine.3

Public health practice differs substantiallyfrom clinical practice. The context, mandateand range of activities carried out by publichealth practitioners encompass a wide set ofconsiderations. Most public health depart-ments are part of state, provincial or federalgovernments. The overarching concern forthe individual patient found in clinicalethics is not neatly analogous to a concernfor the health of a population. As well, thereis no clear analogy to the fiduciary roleplayed by physicians. Simply put, popula-tions are constituted by diverse communitiesof heterogeneous beliefs and practices. Thesemay at times come into conflict. Individualversus community rights and conflicts with-in and between communities are the morelikely locus of ethical reflection in publichealth practice. Hence, public health ethicsmust recognize and be able to reasonthrough issues relating to social, political andcultural contexts; the existence of competingvalues and perspectives and perhaps, incom-mensurable world views. Given these con-siderations, it is clear that the straight-forward application of the principles of auto-nomy, beneficence, non-malfeasance and jus-tice in public health practice is problematic.

The principalist framework has comeunder heavy criticism in clinical ethics.4

Modern bioethics, which concerns itselfwith ethical issues both within and beyondclinical medicine, consists of a wide range oftheories including virtue ethics, feministethics, and utilitarianism (to name a few), all

The translation of the Abstract appears at the end of the article.

Department of Family and Community Medicine, Public Health Sciences and The Joint Centre forBioethics, University of Toronto, Primary Care Research Unit, Sunnybrook and Women’s CollegeHealth Sciences Centre, Toronto, ONCorrespondence: Dr. R.E.G. Upshur, Primary Care Research Unit Room E349B, Department of Familyand Community Medicine, Sunnybrook and Women’s College Health Science Centre, 2075 BayviewAvenue, Toronto, ON M4N 3M5, Tel: 416-480-4753, Fax: 416-480-4536, E-mail:rupshur@idirect.comAcknowledgements: Dr. Upshur is supported by a Canadian Institutes of Health Research NewInvestigator Award and a Research Scholarship from the Department of Family and CommunityMedicine, University of Toronto. The author thanks Shari Gruman for her assistance in preparing themanuscript.

MARCH – APRIL 2002 CANADIAN JOURNAL OF PUBLIC HEALTH 101

FAMILY MEDICINE–WORLD PERSPECTIVE

Building a Pan-Canadian Primary Care SentinelSurveillance Network: Initial Development andMoving ForwardRichard Birtwhistle, MD, MSc, Karim Keshavjee, MD, MBA,Anita Lambert-Lanning, MLS, Marshall Godwin, MD, MSc, Michelle Greiver, MD,Donna Manca, MD, and Claudia Lagace, MSc

The development of a pan-Canadian network of primary care research networks for studying issues inprimary care has been the vision of Canadian primary care researchers for many years. With the oppor-tunity for funding from the Public Health Agency of Canada and the support of the College of FamilyPhysicians of Canada, we have planned and developed a project to assess the feasibility of a network ofnetworks of family medicine practices that exclusively use electronic medical records. The CanadianPrimary Care Sentinel Surveillance Network will collect longitudinal data from practices across Canadato assess the primary care epidemiology and management of 5 chronic diseases: hypertension, diabetes,depression, chronic obstructive lung disease, and osteoarthritis. This article reports on the 7-monthfirst phase of the feasibility project of 7 regional networks in Canada to develop a business plan, includ-ing governance, mission, and vision; develop memorandum of agreements with the regional networksand their respective universities; develop and obtain approval of research ethics board applications;develop methods for data extraction, a Canadian Primary Care Sentinel Surveillance Network database,and initial assessment of the types of data that can be extracted; and recruitment of 10 practices at eachnetwork that use electronic medical records. The project will continue in phase 2 of the feasibility test-ing until April 2010. (J Am Board Fam Med 2009;22:412–22.)

