The Institute of Medicine (IOM) framework has been used frequently to assess and monitor quality ... more The Institute of Medicine (IOM) framework has been used frequently to assess and monitor quality in secondary and tertiary care, but not in primary care. This article describes and proposes a conceptual framework for categorizing primary care indicators that align with the IOM's six aims for quality in healthcare performance (Safe, Effective, Patient-Centred, Timely, Efficient and Equitable.) Using an iterative process, the authors developed and compared a primary care framework for categorizing indicators in the Quality in Family Practice Book of Tools (QBT) with the IOM aims and other local healthcare systems frameworks (Integrated and Continuous, Appropriate Practice Resources). They also compared, cross-matched and analyzed their QBT categories and indicators with other international primary care assessment tools. And they compared the QBT titles and descriptions of groups of indicators with those published in the international tools.
Journal of the Canadian Association of Gastroenterology, 2019
Background Colorectal cancer (CRC) screening with guaiac fecal occult blood test (gFOBT) reduces ... more Background Colorectal cancer (CRC) screening with guaiac fecal occult blood test (gFOBT) reduces CRC-related death. Average risk individuals should be recalled for screening with gFOBT every 2 years in order to maximize effectiveness. However, adherence with repeated testing is often suboptimal. Our aim was to evaluate whether adding a gFOBT kit to a mailed recall letter improves participation compared with a mailed recall letter alone, among previous responders to a mailed invitation. Methods We conducted a cluster randomized controlled trial, with the primary care provider as the unit of randomization. Eligible patients had completed a gFOBT and tested negative in an earlier pilot study and were now due for recall. The intervention group received a mailed CRC screening recall letter from their primary care provider plus a gFOBT kit (n = 431) while the control group received a mailed CRC screening mailed recall letter alone (n = 452). The primary outcome was the uptake of gFOBT or ...
Canadian family physician Médecin de famille canadien, 1988
The authors surveyed 16 Canadian Family Medicine Departments to ascertain the availability and co... more The authors surveyed 16 Canadian Family Medicine Departments to ascertain the availability and content of faculty development activities. The majority of Departments sponsored some faculty development; they were limited, however, by financial constraints, a lack of available manpower, and time restrictions. Few departments had a specified plan for faculty development. No comprehensive orientation activities were available for new faculty, and little attention was paid to established part-time faculty. Although teaching workshops were the most popular faculty-development activity, most programs were planned on an ad hoc basis. A number of effective local programs were not shared nationally. The authors discuss the implications of these results and the need for greater national and regional co-ordination.
Objective: The objective of the Cardiovascular Health Awareness Program (CHAP) is to improve the ... more Objective: The objective of the Cardiovascular Health Awareness Program (CHAP) is to improve the processes of care related to the cardiovascular health of older adults. Participants: Two Ontario communities including family physicians (FP), pharmacists, public health units and nurses, volunteer peer health educators, older adult patients and community organizations. Setting: Community pharmacies and family physician offices. Intervention: CHAP is designed to close a process of care loop around cardiovascular health awareness that originates from, and returns to, the FP. Older patients are invited by their FP to attend pharmacy CHAP sessions. At these sessions, trained volunteer peer health educators (PHEs) assist patients both in recording their blood pressure using a calibrated automated device and in completing a cardiovascular risk profile. This information is relayed to their respective FP via an automated computerized database. Pharmacists and patients receive copies of the results. Based on these cumulative risk profiles, patients are advised to follow-up with their FP. Outcomes: Of the FPs and pharmacists asked, 47% and 79%, respectively, agreed to participate in the project. 39% of older adult patients invited by their FPs attended the CHAP community pharmacy sessions. Of these, 100% agreed to having their risk profile, including their blood pressure readings, forwarded to their FP. Positive feedback about CHAP was expressed by the volunteer PHEs, the FPs and the pharmacists. Conclusion: The community-based pharmacy CHAP sessions are a feasible way of improving patient, physician, and pharmacist access to reliable blood pressure measurements and to cardiovascular health information. A randomized trial is in progress that will assess the impact of CHAP on monitoring of blood pressure.
