OBJECTIVE: To identify elements of data that have been shown to contribute to continuity of information between primary care providers and medical specialists providing care to adult asthma patients. DESIGN: Systematic review of the literature followed by a 2-round modified Delphi consensus process. SETTING: Province of Ontario. PARTICIPANTS: Eight expert panelists, including 3 practising family physicians, a medical specialist knowledgeable in the treatment of asthma, a family physician previously involved in provincial initiatives related to primary care reform, an e-health technologist, a developer of evidence-based guidelines, and an operations and programs specialist. METHODS: We completed a systematic literature review to identify important components of consultation reports. We then engaged an 8-member panel in a 2-round modified Delphi consensus process, which led to the identification of components deemed essential to good continuity of information. MAIN FINDINGS: After 2 rounds, expert panelists reached consensus on 15 components, referred to here as minimum essential elements, of consultation reports generated by medical specialists in response to referring primary care providers' consultation requests. CONCLUSION: The expert panelists considered inclusion of the minimum essential elements in consultation reports essential to achieving good continuity of information. We assembled these elements in a suggested format for a consultation report. The format can be easily modified by practitioners caring for patients with other chronic diseases.

OBJECTIVE: To identify performance indicators for family practice that focus on organizational structures and clinical processes of care, to review evidence linking indicators to patient outcomes, to have providers select indicators they consider important for performance assessment, and to obtain provider views on challenges to developing a performance assessment system. DESIGN: Review of published and unpublished literature and contact with international experts resulted in a list of 131 structure and process indicators and associated evidence. This information was used in a two-round modified Delphi consensus process, which was followed by interviews with each of the 12 consensus panel members. SETTING: Ontario family practices. PARTICIPANTS: Eleven family physicians and one nurse practitioner from Ontario. MAIN OUTCOME MEASURES: Survey package with 131 indicators and associated evidence was mailed to panel members who rated each of the indicators on a Likert scale from 1 (not at all important for performance assessment) to 9 (essential for performance assessment). Interviews were conducted with panel members to discuss indicator feasibility and data sources. Consensus score and median importance score for each indicator were main outcome measures; interviews identified barriers to performance assessment. RESULTS: Fifty-one indicators achieved high consensus, 19 moderate consensus, and 38 low consensus. Clinical indicators that reached a high level of consensus were generally supported by grade A or B recommendations and level I to III evidence. Clinical indicators that achieved moderate consensus often had fair support in the literature. Low consensus was mainly associated with fair or equivocal evidence. During follow-up interviews, consensus panel members voiced frustration with inconsistencies in the evidence and practice guidelines upon which indicators are often based, and with poor transfer of patient information between health care providers. Lack of detail in patient care documentation and inconsistent documentation were mentioned frequently as threats to data quality. CONCLUSION: Despite challenges to performance measurement noted by the panel, study results support the continued development, refinement, and testing of primary care performance indicators.

BACKGROUND: Although walk-in clinics are an increasingly common feature of Ontario's health care system, the quality of care they provide is the subject of continuing debate. In this study we examined differences in patient satisfaction and quality of care for common acute conditions in walk-in clinics, family practices and emergency departments. METHODS: For this prospective cohort study, we recruited 12 walk-in clinics, 16 family practices and 13 emergency departments from 11 geographic areas in greater Toronto, Hamilton-Burlington and London, Ont. An expert review panel selected and established quality-of-care criteria for 8 common acute conditions. Patients who sought initial care for 1 of the 8 conditions were recruited by an on-site data collector. We used a questionnaire to assess the satisfaction of 433 patients with patient-centred communication, the physician's attitude and any delay in the waiting room during the study visit. Abstractors reviewed 600 charts for the study patients to assess whether the quality-of-care criteria had been met. A quality score for each case was computed as the percentage of applicable criteria that were met. Mean quality scores for the 3 settings were computed, with adjustment for potentially confounding variables (sex, age, city and diagnosis). RESULTS: After adjustment for 12 patient characteristics, walk-in clinic patients were significantly more satisfied than emergency department patients on all 3 satisfaction scales. Family practice patients were more satisfied than walk-in clinic patients on all 3 satisfaction scales, but the difference was statistically significant only for satisfaction with waiting time. Adjusted mean quality-of-care scores were 73.1% for emergency departments, 69.9% for walk-in clinics and 64.1% for family practices. The scores for walk-in clinics and emergency departments were significantly higher than that for family practices. INTERPRETATION: Satisfaction with waiting time was highest among family practice patients. Both family practices and walk-in clinics were perceived more positively than emergency departments on all 3 dimensions of satisfaction. Overall quality-of-care scores were higher in walk-in clinics and emergency departments than in family practices.