The development of a pan-Canadian network ofprimary care research networks (PBRNs) for study-ing issues in primary care has been the vision ofCanadian primary care researchers for many years.1

We are not alone in this research goal. The Euro-

pean General Practice Research Workshop starteda European General Practice Research Agenda in2002.2 There are a number of research networkswithin the European Union, such as the GeneralPractice Research Database in the United King-dom3 and the Netherlands Information Network ofGeneral Practice.4 In addition, the BEACH projectin Australia5 has been particularly successful con-ducting surveillance-based projects. The Distrib-uted Network for Ambulatory Research in Thera-peutics is a recent initiative in the United States tobring together practices with electronic medicalrecords in 8 different organizations.6 Van Weel andRosser7 have argued for such primary care net-works to be supported on a global scale. The Col-lege of Family Physicians of Canada (CFPC) hassuccessfully run a National Research System since1976 and has conducted many funded projects on avariety of primary care topics.8 Some Canadianphysicians were part of the US Ambulatory Senti-nel Practice Network until its demise but there has

This article was externally peer reviewed.Submitted 15 April 2009; revised 18 May 2009; accepted

19 May 2009.From the Department of Family Medicine, Queen’s Uni-

versity, Kingston (RB); Infoclin Inc., Toronto (KK); and theCollege of Family Physicians of Canada, Mississauga(AL-L), Ontario; the Department of Family Medicine, Me-morial University of Newfoundland, St. John’s (MG); theDepartment of Family Medicine, University of Toronto,Ontario (MG); the Department of Family Medicine, Uni-versity of Alberta, Edmonton (DM); and the Chronic Dis-ease Surveillance Division, Public Health Agency of Canada,Ottowa, Ontario (CL), Canada.

Funding: The funding for this project comes from a Con-tribution Agreement # 6271–15-2007/3970697 with thePublic Health Agency of Canada and the College of Physi-cians of Canada.

Conflict of interest: none declared.Corresponding author: Richard Birtwhistle, MD, MSc, De-

partment of Family Medicine, 220 Bagot Street, Kingston,Ontario Canada K7L 5N6 (E-mail: birtwhis@queensu.ca).

412 JABFM July–August 2009 Vol. 22 No. 4 http://www.jabfm.org

FAMILY MEDICINE–WORLD PERSPECTIVE

Building a Pan-Canadian Primary Care SentinelSurveillance Network: Initial Development andMoving ForwardRichard Birtwhistle, MD, MSc, Karim Keshavjee, MD, MBA,Anita Lambert-Lanning, MLS, Marshall Godwin, MD, MSc, Michelle Greiver, MD,Donna Manca, MD, and Claudia Lagace, MSc

The development of a pan-Canadian network of primary care research networks for studying issues inprimary care has been the vision of Canadian primary care researchers for many years. With the oppor-tunity for funding from the Public Health Agency of Canada and the support of the College of FamilyPhysicians of Canada, we have planned and developed a project to assess the feasibility of a network ofnetworks of family medicine practices that exclusively use electronic medical records. The CanadianPrimary Care Sentinel Surveillance Network will collect longitudinal data from practices across Canadato assess the primary care epidemiology and management of 5 chronic diseases: hypertension, diabetes,depression, chronic obstructive lung disease, and osteoarthritis. This article reports on the 7-monthfirst phase of the feasibility project of 7 regional networks in Canada to develop a business plan, includ-ing governance, mission, and vision; develop memorandum of agreements with the regional networksand their respective universities; develop and obtain approval of research ethics board applications;develop methods for data extraction, a Canadian Primary Care Sentinel Surveillance Network database,and initial assessment of the types of data that can be extracted; and recruitment of 10 practices at eachnetwork that use electronic medical records. The project will continue in phase 2 of the feasibility test-ing until April 2010. (J Am Board Fam Med 2009;22:412–22.)

The development of a pan-Canadian network ofprimary care research networks (PBRNs) for study-ing issues in primary care has been the vision ofCanadian primary care researchers for many years.1

We are not alone in this research goal. The Euro-

pean General Practice Research Workshop starteda European General Practice Research Agenda in2002.2 There are a number of research networkswithin the European Union, such as the GeneralPractice Research Database in the United King-dom3 and the Netherlands Information Network ofGeneral Practice.4 In addition, the BEACH projectin Australia5 has been particularly successful con-ducting surveillance-based projects. The Distrib-uted Network for Ambulatory Research in Thera-peutics is a recent initiative in the United States tobring together practices with electronic medicalrecords in 8 different organizations.6 Van Weel andRosser7 have argued for such primary care net-works to be supported on a global scale. The Col-lege of Family Physicians of Canada (CFPC) hassuccessfully run a National Research System since1976 and has conducted many funded projects on avariety of primary care topics.8 Some Canadianphysicians were part of the US Ambulatory Senti-nel Practice Network until its demise but there has

