Abstract Purpose The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is Canada's first national chronic disease surveillance system based on electronic health record (EHR) data. The ...purpose of this study was to develop and validate case definitions and case-finding algorithms used to identify 8 common chronic conditions in primary care: chronic obstructive pulmonary disease (COPD), dementia, depression, diabetes, hypertension, osteoarthritis, parkinsonism, and epilepsy. Methods Using a cross-sectional data validation study design, regional and local CPCSSN networks from British Columbia, Alberta (2), Ontario, Nova Scotia, and Newfoundland participated in validating EHR case-finding algorithms. A random sample of EHR charts were reviewed, oversampling for patients older than 60 years and for those with epilepsy or parkinsonism. Charts were reviewed by trained research assistants and residents who were blinded to the algorithmic diagnosis. Sensitivity, specificity, and positive and negative predictive values (PPVs, NPVs) were calculated. Results We obtained data from 1,920 charts from 4 different EHR systems (Wolf, Med Access, Nightingale, and PS Suite). For the total sample, sensitivity ranged from 78% (osteoarthritis) to more than 95% (diabetes, epilepsy, and parkinsonism); specificity was greater than 94% for all diseases; PPV ranged from 72% (dementia) to 93% (hypertension); NPV ranged from 86% (hypertension) to greater than 99% (diabetes, dementia, epilepsy, and parkinsonism). Conclusions The CPCSSN diagnostic algorithms showed excellent sensitivity and specificity for hypertension, diabetes, epilepsy, and parkinsonism and acceptable values for the other conditions. CPCSSN data are appropriate for use in public health surveillance, primary care, and health services research, as well as to inform policy for these diseases.
OBJECTIVES: To understand the approaches to learning of practising physicians in their workplace and to assess the relation of these approaches to their motivation for, preferred methods of, and ...perceived barriers to continuing medical education. DESIGN: Postal survey of 800 Ontario physicians. PARTICIPANTS: 373 physicians who responded. MAIN OUTCOME MEASURES: Correlations of approaches to learning and perceptions of workplace climate with methods, motives, and barriers to continuing medical education. RESULTS: Perceived heavy workload was significantly associated with the surface disorganised (r=0.463, P<0.01) and surface rational approach (r=0.135, P<0.05) to learning. The deep approach to learning was significantly correlated with a perception of choice-independence and a supportive-receptive climate at work (r=0.341 and 0.237, P<0.01). Physicians who adopt a deep approach to learning seem to be internally motivated to learn, whereas external motivation is associated with surface approaches to learning. Heavy workload and a surface disorganised approach to learning were correlated with every listed barrier to continuing medical education. The deep approach to learning was associated with independent learning activities and no barriers. CONCLUSIONS: Perception of the workplace climate affects physicians' approaches to learning at work and their motivation for and perceived barriers to continuing medical education. Younger, rural, family physicians may be most vulnerable to feeling overworked and adopting less effective approaches to learning. Further work is required to determine if changing the workplace environment will help physicians learn more effectively.
Controlled clinical trials of health care interventions are either explanatory or pragmatic. Explanatory trials test whether an intervention is efficacious; that is, whether it can have a beneficial ...effect in an ideal situation. Pragmatic trials measure effectiveness; they measure the degree of beneficial effect in real clinical practice. In pragmatic trials, a balance between external validity (generalizability of the results) and internal validity (reliability or accuracy of the results) needs to be achieved. The explanatory trial seeks to maximize the internal validity by assuring rigorous control of all variables other than the intervention. The pragmatic trial seeks to maximize external validity to ensure that the results can be generalized. However the danger of pragmatic trials is that internal validity may be overly compromised in the effort to ensure generalizability. We are conducting two pragmatic randomized controlled trials on interventions in the management of hypertension in primary care. We describe the design of the trials and the steps taken to deal with the competing demands of external and internal validity.
External validity is maximized by having few exclusion criteria and by allowing flexibility in the interpretation of the intervention and in management decisions. Internal validity is maximized by decreasing contamination bias through cluster randomization, and decreasing observer and assessment bias, in these non-blinded trials, through baseline data collection prior to randomization, automating the outcomes assessment with 24 hour ambulatory blood pressure monitors, and blinding the data analysis.