Objective. High blood pressure is an important and modifiable cardiovascular disease risk factor ... more Objective. High blood pressure is an important and modifiable cardiovascular disease risk factor that remains under-detected and under-treated. Community-level interventions that address high blood pressure and other modifiable risk factors are a promising strategy to improve cardiovascular health in populations. The present study is a community cluster-randomised trial testing the effectiveness of CHAP (Cardiovascular Health Awareness Program) on the cardiovascular health of older adults. Methods. Thirty-nine mid-sized communities in Ontario, Canada were stratified by geographic location and size of the population aged ≥ 65 years and randomly allocated to receive CHAP or no intervention. In CHAP communities, residents aged ≥65 years were invited to attend cardiovascular risk assessment sessions held in pharmacies over 10 weeks in Fall, 2006. Sessions included blood pressure measurement and feedback to family physicians. Trained volunteers delivered the program with support from pharmacists, community nurses and local organisations. Results. The primary outcome measure is the relative change in the mean annual rate of hospital admission for acute myocardial infarction, congestive heart failure and stroke (composite end-point) among residents aged ≥65 years in intervention and control communities, using routinely collected, population-based administrative health data. Conclusion. This paper highlights considerations in design, implementation and evaluation of a large-scale, community-wide cardiovascular health promotion initiative.
Objective To evaluate the effectiveness of the community based Cardiovascular Health Awareness Pr... more Objective To evaluate the effectiveness of the community based Cardiovascular Health Awareness Program (CHAP) on morbidity from cardiovascular disease. Design Community cluster randomised trial. Setting 39 mid-sized communities in Ontario, Canada, stratified by location and population size. Participants Community dwelling residents aged 65 years or over, family physicians, pharmacists, volunteers, community nurses, and local lead organisations. Intervention Communities were randomised to receive CHAP (n=20) or no intervention (n=19). In CHAP communities, residents aged 65 or over were invited to attend volunteer run cardiovascular risk assessment and education sessions held in community based pharmacies over a 10 week period; automated blood pressure readings and self reported risk factor data were collected and shared with participants and their family physicians and pharmacists. Main outcome measure Composite of hospital admissions for acute myocardial infarction, stroke, and congestive heart failure among all community residents aged 65 and over in the year before compared with the year after implementation of CHAP. Results All 20 intervention communities successfully implemented CHAP. A total of 1265 three hour long sessions were held in 129/145 (89%) pharmacies during the 10 week programme. 15 889 unique participants had a total of 27 358 cardiovascular assessments with the assistance of 577 peer volunteers. After adjustment for hospital admission rates in the year before the intervention, CHAP was associated with a 9% relative reduction in the composite end point (rate ratio 0.91, 95% confidence interval 0.86 to 0.97; P=0.002) or 3.02 fewer annual hospital admissions for cardiovascular disease per 1000 people aged 65 and over. Statistically significant reductions favouring the intervention communities were seen in hospital admissions for acute myocardial infarction (rate ratio 0.87, 0.79 to 0.97; P=0.008) and congestive heart failure (0.90, 0.81 to 0.99; P=0.029) but not for stroke (0.99, 0.88 to 1.12; P=0.89). Conclusions A collaborative, multi-pronged, community based health promotion and prevention programme targeted at older adults can reduce cardiovascular morbidity at the population level. Trial registration Current controlled trials ISRCTN50550004.
Objective. High blood pressure is an important and modifiable cardiovascular disease risk factor ... more Objective. High blood pressure is an important and modifiable cardiovascular disease risk factor that remains under-detected and under-treated. Community-level interventions that address high blood pressure and other modifiable risk factors are a promising strategy to improve cardiovascular health in populations. The present study is a community cluster-randomised trial testing the effectiveness of CHAP (Cardiovascular Health Awareness Program) on the cardiovascular health of older adults. Methods. Thirty-nine mid-sized communities in Ontario, Canada were stratified by geographic location and size of the population aged ≥ 65 years and randomly allocated to receive CHAP or no intervention. In CHAP communities, residents aged ≥65 years were invited to attend cardiovascular risk assessment sessions held in pharmacies over 10 weeks in Fall, 2006. Sessions included blood pressure measurement and feedback to family physicians. Trained volunteers delivered the program with support from pharmacists, community nurses and local organisations. Results. The primary outcome measure is the relative change in the mean annual rate of hospital admission for acute myocardial infarction, congestive heart failure and stroke (composite end-point) among residents aged ≥65 years in intervention and control communities, using routinely collected, population-based administrative health data. Conclusion. This paper highlights considerations in design, implementation and evaluation of a large-scale, community-wide cardiovascular health promotion initiative.
