Projects
Case-based On-line Learning
(CBOLL)
Integrating Physician Services
in the Home (IPSITH)
Improving Communication
Between Doctors And Breast Cancer Patients
Case-Based On-Line Learning (CBOLL)
Funding Source: Canadian Institutes of Health Research (CIHR)
Abstract: Background: Past literature has demonstrated that: 1) local norms and opinion leaders are considered important to
the process of dissemination for changing practice; 2) opportunities available to busy family physicians for local continuing
education are scarce; and 3) internet applications are reportedly being used for a variety of tasks by family physicians but have
had limited formal evaluation.
Objective and hypothesis: This study evaluates the effectiveness of an education intervention to improve family practice. An
innovative on-line discussion group education program of evidence-based guidelines (a program which showed much promise in
a feasibility study) is being tested in a randomized, controlled trial using physician practice behaviours as the outcome. The main
hypothesis is that family physicians randomized to the on-line case-based learning (CBOLL) group will more frequently exhibit
targeted evidence-based practice behaviours than family physicians allocated to the wait-list control group.
Outcome measures: Outcome data is being collected by masked (incognito) standardized patient visits to the family physicians'
offices, a chart audit and a physician knowledge questionnaire.
For further information please contact Joanne Galajda, research project coordinator.
Diabetes Projects
Title: SANDY LAKE HEALTH AND DIABETES PROJECT, PHASE 2: DIABETES INCIDENCE AND COMPLICATIONS PREVELANCE
Funding Source: Canadian Institutes of Health Research (CIHR)
Abstract: Over the past several decades an epidemic of type 2 diabetes has emerge among First Nations communities in
Canada. Although important discoveries have been made regarding the burden of this disease and risk factors for its
development, there remain 2 major gaps in our understanding of diabetes in Canada's First Nations: (1) Little is know about the
number of new cases of diabetes that develop each year (the diabetes "incidence rate"), and (2) there is only limited information
available about the frequency (or "prevalence rate") of the complications of diabetes among Native Canadians. This information
is important in estimating the upcoming burden of diabetes in First Nations communities, in targeting future health resources to
care for diabetic patients, and in understanding which factors increase the risk of developing diabetes and its complications. The
objectives of our project are to measure the incidence of diabetes and the prevalence of associated complications in partnership
with Sandy Lake First Nations, Ontario, a community with which we have worked for the past decade in addressing the
challenges of diabetes (sandylakediabetes.com).
For further information please contact Dr. Stewart Harris or Elizabeth Ford
Title: THE DEVELOPMENT OF EDUCATIONAL STRATEGIES FOR FAMILY PHYSICIANS IN THE USE OF PHYSICAL
ACTIVITYAND DIETARY COUNSELLING IN THE PREVENTION AND CONTROL OF TYPE 2 DIABETES
Funding Source: Health Canada/Canadian College of Family Physicians
Abstract: The project will examine the educational needs of family physicians and will explore effective diabetes prevention
programs, interventions and current educational programs for health professionals. Strategies will then be developed to:
· Promote tools and disseminate information for family physicians in the use of physical activity and dietary counselling in
the prevention and/or control of type 2 diabetes,
· Explore and link up with other organizations, such as the Dieticians of Canada, and combine promotional efforts targeting
diet and physical activity in the area of prevention and/or control of type 2 diabetes.
· Leverage existing CFPC partnerships with organizations such as the Canadian Fitness and Lifestyle Research Institute
(CFLRI), the Active Living Coalition for Older Adults (ALCOA) and The Foundation for Active Healthy Kids to more
effectively reach project goals.
For further information please contact Dr. Stewart Harris
Title: DIABETES, HOMOCYSTEINE, CRP, AND THE LIPID OXIDATION HYPOTHESIS OF VASCULAR DISEASE IN THE SANDY
LAKE OJI-CREE
Funding Source: Canadian Diabetes Association, The Charles H. Best Trust Fund
Abstract: Objectives: to understand the association of diabetes and determinants of vascular disease in the Sandy Lake
Oji-Cree. Rationale: aboriginal population of Canada has traditionally been at low risk for heart disease. However, the Sandy
Lake Oji-Cree now have a prevalence of 26% for diabetes and 11% for impaired glucose tolerance. We hypothesize that plasma
homocysteine (tHcys), C-reactive protein (CRP) and other chronic inflammatory proteins, and indices of oxidative stress
(isoprostanes, glycated phosphatidylethanolamine (PtdEtn)) and cardiovascular metabolic syndrome (CDS)(small LDL) are
elevated in this population. These factors have been chosen because they are candidates for a causal interaction with diabetes
and strong risk factors for vascular disease. Proposed Research: determination of plasma concentrations of tHcys, folate, B6
and B12 in 729 samples from the Sandy Lake Oji-Cree survey. Statistical analysis of the concentration of tHcys for the Oji-Cree
divided into age </>/equal to 18. Analysis of statistical association of tHcys with folate, B12, B6, creatinine and uric acid
concentrations for men/women separately with adjustment for covariate age. Analysis for statistical interaction between diabetes
status and plasma tHcys levels. Analysis of statistical interaction between plasma folate and MTHFR genotype as determinants of
plasma tHcys. Determination of plasma concentrations of chronic inflammatory proteins CRP, SAA and IL-6 in 729 samples.
