What Shapes Family Physicians\u27 Patterns of Care for Community Patients at End of Life?

Family physicians (FPs) care for the majority of community patients approaching end of life. Variations among FPs in care activities for these patients have potential implications for equitable access to care. This thesis used mixed methods to explore how FPs in southwestern Ontario, Canada care for these patients, and what shapes the variations. In the primary study, using grounded theory based on in-depth interviews, FPs reported differing in the timing, location and purpose of their activities. These variations were shaped by a process of ‘making it fit’, in which FPs weighed the implications of choices in their unique contexts. In the second study, a secondary analysis of family physician survey data, FPs reported differences in their potential availability to provide care to community patients at end of life. Attitude toward FP participation in palliative care at home and remuneration by alternate funding plan were both strongly associated with potential availability

Methods to Describe Referral Patterns in a Canadian Primary Care Electronic Medical Record Database: Modelling Multilevel Count Data

Background: A referral from a family physician (FP) to a specialist is an inflection point in the patient journey, with potential implications for clinical outcomes and health policy. Primary care electronic medical record (EMR) databases offer opportunities to examine referral patterns. Until recently, software techniques were not available to model these kinds of multi-level count data. Objective: To establish methodology for determining referral rates from FPs to medical specialists using the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) EMR database. Method: Retrospective cohort study, mixed effects and multi-level negative binomial regression modelling with 87,258 eligible patients between 2007 and 2012. Mean referrals compared by patient sex, age, chronic conditions, FP visits, and urban/rural practice location. Proportion of variance in referral rates attributable to the patient and practice levels. Results: On average, males had 0.26, and females 0.31 referrals in a 12-month period. Referrals were significantly higher for females, increased with age, FP visits, and number of chronic conditions (p\u3c.0001). Overall, 14% of the variance in referrals could be attributed to the practice level, and 86% to patient level characteristics. Conclusions: Both patient and practice characteristics influenced referral patterns. The methodologic insights gained from this study have relevance to future studies on many research questions that utilize count data, both within primary care and broader health services research. The utility of the CPCSSN database will continue to increase in tandem with data quality improvements, providing a valuable resource to study Canadian referral patterns over time

Stratospheric Effects on UV, Speed of Sound, Pressure, and Temperature

The atmosphere is composed of several layers, each with its own distinct environment varying in temperature, pressure, and levels of UV radiation. Quantifying these varying parameters proves to be useful in understanding atmospheric composition in greater detail. Variance in the composition of the atmosphere allows for the study of the evolution of physical phenomena at different altitudes. Our group quantified this variance using a high-altitude weather balloon and designed an experimental method to observe the nature of sound propagation through varying altitudes. The goal was to develop an altitude-dependent model of the speed of sound by using an open-air, microcontroller-based payload. Using our platform, we found that the open-air payload design results in noisy readings. Additionally, our method was restricted to low altitude environments, unable to produce reliable data above 6,700 meters. We address possible improvements and constraints in developing an open-air payload design to derive an altitude-dependent model for sound propagation. Furthermore, we present our findings on the variations in pressure, temperature, and levels of UV radiation during balloon flights at altitudes of up to 30,000 meters. These variations included a proportional decrease in pressure, a temperature inversion at 15,000 meters, and an exceptional increase in both UVA and UVB radiation as altitude increases

Patterns of referral in a Canadian primary care electronic health record database: retrospective cross-sectional analysis

Background Databases derived from primary care electronic health records (EHRs) are ideally suited to study clinical influences on referral patterns. This is the first study outside the United Kingdom to use an EHR database to describe rates of referral per patient from family physicians to specialists. Objective To use a primary care EHR database to describe referrals to specialist physicians; to partition variance in referral rates between the practice and patient levels. Methods Retrospective cross-sectional analysis of de-identified EHRs of 33 998 patients from 10 primary care practices in Ontario, Canada. The study cohort included all patients who visited their family physician 1 April 2007 to 31 March 2008 (n_24 856). Specialist referrals for each patient were counted for 12 months following their index visit. Rates of referral were compared by sex, age, number of office visits, practice location and specialist type using t-tests or Pearson's correlation. Variance partitioning determined the proportion of variance in the overall referral rate accounted for by the practice and patient levels. Results In total, 7771 patients (31.3%) had one or more referrals. The overall referral rate was 455/ 1000 patients/year (95% CI, 444_465). Rates were higher for females, older patients and rural practices. The referral rate correlated with thenumber of family physician office visits. Ninety-two percent of the total variance in referral rates was attributable to the patient (vs. practice) level. Conclusions A Canadian primary care EHR database showed similar patterns of referral to those reported from administrative databases. Most variance in referral rates is explained at the patient level

Methods to Describe Referral Patterns in a Canadian Primary Care Electronic Medical Record Database: Modelling Multilevel Count Data

Background:  A referral from a family physician (FP) to a specialist is an inflection point in the patient journey, with potential implications for clinical outcomes and health policy. Primary care electronic medical record (EMR) databases offer opportunities to examine referral patterns. Until recently, software techniques were not available to model these kinds of multi-level count data. Objective:  To establish methodology for determining referral rates from FPs to medical specialists using the Canadian Primary Care Sentinel Surveillance Network (CPCSSN) EMR database. Method: Retrospective cohort study, mixed effects and multi-level negative binomial regression modelling with 87,258 eligible patients between 2007 and 2012. Mean referrals compared by patient sex, age, chronic conditions, FP visits, and urban/rural practice location.  Proportion of variance in referral rates attributable to the patient and practice levels. Results:  On average, males had 0.26, and females 0.31 referrals in a 12-month period.  Referrals were significantly higher for females, increased with age, FP visits, and number of chronic conditions (p<.0001). Overall, 14% of the variance in referrals could be attributed to the practice level, and 86% to patient level characteristics. Conclusions:  Both patient and practice characteristics influenced referral patterns. The methodologic insights gained from this study have relevance to future studies on many research questions that utilize count data, both within primary care and broader health services research. The utility of the CPCSSN database will continue to increase in tandem with data quality improvements, providing a valuable resource to study Canadian referral patterns over time