Papers by Richard Birtwhistle
Canadian Journal of Public Health-revue Canadienne De Sante Publique, Nov 1, 2000
Au-delà du plaisir Guide canadien sur la contraception La Société des obstétriciens et gynécologu... more Au-delà du plaisir Guide canadien sur la contraception La Société des obstétriciens et gynécologues du Canada, 2000 12,95 $ Vous trouverez, dans le présent livre, tout ce que vous désirez savoir en matière de contraception. Chacune des méthodes contraceptives y est présentée sous forme de question-réponse, des questions traitant de points très importants comme, par exemple, « Quelle est l'efficacité de la méthode X pour éviter une grossesse et protéger contre les infections sexuellement transmissibles et le VIH »? Au-delà du plaisir est un excellent guide, non seulement pour les adolescentes et adolescents, mais aussi pour les parents, pour les professionnels et pour toute personne intéressée à recevoir une information honnête et des renseignements concrets en matière de contraception et des infections sexuellement transmissibles.
Hypertension screening in a primary care clinic
PubMed, Jul 1, 1986
A chart audit of 250 randomly selected adult patients at a university-based family practice unit ... more A chart audit of 250 randomly selected adult patients at a university-based family practice unit showed that 91.9% had attended the clinic during a five-year period (89.0% for males and 94.5% for females). Overall, 80.6% of the patients had their blood pressure recorded on the office chart in the five-year period (75.3% for males and 85.0% for females). For males 30-39 years old, however, the rate was only 54.5%. Flow sheets are suggested as a practical method for recording health maintenance items in an effort for the primary care physician to follow the recommended guidelines for hypertension screening.
Canadian Medical Association Journal, Nov 17, 2019
his guideline from the Canadian Task Force on Preventive Health Care focuses on screening for thy... more his guideline from the Canadian Task Force on Preventive Health Care focuses on screening for thyroid dysfunction among asymptomatic nonpregnant adults in primary care beyond usual care and vigilance for signs and symptoms of thyroid dysfunction. Thyroid dysfunction is diagnosed based on abnormal levels of serum thyroid-stimulating hormone (TSH) and can be characterized as either hypo-or hyperthyroidism. Hypothyroidism results from impaired thyroid hormone production (i.e., thyroxine [T 4 ] or triiodothyronine [T 3 ]), leading to elevated levels of TSH. Hypothyroidism is often caused by autoimmune disorders (e.g., Hashimoto thyroiditis) or occurs as a sequela of hyperthyroidism treatment, which can render the thyroid gland nonfunctional. 1 Hyperthyroidism results from an overproduction of thyroid hormone, leading to the suppression of TSH. 1 Causes of hyperthyroidism include Graves disease, toxic multinodular goitre and toxic adenoma. 2 Signs and symptoms of thyroid dysfunction are variable between patients and often nonspecific. For hypothyroidism, symptoms may include tiredness, sensitivity to cold, dry skin, hair loss, weight gain and slowed movements and thoughts. 1,3-6 For hyperthyroidism, symptoms may include sinus tachycardia, atrial fibrillation, hyperactivity or irritability, intolerance to heat, tremor and weight loss. 1,2,7 Some people with thyroid dysfunction are asymptomatic. 8 If left untreated, hypothyroidism may increase the risk of cardiac dysfunction, hypertension, dyslipidemia, cognitive impairment and, in rare cases, myxedema coma. 3,9 Untreated hyperthyroidism may increase the risk of cardiac conditions (e.g., atrial fibrillation, heart failure) or bone fractures, and could lead to thyroid storm, an uncommon, life-threatening condition associated with tachycardia, extreme fatigue, fever and nausea. 2,10 Minor variations in thyroid function as measured by abnormal levels of TSH are often self-limiting. Observational studies have reported that levels of TSH appear to revert to normal without treatment in 37%-62% of patients with initially elevated levels and 51% with initially low levels, particularly for milder cases of thyroid dysfunction (mean follow-up 32-60 mo). 11,12 Screening is intended to detect thyroid dysfunction in asymptomatic patients in order to prevent adverse consequences of untreated thyroid dysfunction. 13 Screening is done by performing a blood test for TSH. Abnormal levels of TSH are followed up with additional diagnostic testing that often includes blood tests to measure thyroid hormone levels or other tests (e.g., ultrasound) as warranted. An estimated 10% of Canadians aged 45 years or older report that they have been diagnosed with thyroid dysfunction, and prevalence is higher in women (16%) than in men (4%). 14 Prevalence has also been reported to be higher in adults older than 85 years (16%), 14 GUIDELINE HEALTH SERVICES CPD