Clinical trials conducted in community practices present investigators with difficult methodological choices related to maintaining a balance between internal validity (reliability of the results) and external validity (generalizability). The attempt to achieve methodological purity can result in clinically meaningless results, while attempting to achieve full generalizability can result in invalid and unreliable results. Achieving a creative tension between the two is crucial.
The objective of this study was to assess the validity of electronic medical records-based diagnostic algorithms for 5 chronic conditions.
A retrospective validation study using primary chart ...abstraction. A standardized abstraction form was developed to ascertain diagnoses of diabetes, hypertension, osteoarthritis, chronic obstructive pulmonary disease, and depression. Information about billing, laboratory tests, notes, specialist and hospital reports, and physiologic data was collected. An age-stratified random sample of 350 patient charts was selected from Kingston, Ontario, Canada. Approximately 90% of those charts were allocated to people aged ≥60 years.
Three hundred thirteen patient records were included in the study. Patients' mean age was 68 years and 52% were women. High interrater reliability was indicated by 92% complete agreement and a κ statistic of 89.3%. The sensitivities of algorithms were 100% (diabetes), 83% (hypertension), 45% (osteoarthritis), 41% (chronic obstructive pulmonary disease), and 39% (depression). The lowest specificity was 97%, for depression. The positive predictive value ranged from 79% (depression) to 100%, and the negative predictive value ranged from 68% (osteoarthritis) to 100%.
The diagnostic algorithms for diabetes and hypertension demonstrate adequate accuracy, thus allowing their use for research and policy-making purposes. The algorithms for the other 3 conditions require further refinement to attain better sensitivities.
Automated blood pressure (BP) devices are commonly used in doctor's offices. How BP measured on these devices relates to ambulatory BP monitoring is not clear.
To assess how well office-based manual ...and automated BP predicts ambulatory BP.
Using data on 654 patients, we assessed how well sphygmomanometer measurements and measurements taken with an automated device (BpTRU) predicted results on ambulatory BP monitoring. We assess positive and negative predictive values and overall accuracy. We look at different cut-points for systolic (130, 135 and 140 mmHg) and diastolic (80, 85 and 90 mmHg) BP.
A single automated office BP (AOBP) assessment provides superior predictive values and overall accuracy compared to three manual office BP assessments. For systolic BP, the predictive values are ≤69% for any of the cut-points while the positive predictive values for the single automated measurement is between 80.0% and 86.9% and the overall accuracy gets as high as 74% for the 130 mmHg cut-point. For diastolic BP, the automated readings are also more predictive but in this case, it is the negative predictive values that are better, as well as the overall accuracy.
Based on the results, we suggest that 135/85 mmHg continue to be used as the cut-point defining high BP with the BpTRU device. However, future research might suggests that values in a grey zone between 130-139 mmHg systolic and 80-89 mmHg diastolic be confirmed using ambulatory BP monitoring. As well, three AOBP assessments might produce much greater accuracy than the single AOBP assessment used in the study.
The development of a pan-Canadian network of primary care research networks for studying issues in primary care has been the vision of Canadian primary care researchers for many years. With the ...opportunity for funding from the Public Health Agency of Canada and the support of the College of Family Physicians of Canada, we have planned and developed a project to assess the feasibility of a network of networks of family medicine practices that exclusively use electronic medical records. The Canadian Primary Care Sentinel Surveillance Network will collect longitudinal data from practices across Canada to 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-month first phase of the feasibility project of 7 regional networks in Canada to develop a business plan, including governance, mission, and vision; develop memorandum of agreements with the regional networks and 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 each network that use electronic medical records. The project will continue in phase 2 of the feasibility testing until April 2010.
Two questionnaires were developed to investigate the workplace learning of physicians. The Approaches to Work Questionnaire for Physicians and the Workplace Climate Questionnaire for Physicians were ...adapted from general measures developed by Kirby, Knapper, Evans, Carty, and Gadula. These questionnaires were administered to a random sample of Ontario physicians. Consistent with the results of Kirby et al., three dimensions of approaches to work were observed: Deep, Surface-Rational, and Surface-Disorganized. Three dimensions of workplace climate were also found, Supportive-Receptive, Choice-Independence, and Workload. Results indicate that physicians adopt primarily a Deep approach to work, but that there is a smaller tendency toward Surface-Disorganized learning, one that is strongly correlated with perceptions of heavy workload. The Deep approach was associated with work environments perceived to be Supportive-Receptive and offer Choice-Independence. The use of these questionnaires in research and practice is discussed.
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