Statistical analysis of concentration of CRP, SAA and IL-6 for the Oji-Cree divided into age </>equal to 18. Analysis of the
statistical association of CRP/SAA/IL-6 with indices of obesity, BMI, percent body fat, and waist-to-hip ratio for men and women
separately with adjustment for the covariate age. Analysis of differences in CRP/SAA/IL-6 among subjects classified as normal,
impaired glucose tolerance or diabetic. Analysis for statistical association of plasma isoprostanes, glycated PtdEtn, LDL particle
size, Lp(a), vitamin E and carotinoids and diabetes status for men/women separately with adjustment for the covariate age.
For further information please contact Dr. Stewart Harris
Title: THE IMPACT OF COST-EFFECTIVENESS OF POINT-OF CARE TESTING ON THE MANAGEMENT OF PATIENTS WITH
TYPE 2 DIABETES IN A GROUP FAMILY PRACTICE SETTING
Funding Source: Medical Research Council/Rx&D Research Program
Abstract: The 1998 CDA clinical practice guidelines (CPGs) recommend ongoing evaluation of glycemic control & screening for
complications. The availability of more immediate laboratory results (Point-of-Care testing) carried out during the
physician-patient encounter may influence patient treatment/adherence as well as affect overall costs to healthcare system.
Point-of-Care (POC) has been defined as "any investigation carried out in a clinical setting or the patient's home for which the
result is available without reference to a laboratory & rapidly enough to affect patient management". Currently, there is a paucity
of research studying the effectiveness of POC technology in community-based family practice. Purpose: to evaluate the effect of
POC technology on the management of patients with type 2 diabetes mellitus (type 2 DM) in family practice group settings.
Objective: to examine the effect of 2 POC machines: (1)DCA 2000® System for glycated haemoglobin (HbA1C) testing & (2)
Clinitek® 50 Urine Chemistry Analyzer System for albumin:creatinine ratio (a:c ratio) on the care of patients with type 2 DM
including a cost-effectiveness evaluation. Design: a cluster-randomized, controlled trial will be used to evaluate the intervention.
Research will be performed in a maximum of 8 consenting group family practice sites (4-6 physicians/group) in Southwestern
Ontario. Intervention: The Clinitek® 50 and the DCA 2000® together will be randomly allocated into half of the practices. The
intervention will last 12 months. Measures: The primary outcome measure will be glycemic control as measured by HbA1C
values. Secondary measures include: frequency of HbA1C testing; patient compliance, communication and satisfaction;
proportion of patients tested for HbA1C & screened for nephropathy; adherence to the other CPG recommendations; & net
health benefits. Rationale: management of type 2 DM, will benefit from the immediate feedback that POC testing offers. With
POC technology providing faster results, the management of patients with type 2 DM may be improved. Formal evaluation is
needed to best determine its optimal role in community-based family practice.
For further information please contact Dr. Stewart Harris
Title: TELECONFERENCED EDUCATIONAL DETAILING (TED)- AN INNOVATIVE CME PROGRAM FOR FAMILY PHYSICIANS TO
ENHANCE THE MANAGEMENT OF PATIENTS WITH TYPE 2 DIABETES
Funding Source: SmithKline Beecham Pharma
Abstract: The complexity and chronic nature of diabetes presents special challenges for family physicians. Adherence to clinical
practice guidelines (CPGs) is reported to be low to moderate. One of the primary barriers to diabetes management is effective
educational strategies and the time factor for learning.
The purpose of this Canadian project is to evaluate the impact of a Teleconferenced Educational Detailing Continuing Medical
Education program (TED) on diabetes management in primary care.
A cluster-randomized, controlled trial, stratified by regional site, will be used to evaluate the intervention. One hundred and
fourteen family doctors are participating as the principal investigators in the REACT2 Diabetes study. This is a phase IV clinical
trial evaluating the oral insulin resistance reducing agent, Avandia™. These family doctors have the opportunity to volunteer to
participate in TED.
The intervention in this study will include 8 1-hour, small-group educational sessions consisting of topics relating to diabetes
management (Diagnosis and Classification, Screening, Microvascular Complications, Cardiovascular Complications, Elderly, Oral
Medications, Insulin, and Office Strategies). The first session will be face-to-face and the next 7 sessions will be held via
teleconference. The majority of the time will be spent on individual case discussions. Diabetes specialists in each geographic
region will facilitate the case-based discussion.
Outcome measures will include: patient quality of life and physician knowledge questionnaires, chart audit focussing on glycemic
control and the prevention of diabetes-related complications. Therefore, this evaluation within the REACT2 Diabetes study will
assess the impact of TED on improving the management of type 2 diabetes using the objective clinical endpoints together with
patient focused outcomes and quality of life.