BMC Medical Informatics and Decision Making, Jul 20, 2020
Background: Building and validating electronic algorithms to identify patients with specific dise... more Background: Building and validating electronic algorithms to identify patients with specific disease profiles using health data is becoming increasingly important to disease surveillance and population health management. The aim of this study was to develop and validate an algorithm to find patients with ADHD diagnoses within primary care electronic medical records (EMR); and then use the algorithm to describe the epidemiology of ADHD from 2008 to 2015 in a Canadian Primary care sample. Methods: This was a cross sectional time series that used data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN), a repository of primary care EMR data. A sample of electronic patient charts from one local clinic were manually reviewed to determine the positive predictive value (PPV) and negative predictive value (NPV) of an ADHD case-finding algorithm. In each study year a practice population was determined, and the algorithm was used to measure an observed prevalence of ADHD. The observed prevalence was adjusted for misclassification, as measured by the validity indices, to obtain an estimate of the true prevalence. Estimates were calculated by age group (4-17 year olds, 18 to 34 year olds, and 35 to 64 year olds) and gender, and compared over time. Results: The EMR algorithm had a PPV of 98.0% (95% CI [92.5, 99.5]) and an NPV of 95.0% (95% CI [92.9, 98.6]). After adjusting for misclassification, it was determined that the prevalence of patients with a clinical diagnosis of ADHD has risen in all age groups between 2008 and 2015, most notably in children and young adults (6.92, 95% CI [5.62, 8.39] to 8.57, 95% CI [7.32, 10.00]; 5.73, 95% CI [4.40, 7.23] to 7.33, 95% CI [6.04, 8.78], respectively). The well-established gender gap persisted in all age groups across time but was considerably smaller in older adults compared to children and young adults. Conclusion: Overall, the ADHD case-finding algorithm was found to be a valid tool to assess the epidemiology of ADHD in Canadian primary care practice. The increased prevalence of ADHD between 2008 and 2015 may reflect an improvement in the recognition and treatment of this disorder within primary care.
BMC Medical Education, Jun 11, 2019
Background: The rapid expansion of genetic knowledge, and the implications for healthcare has res... more Background: The rapid expansion of genetic knowledge, and the implications for healthcare has resulted in an increased role for Primary Care Providers (PCPs) to incorporate genetics into their daily practice. The objective of this study was to explore the self-identified needs, including educational needs, of both urban and rural Primary Care Providers (PCPs) in order to provide genetic care to their patients. Methods: Using a qualitative grounded theory approach, ten key informant interviews, and one urban and two rural PCP focus groups (FGs) (n = 19) were conducted. All PCPs practiced in Southeastern Ontario. Data was analyzed using a constant comparative method and thematic design. The data reported here represent a subset of a larger study. Results: Participants reported that PCPs have a responsibility to ensure patients receive genetic care. However, specific roles and responsibilities for that care were poorly defined. PCPs identified a need for further education and resources to enable them to provide care for individuals with genetic conditions. Based on the findings, a progressive stepped model that bridges primary and specialty genetic care was developed; the model ranged from PCPs identifying patients with genetic conditions that they could manage alone, to patients who they could manage with informal or electronic consultation to those who clearly required specialist referral. Conclusions: PCPs identified a need to integrate genetics into primary care practice but they perceived barriers including a lack of knowledge and confidence, access to timely formal and informal consultation and clearly defined roles for themselves and specialists. To address gaps in PCP confidence in providing genetic care, interventions that are directed at accessible just-in-time support and consultation have the potential to empower PCPs to manage patients' genetic conditions. Specific attention to content, timing, and accessibility of educational interventions is critical to address the needs of both urban and rural PCPs. A progressive framework for bridging primary to specialty care through a 'stepped' model for providing continuing medical education, and genetic care can was developed and can be used to guide future design and delivery of educational interventions and resources.