This article was externally peer reviewed.Submitted 15 April 2009; revised 18 May 2009; accepted

19 May 2009.From the Department of Family Medicine, Queen’s Uni-

versity, Kingston (RB); Infoclin Inc., Toronto (KK); and theCollege of Family Physicians of Canada, Mississauga(AL-L), Ontario; the Department of Family Medicine, Me-morial University of Newfoundland, St. John’s (MG); theDepartment of Family Medicine, University of Toronto,Ontario (MG); the Department of Family Medicine, Uni-versity of Alberta, Edmonton (DM); and the Chronic Dis-ease Surveillance Division, Public Health Agency of Canada,Ottowa, Ontario (CL), Canada.

Funding: The funding for this project comes from a Con-tribution Agreement # 6271–15-2007/3970697 with thePublic Health Agency of Canada and the College of Physi-cians of Canada.

Conflict of interest: none declared.Corresponding author: Richard Birtwhistle, MD, MSc, De-

partment of Family Medicine, 220 Bagot Street, Kingston,Ontario Canada K7L 5N6 (E-mail: birtwhis@queensu.ca).

412 JABFM July–August 2009 Vol. 22 No. 4 http://www.jabfm.org

The Impact of Not Having

a Primary Care Physician

Among People with Chronic Conditions

July 2008

ICES Investigative Report

Evidence Guiding Health Care

The Impact of Not Having a Primary Care Physician Among People with Chronic Conditions Executive Summary

Institute for Clinical Evaluative Sciences viJuly 2008

Executive Summary

Background

Primary care plays a pivotal role in health care systems as the � rst point of access to care. According to recent surveys, nearly one in ten (nine percent) of Ontarians reported not having a regular medical doctor, and many more people said they had problems accessing primary care.

Individuals with chronic illnesses and conditions place substantial demands on the health care system. One might expect that these individuals in particular would experience adverse consequences from not receiving appropriate primary care.

Purpose and methods

The purpose of this study was to examine speci� c health system impacts related to Ontarians with chronic health conditions who did not have a primary care physician at the time they were surveyed. Data from Cycle 1.1 of the Canadian Community Health Survey (CCHS) from 2000–01 were obtained and analyzed, along with a 20% random sample of Ontario’s population (2003–05). This information was then linked to data on health care use in Ontario in 2005–06.

Several sub-groups of Ontarians with chronic health conditions were examined in relation to emergency department (ED) visits and medical non-elective hospital admissions. These sub-groups were: people without a regular medical doctor (CCHS data); people with a history of fewer than three physician visits in the previous two-year period (20% random population sample data); and people with a history of three or more physician visits but whose scores were low (< 50%) on a continuity of care index (20% random population sample data). Continuity of care was de� ned as the proportion of visits made by each person to the same physician. Regression analyses were used to control for sociodemographic characteristics and case mix.

Among Ontarians with at least one chronic condition, 4.6 percent reported having no regular medical provider (CCHS data analysis); 5.2 percent had made fewer than three visits to a physician in a two-year period (20% random population sample data analysis); and 10.1 percent showed patterns of health system usage suggesting low continuity of care (20% random population sample data analysis).

Findings about Ontarians without a regular doctor

After adjustment, Ontarians with chronic conditions who said they did not have a regular medical doctor (CCHS data analysis) were 1.22 times more likely to have visited an emergency department (ED) (95% CI 1.02, 1.46) in the previous two years than those who reported having a regular doctor. This translates to an estimated 17,741 excess ED visits.

People in this same sub-group were also 1.32 times more likely to have had a medical non-elective hospital admission 95% CI (0.85, 2.06) in the previous two years compared to those who reported having a regular doctor. This translates to an estimated 1,932 excess hospital admissions attributable to not having a regular doctor.

The Impact of Not Having a PrimaryCare Physician Among People with

Chronic Conditions

ICES Investigative Report

Authors

Richard H. Glazier, MD, MPH, CCFP

Rahim Moineddin, PhD

Mohammad M. Agha, PhD

Brandon Zagorski, MS

Ruth Hall, PhD

Doug G. Manuel, MD, MSc, FRCPC

Lyn M. Sibley, PhD

Alexander Kopp, BA

July 2008