BACKGROUND: In Canada, walk-in clinics (WICs) are a focus for debate about access to and the costs and quality of primary care. While WICs may offer patients easier access through longer hours and shorter waits, it has been argued that they may also lead to unnecessary utilization, duplication of services, lack of continuity of care, decreased quality and increased costs. OBJECTIVES: The main objectives were to analyse the characteristics and attitudes of physicians working in different family practice types including WICs. METHODS: We analysed the results of a 1998 survey of 728 primary care physicians in Ontario to compare physicians working in WICs with those working in solo and group family practices. RESULTS: Our survey found that few physicians worked most or all of their hours in WICs; most worked in WICs and other family practice types. Compared to family physicians in solo and group practices, physicians working in WICs saw more patients who were not their regular patients, patients without appointments and children. They reported slightly higher frequencies of problems such as backlogs (patient queues) and patients who had sought care from other doctors for the same problem. WIC physicians were less satisfied than other physicians with their relations with patients. They were, however, more satisfied with the availability of consultation, support staff, hours, income, and vacation coverage. Further, WIC physicians assessed the quality of care in WICs to be neither better nor worse than that in other family practices. CONCLUSIONS: We conclude that there are important similarities as well as differences, between physicians in WICs and those in more conventional family practices. The assessments of primary care physicians do not support the generally negative reputation of WICs. Instead, greater consideration should be given to the system-level issues which produce demand for WICs.

OBJECTIVE: To compare walk-in clinics with other primary care settings on characteristics associated with best practices in primary care. DESIGN: A mailed self-administered questionnaire asked about organizational and clinical characteristics of primary care practices located in major urban and suburban areas in Ontario. SETTING: Four types of fee-for-service group practices: walk-in and urgent-care clinics (WICs), mixed practices (MPs), after-hours clinics (AHCs), and group family practices (GFPs). PARTICIPANTS: A physician or a staff member involved in practice administration. MAIN OUTCOME MEASURES: The four practice types were compared on organizational characteristics and measures of access, continuing care, comprehensiveness, coordination, and mechanisms for monitoring quality of care. RESULTS: Walk-in clinics, MPs, and AHCs were open more hours during evenings and weekends and were more likely to see patients without appointments; GFPs were more likely to have on-call arrangements. Group family practices saw a larger proportion of patients for whom they provided ongoing care; WICs and MPs reported that more than 60% of their visits were with "regular" patients. Walk-in clinics were less likely to provide preventive services and psychological counseling than were GFPs and MPs. A few WICs, MPs, and GFPs had procedures to support coordination of care or to monitor quality of care. CONCLUSION: Although WICs, MPs, and AHCs provided walk-in services to Ontario patients, WICs and MPs also provided a substantial amount of ongoing care and preventive services. Independent AHCs appeared to most closely fit the "walk-in clinic" stereotype.

Objective: To determine if the addition of alternative therapy to conventional medicine enhances the treatment of pain in postherpetic neuralgia (PHN). Methodology: A review of literature from 1988-1998 was conducted on the MEDLINE database, searching for information on the current treatment of PHN. The literature review found that although many medications have been used to reduce the pain of PHN, no treatments have been completely successful in decreasing pain. Data on pain reduction in PHN following treatment with a multifaceted alternative therapy combined with conventional treatment were compiled from a group of patients in the principal investigator's family medicine practice. Results: The alternative therapy employed in this study, combined with selected medications, showed an average pain reduction of 72.1 percent. There was a 77-percent average pain reduction in patients with herpes zoster (HZ) onset of more than one year and a 68-percent reduction in patients with HZ onset between one month and one year. Almost two-thirds of the 56 PHN patients reported pain reductions of between 75 and 100 percent. Conclusion: These preliminary data suggest the combination of alternative therapy and selected conventional medications provides good pain relief for most patients presenting with PHN. Randomized trials with appropriate control groups are needed to validate the effectiveness of this therapy in the treatment of PHN.