European Journal of Cancer Care, Nov 10, 2019
A prolonged cancer diagnostic interval, defined as the time from when a patient first presents to... more A prolonged cancer diagnostic interval, defined as the time from when a patient first presents to the healthcare system for screening or symptom evaluation to their final diagnosis, may contribute to a later stage at diagnosis and increase patient anxiety (Caplan,
British Journal of Nutrition, Oct 13, 2009
It has been estimated that up to one-third of patients with diabetes mellitus use some form of co... more It has been estimated that up to one-third of patients with diabetes mellitus use some form of complementary and alternative medicine. Momordica charantia (bitter melon) is a popular fruit used for the treatment of diabetes and related conditions amongst the indigenous populations of Asia, South America, India and East Africa. Abundant pre-clinical studies have documented the anti-diabetic and hypoglycaemic effects of M. charantia through various postulated mechanisms. However, clinical trial data with human subjects are limited and flawed by poor study design and low statistical power. The present article reviews the clinical data regarding the anti-diabetic potentials of M. charantia and calls for better-designed clinical trials to further elucidate its possible therapeutic effects.
How do external practice facilitators (PFs) support quality improvement activities of family health teams (FHTs), participating in the quality improvement and innovation partnership (QIIP) learning collaboratives?
BMJ, Mar 11, 2004
Editor-Last month the prime minister, Tony Blair, lent his weight to random drug testing in schoo... more Editor-Last month the prime minister, Tony Blair, lent his weight to random drug testing in schools in an interview for a downmarket newspaper. 1 He proposed a national programme be implemented soon, adhering to unspecified central directives. The Department of Health has 19 criteria for introducing new screening programmes. 2 At least 18 of these 19 criteria are not met for widespread, wide spectrum drug urine analysis in schools. The remaining criterion is that the condition is an important health problem. Drug use in young people is indeed associated with many health risks, 3 but a single, positive urine test, for any illicit drug, is probably not meaningful in a clinical sense. Each schoolchild's context of use (family history, social and emotional development) is crucial to interpreting any supposed "drug career." Use by a homeless pregnant teenage runaway from local authority care with a history of deliberate self harm and high risk sex work to pay for her drugs may be very different from a single experimental use at home with adults during a family party. Three failed criteria are especially pertinent to screening for school age drug use: (1) There should be an agreed policy on the further diagnostic investigation of people with a positive test result and on the choices available to them. (2) There should be an effective treatment or intervention for patients identified through early detection. (3) Clinical management of the condition and patient outcomes should be optimised by all healthcare providers before participation in a screening programme. In three years of experience of school health provision for alcohol and drug problems and their related referral networks I do not know of one school that could satisfy these criteria, especially the underpinning policy of promoting informed choice for children and families. 2 Woody Caan professor of public health
BMJ Open Gastroenterology, Jun 1, 2022
Objective There is substantial variation in colonoscopy use and evidence of long wait times for t... more Objective There is substantial variation in colonoscopy use and evidence of long wait times for the procedure. Understanding the role of system-level resources in colonoscopy utilisation may point to a potential intervention target to improve colonoscopy use. This study characterises colonoscopy resource availability in Ontario, Canada and evaluates its relationship with colonoscopy utilisation. Design We conducted a population-based study using administrative health data to describe regional variation in colonoscopy availability for Ontario residents (age 18-99) in 2013. We identified 43 colonoscopy networks in the province in which we described variations across three colonoscopy availability measures: colonoscopist density, private clinic access and distance to colonoscopy. We evaluated associations between colonoscopy resource availability and colonoscopy utilisation rates using Pearson correlation and log binomial regression, adjusting for age and sex. Results There were 9.4 full-time equivalent colonoscopists per 100 000 Ontario residents (range across 43 networks 0.0 to 21.8); 29.5% of colonoscopies performed in the province were done in private clinics (range 1.2%-55.9%). The median distance to colonoscopy was 3.7 km, with 5.9% travelling at least 50 km. Lower colonoscopist density was correlated with lower colonoscopy utilisation rates (r=0.53, p<0.001). Colonoscopy utilisation rates were 4% lower in individuals travelling 50 to <200 km and 11% lower in individuals travelling ≥200 km to colonoscopy, compared to <10 km. There was no association between private clinic access and colonoscopy utilisation. Conclusion The substantial variations in colonoscopy resource availability and the relationship demonstrated between colonoscopy resource availability and use provides impetus for health service planners and decisionmakers to address these potential inequalities in access in order to support the use of this medically necessary procedure. ⇒ Poor access to colonoscopy may be detrimental to patients through its impact on colonoscopy utilisation.
