Background
Methods
Context
Study design
Site selection
Site | Region | Date of creation | Study period (chart review) | Date of interviews/focus groups | Number of registered patients | Number of family physicians | Number of nurses | Number of participants to interview and focus groups | ||||
---|---|---|---|---|---|---|---|---|---|---|---|---|
MD | RN | MAN | SPE | Total | ||||||||
A | Metropolitan | 2003 | Oct. 2008–Jul. 2009 (PRE) Oct. 2011–Jul. 2012 (POST) | 2012/2014 | 19,000 | 12 | 9 | 6 | 2 | 1 | 0 | 9 |
B | Semi-rural | 2005 | Oct. 2008–Jul. 2009 (PRE) Oct. 2011–Jul. 2012 (POST) | 2012/2014 | 10,800 | 7 | 3 | 6 | 3 | 0 | 0 | 9 |
C | Metropolitan | 2008 | Oct. 2008–Jul. 2009 (PRE) Oct. 2011–Jul. 2012 (POST) | 2012/2014 | 17,500 | 28 | 2 | 2 | 2 | 2 | 2 | 8 |
D | Semi-rural | 2009 | Oct. 2009–Jul. 2010 (PRE) Oct. 2012–Jul. 2013 (POST) | 2013/2015 | 7000 | 7 | 2 | 6 | 2 | 1 | 0 | 9 |
E | Semi-rural | 2009 | Oct. 2009–Jul. 2010 (PRE) Oct. 2012–Jul. 2013 (POST) | 2013/2015 | 4000 | 2 | 2 | 2 | 1 | 0 | 0 | 3 |
F | Semi-rural | 2009 | Oct. 2009–Jul. 2010 (PRE) Oct. 2012–Jul. 2013 (POST) | 2013/2015 | 3166 | 2 | 2 | 2 | 1 | 0 | 0 | 3 |
G | Metropolitan | 2004 | Oct. 2008–Jul. 2009 (PRE) Oct. 2011–Jul. 2012 (POST) | 2012/2014 | 15,000 | 19 | 3 | 1 | 1 | 0 | 1 | 3 |
H | Semi-rural | 2007 | Oct. 2008–Jul. 2009 (PRE) Oct. 2011–Jul. 2012 (POST) | 2012/2014 | 3600 | 8 | 4 | 7 | 4 | 1 | 0 | 12 |
All | – | – | – | – | 80,066 | 85 | 24 | 32 | 16 | 5 | 3 | 56 |
Quantitative study
Population
Outcomes
Qualitative study
Analysis and integration of quantitative and qualitative results
Step 1: Descriptive quantitative analysis and cluster analysis
Step 2: Thematic inductive analysis
Step 3: Integration of qualitative and quantitative results
Results
Descriptive and cluster analysis (step 1)
Thematic inductive analysis (step 2)
Integration of qualitative and quantitative results (step 3)
Conditions related to changes in AD diagnosis rate following passive dissemination of recommendations
Because sometimes, when we’re talking in the office and I know the person well, he’ll be very interactive and social and I’ll miss the fact that their cognitive functioning is impaired. FP, site G (cluster D1)
Unfortunately, the colleague who received the formation went on sick leave so we limited our activities a bit. We tried to prioritize… I don’t like the word but, we tried to focus on what was a priority for the clinic. So maybe we went for chronic diseases with physical impacts such as diabetes, hypertension etc. Unfortunately, cognitive impairments, as far as management goes, have not really received that much attention. We continue to screen for it, we’re trying to do it as much as possible with all the patients we meet and all the patients who need it. FP, site C (cluster D2)
We also have a geriatrician assigned to us who can give us a kind of training/conference. […] On at least two occasions the geriatrician has given us training sessions on dementia-related subjects. FP, site G (cluster D1)
We have a typical referral process in place. They […] typically provide a very good note back to us, better than most other specialists who sometimes never even send anything back. It’s too common that we don’t get back any letters from consultants considering that communications means are really suboptimal. I think with the memory clinics, it’s much better. FP, site A (cluster D1)
If I need to, it’s easy to make referrals and collaborate. Also, it’s easy to make referrals to psychogeriatric services when we see behavioral or atypical problems. FP, site E (cluster D2)
Our medical team is basically high quality. Many of them are always very up-to-date in many different areas. Initially there was a keen interest in Alzheimer disease. FP, site C (cluster D2)
Interviewer 1: Do you have a family physician or a healthcare professional who’s assumed a leadership role or an influential role in disseminating information of the [recommendations]?Respondent: Not to my knowledge. FP, site A (cluster D1)
A physician who had taken an interest worked on maintaining everyone’s determination by regularly shaking up his troops. […] The nurse came with this project and with Dr. X, they motivated the whole medical staff. FP, site C (cluster D2)
Interviewer: Can you think of some potential barriers there could be to the implementation of these [recommendations]?Respondents: The biggest barrier is making dementia one of our objectives, to get people interested in it. There is no doubt about that. FP, site D (cluster D3)
Dementia is a real pain, it’s a lot to absorb. […] And the physician alone, with only two nurses for twelve physicians, we won’t be able to make it. FP, site D (cluster D3)
I’m not comfortable making the diagnosis. I feel insecure. I don’t know how to do it. I’d even say that I’m useless. FP, site F (cluster D3)
They mentioned a lack of training. They can’t go to the meetings because the two clinics are so far apart, the travel time is too great. Dr. X used to go to their clinic occasionally, but he hasn’t been there in a long time. Field notes, site F (cluster D3)
There used to be a doctor from another FMG who came to see us to talk about dementia, but he doesn’t come anymore. Now there’s no-one in charge of this issue. Focus group, site F (cluster D3)
I don’t think there was a lack of interest on anyone’s part (…) Everyone is open to the elderly. FP, site B (cluster D4)