For further information please contact Dr. Stewart Harris
Title: INDUCTION OF PANCREATIC BETA CELL INSENSITIVITY TO GLUCOSE BY FFA
Funding Source: Canadian Diabetes Association, The Charles H. Best Trust Fund
Abstract: Type 2 (adult onset) diabetes results in part from the inability of the pancreas to produce sufficient insulin to control
the blood sugar and other aspects of the body's metabolism. Exactly what causes the pancreas to fail in type 2 diabetes is not
know, and is the subject of investigation in our studies. An elevation of fats in the blood, called free fatty acids, is frequently seen
in individuals who are obese, pre-diabetic. We are testing whether this elevation of plasma free fatty acids is responsible for the
impairment of pancreatic function in individuals who are predisposed to developing type 2 diabetes. We propose to administer a
solution of fat intravenously for 2 to 5 days to such individuals and then to examine how their pancreas responds to stimulation.
We will study healthy lean non-diabetic individuals, obese individuals whose body is resistant to the effects of insulin, in Native
Canadians from the Sandy Lake community in Northern Ontario, who have been identified as carrying a defective gene which
predisposes them to developing type 2 diabetes. These studies will help us to understand what causes the pancreatic
dysfunction which is typical of type 2 diabetes, in order to then design treatments which will counteract this abnormality.
For further information please contact Dr. Stewart Harris
Title: FAMILY PHYSICIAN GROUP PRACTICE CONSENSUS: A METHOD OF DISSEMINATE PRACTICE GUIDELINES
Funding Source: MRC/PMAC (Medical Research Council of Canada/Pharmaceutical Manufacturers Association of Canada)
Abstract: In 1998, an Expert Advisory Committee from the Canadian Diabetes Association (CDA) published clinical practice
guidelines (CPGs) for primary care physicians to promote comprehensive care/effective management of patients with type 2
Diabetes Mellitus (DM).
Traditional guideline dissemination techniques have demonstrated limited effectiveness. Alternative strategies including
academic detailing/systematic changes introduced in the office setting have been shown to affect change in practice. Enhancing
the use of guidelines by primary care physicians has potential to improve health of patients with type 2 DM. Objective: Develop a
model to facilitate dissemination/implementation of CDA 1998 CPGs. Evaluate the effectiveness of the model to: increase the
level of knowledge of CPGs within the group practice setting, increase adherence of the CDA 1998 CPGs within the group
practice setting, and facilitate the utilization of the CDA 1998 CPGs within the office management system. Method: A pre-post
wait listed, randomized control trial will be used to evaluate the model. Subjects will be family physicians in a group setting, their
staff/patients with type 2 DM. There will be 4-group practice per study location. Main outcome measures are: physician
knowledge of CDA guidelines (Physician Knowledge and Practice Survey), the Physician type 2 Diabetes Management
Questionnaire; physician adherence to guidelines (chart audit); patient glycemic control using HbA1c (chart audit); office
management audit (Office Management Questionnaire). Ten charts per physician will be randomly chosen from
consenting/eligible patients. All baseline measures will be re-applied 6-months and 12-months post-intervention. The intervention
include: an intensive, 1/2-day, small group, case-based, CME session with an expert peer (site investigator) highlighting the new
CDA CPGs; individual results of the audit in a confidential summary; a summary of the group practice audit results; a 1/2-day
strategy session with office staff to focus on office efficiency strategies for the management of patients with type 2 DM.
For further information please contact Dr. Stewart Harris
Title: AN INNOVATIVE STRATEGY FOR FAMILY PHYSICIANS IN THE DISSEMINATION OF NEW CLINICAL PRACTICE
GUIDELINES FOR THE MANAGEMENT OF TYPE 2 DIABETES MELLITUS (NIDDM)
Funding Source: Canadian Diabetes Association
Abstract: In 1998, an Expert Advisory Committee from the Canadian Diabetes Association (CDA) published clinical practice
guidelines (CPGs) for primary care physicians to promote comprehensive care and effective management of patients with type 2
Diabetes Mellitus. The 1998 CDA CPGs reflect the most recent evidence that tight control of glycemia reduces the long-term
complications of this disease. The benefits generally associated with CPGs include dissemination of evidence-based information
related to practice, reduced variation in clinical practice, improved quality of care, and, reduced health care costs. The current
literature on practice behaviour, however, indicates CPGs are not widely applied in day to day practice. New dissemination
strategies are required if we are to improve the implementation of CPGs. Traditional guidelines dissemination techniques (such
as CME presentations) have demonstrated limited effectiveness. In contrast, alternative strategies including academic detailing
and systematic changes have been shown to affect change in practice.
The purpose of this study is to develop and evaluate an innovative multi-faceted model for dissemination of the new 1998 CPGs.
Using a randomized control design, family physicians currently participating in the "Family Physicians' Practice Patterns and
Experience in the Management of type 2 Diabetes Mellitus" research study will be allocated to an experimental or control group.
Physician knowledge, physician practice patterns and patient glycosylated haemoglobin will be used as outcome measures.
Expanded use of these guidelines by primary care physicians has the potential to improve the health of patients with type 2
Diabetes Mellitus.
This current study will partially fund the research coordinator and secretary in the proposed budget.
For further information please contact Dr. Stewart Harris