Primary Care Electronic Health Data: Good to the Last Byte
Elsevier eBooks, 2018
Abstract: The Commonwealth survey compares 11 countries in relationship to a variety of primary c... more Abstract: The Commonwealth survey compares 11 countries in relationship to a variety of primary care indicators, including quality and access to care, efficiency, equity and healthy lives. Of the 11 countries, France and Canada rank ninth and tenth, respectively. The cost of care is about the same except in the United States, which is higher. Some of the gap may be explained with the use of electronic medical records (EMR) in the higher-performing countries. This is not only whether or not primary care practitioners have an electronic records system but also whether they are used in a meaningful way to make practices more efficient and to provide better care.
International Journal for Population Data Science, Apr 18, 2017
Flexible Sigmoidoscopy: Response
Canadian Family Physician, Apr 1, 1990
PubMed, 2019
This article has been peer reviewed. Can Fam Physician 2019;65:9-11 La traduction en français de ... more This article has been peer reviewed. Can Fam Physician 2019;65:9-11 La traduction en français de cet article se trouve à www.cfp.ca dans la table des matières du numéro de janvier 2019 à la page e1.
Lack of detail leaves much to be desired
Canadian Family Physician, Oct 1, 1996
Normal Q-Q plot of MPS II index from patients older than 21
<p>Red line represents a distribution reference line with μ<sub>o</sub> equal t... more <p>Red line represents a distribution reference line with μ<sub>o</sub> equal to the sample mean for a normal distribution.</p
A screenshot of the billing table from SQL server containing unstructured data from patients
<p>A screenshot of the billing table from SQL server containing unstructured data from pati... more <p>A screenshot of the billing table from SQL server containing unstructured data from patients.</p
A screenshot of the MPS II dataset containing all symptoms from patients with dichotomous observations
<p>A screenshot of the MPS II dataset containing all symptoms from patients with dichotomou... more <p>A screenshot of the MPS II dataset containing all symptoms from patients with dichotomous observations.</p
BMC Health Services Research
BackgroundDespite the long-standing experience of rating the evidence for clinical preventive ser... more BackgroundDespite the long-standing experience of rating the evidence for clinical preventive services, the delivery of effective clinical preventive services in Canada and elsewhere is less than optimal. We outline an approach used in British Columbia to assist in determining which effective clinical preventive services are worth doing.MethodsWe calculated the clinically preventable burden and cost-effectiveness for 28 clinical preventive services that received a ‘strong or conditional (weak) recommendation for’ by the Canadian Task Force on Preventive Health Care or an ‘A’ or ‘B’ rating by the United States Preventive Services Task Force. Clinically preventable burden is the total quality adjusted life years that could be gained if the clinical preventive services were delivered at recommended intervals to a British Columbia birth cohort of 40,000 individuals over the years of life that the service is recommended. Cost-effectiveness is the net cost per quality adjusted life year g...
CMAJ Open, 2019
Background: Over 1 million Canadians have class II or III obesity; however, access to weight-loss... more Background: Over 1 million Canadians have class II or III obesity; however, access to weight-loss interventions for these patients remains limited. The purpose of our study was to identify the barriers to accessing medical and surgical weight-loss interventions from the perspectives of 3 groups: family physicians, patients who were referred for weight-loss intervention and patients who were not referred for weight-loss intervention. Methods: Between November 2017 and May 2018, we conducted a qualitative exploratory research study using focus groups with family physicians and interviews with patients with class II or III obesity from 1 region in southern Ontario. We conducted a thematic analysis to identify emergent themes and used the barriers to change theory to classify the similarities and differences between the perspectives of family physicians, referred patients and nonreferred patients in first-and second-order barriers. Results: Seventeen family physicians participated in 7 focus groups (1-4 participants/group), and we interviewed 8 referred patients and 7 nonreferred patients. We identified lack of resource supports, logistics and lack of knowledge about weight-loss interventions as first-order barriers to change, and lack of knowledge about root causes of obesity, lack of patient readiness for change and family physicians' perceptions about surgical weight loss as second-order barriers to change. Family physicians and patients had similar perceptions regarding lack of resource supports in the community, logistical issues, family physicians' lack of knowledge regarding weight-loss interventions, patients' lack of motivation and family physicians' perceptions of bariatric surgery as being high risk. They differed regarding the root cause of obesity, with family physicians attributing obesity to multiple extrinsic and intrinsic causes, whereas patients believed obesity was largely due to intrinsic causes alone. Interpretation: It is important to address first-and second-order barriers to accessing weight-loss interventions through continuing professional development activities for family physicians to help ensure effective and timely treatment for patients with class II or III obesity and related comorbidities.
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Papers by Richard Birtwhistle