It was my luck that geriatricians came to see us at hospital X […] If I need to hospitalize someone, I’ll call the geriatrician who’s on call and it’ll get done, for sure, since I know them and they know me. FP, site B (cluster D4)
Yeah, of course I’m the same person in primary or secondary care […] The nurses here contact my nurse at hospital X and they call each other on a regular basis. FP, site B (cluster D4)
I’ll tell Dr. X [the site’s champion], ‘You should take a look at such-and-such patient…’ That may help a bit, at least it’s reassuring. He’ll tell me, ‘Start with that, give him this med.’ A brief, 5-minute consultation leaning on a counter. It’s having a doctor who’s always on the cutting edge. FP, site B (cluster D4)
Respondent: Half my career is about Alzheimer’s disease. I already had this project in mind and I was thinking about how to involve the nurses. […]Interviewer: Did you initiate the project?[…]Respondent: Yes, I had this in mind since 2004… But I knew it was not the time […] Then the moment came. I talked about it – I had to talk about it – because there were a lot of nurses hours involved. […] We trained them to do cognitive testing. […] We trained all the nurses of the area! But our nurses were the very first to receive the training. FP, site B (cluster D4)
We have gotten so good at this point! I think we’re less and less afraid of starting Aricept. […] We can deal with it! FP, site H (cluster D5)
We’re not afraid of making a diagnosis since we know we’ll have support […] We know we have several other professionals around us. We aren’t making the decision on our own. FP, site H (cluster D5)
Interviewer: How would you describe the motivation of your FMG to improve the quality of care for Alzheimer’s patients after 2009?Respondent: This… In fact, it was like a wave because after that, it tapered off, since the doctors referred many of their patients to me for evaluation, and then for follow-up of the treatment. It means that they were highly motivated at first but then, at some point, it was as if they forgot a bit. Then you would have to go talk about it again. It would need to be discussed regularly if you want them to continue. Nurse, site H (cluster D5)
Conditions related to changes in quality of follow-up following passive dissemination of recommendations
Of course, our patients are aging. So, the more we see our patients being affected, the more we are interested in being well-trained. FP, site G (cluster F1)
Interviewer: The implementation of this project, the screening and management of patients with cognitive impairment or AD in your FMG, can you tell us the story of how it went?Respondent: The story is that it is probably back in 2004, when we became an FMG, we had our first clinical meeting with the nurses in order to prioritize. It was all new for us to work with nurses: which clinical tasks should we ask from them? So, we gave everyone a chance to speak, and we set some priorities. So, the first priority was Coumadin […] After that, it was diabetes, and not long after, Alzheimer disease. FP, site B (cluster F1)
Interviewer 1: Was that really handled by just one person?Respondent: No, no, […] We do not really have one doctor with a specific interest in dementia. FP, site G (cluster F1)
Interviewer: [Did the] organization have a family physician or a healthcare professional who has assumed a leadership role or an influential role in disseminating information of the Bergman report?Respondent: Not to my knowledge. FP, site A (cluster F1)
Interviewer: Oh, when did the nurse leave?Respondent 1: She retired in October but she went on sick leave in March for the whole winter. […] Maybe this can explain why there was less screening during that period… […] It’s really because Nurse X wasn’t there. We had just one nurse for all the doctors here. Nurse, site D (cluster F1)
Interviewer: So next, looking at the quality of follow-up results. […] We were at 40% in 2008-2009 and we had decreased to 25% by 2011-2012.Respondent 1: Well, it’s the maternity leave […] there were some substitutes, we had some substitutes, sure, but they could not do it.Respondent 2: And there were a lot of changes. We had many substitutes during 2008-2009. FP 1 and nurse 1, focus group, site B (cluster F1)
It’s the region […] where we find the youngest client group […] there isn’t a geriatric client base around that clinic. FP, site F (cluster F2)
Before the training with Dr. X, we were wondering a bit about [AD]. I had a nurse working with me […], who was particularly interested, who had gotten some information from Dr. Y […] so [the nurse] had already assembled a minimum of information with the resources at our disposal but [the nurse] went on long-term sick leave. Nurse, site B (cluster F1)
The Alzheimer Society never calls back, they don’t provide the required services. […] We can call them, but they don’t follow up. […] The waiting lists are long, particularly for [home-based] services. […] We can do very good work, but we can’t do it on our own. FP, site H (cluster F2)
I said: ‘Well I’m ready, ready to carry the torch to all the general practitioners, first in my clinic, and then, to see what I can do in the region. FP, site C (cluster F2)
The FMG nurses, we were trained first. […] We spoke about it to the others, because we had a binder, so that’s why there was an increase. It isn’t just me […]. Yes, we’re the team. Nurses 2, 3, and 4, focus group at site H (cluster F2)