Objective: The objective of the Cardiovascular Health Awareness Program (CHAP) is to improve the ... more Objective: The objective of the Cardiovascular Health Awareness Program (CHAP) is to improve the processes of care related to the cardiovascular health of older adults. Participants: Two Ontario communities including family physicians (FP), pharmacists, public health units and nurses, volunteer peer health educators, older adult patients and community organizations. Setting: Community pharmacies and family physician offices. Intervention: CHAP is designed to close a process of care loop around cardiovascular health awareness that originates from, and returns to, the FP. Older patients are invited by their FP to attend pharmacy CHAP sessions. At these sessions, trained volunteer peer health educators (PHEs) assist patients both in recording their blood pressure using a calibrated automated device and in completing a cardiovascular risk profile. This information is relayed to their respective FP via an automated computerized database. Pharmacists and patients receive copies of the results. Based on these cumulative risk profiles, patients are advised to follow-up with their FP. Outcomes: Of the FPs and pharmacists asked, 47% and 79%, respectively, agreed to participate in the project. 39% of older adult patients invited by their FPs attended the CHAP community pharmacy sessions. Of these, 100% agreed to having their risk profile, including their blood pressure readings, forwarded to their FP. Positive feedback about CHAP was expressed by the volunteer PHEs, the FPs and the pharmacists. Conclusion: The community-based pharmacy CHAP sessions are a feasible way of improving patient, physician, and pharmacist access to reliable blood pressure measurements and to cardiovascular health information. A randomized trial is in progress that will assess the impact of CHAP on monitoring of blood pressure.
An approach to preconception health promotion by obtaining a history and through physical examina... more An approach to preconception health promotion by obtaining a history and through physical examination and laboratory investigation is outlined. The controversies are explained, and the current programs that have been developed in the United Kingdom, Canada, and the United States are described. All women of childbearing age should have access to prepregnancy intervention; however, presently, barriers to its comprehensive implementation exist.
Canadian family physician Médecin de famille canadien, 1988
Gestational diabetes mellitus is a relatively common complication of pregnancy. The incidence var... more Gestational diabetes mellitus is a relatively common complication of pregnancy. The incidence varies from 1.6% to 13%, depending on the criteria used for evaluating glucose tolerance in studies where universal screening was employed. The glucose-challenge screening test produces many false-positive results; the patients thus identified are then subjected to further unpleasant oral glucose-tolerance tests to make the diagnosis. The diagnosis labels many pregnant patients as "high risk" and exposes them to a cascade of interventions. The author examines the basis in the literature for universal screening practices. The recommendations of the Second International Workshop-Conference on Gestational Diabetes Mellitus are presented. The author discusses risks and benefits of alternative screening approaches, diagnosis, control, and reviews the current literature.
Canadian family physician Médecin de famille canadien, 1989
There is no Canadian literature on training family physicians in emergency medicine. The author r... more There is no Canadian literature on training family physicians in emergency medicine. The author reviews the content of the current programs at the undergraduate and postgraduate levels. He questions whether the curriculum of family-medicine programs adequately fulfills the trainee's or the community's needs. Increased competence, as well as greatly increased confidence, should result from a four-month emergency medicine rotation. The teaching should be done by full-time specialists in emergency medicine.
Canadian family physician Médecin de famille canadien, 2000
To determine provincial trends in provision of intrapartum care by general practitioners and fami... more To determine provincial trends in provision of intrapartum care by general practitioners and family physicians (GP/FPs) for the 11 years from 1984 to 1995. Analyses of provincial Medical Care Fee-for-Service Utilization data for births from 1984-1985 to 1994-1995. 10 provinces of Canada. Proportion of vaginal births billed by GP/FPs (expressed as total number of vaginal births billed by GP/FPs divided by total number of vaginal births). In 1994-1995, the proportion of vaginal births billed by GP/FPs ranged from 77.2% in British Columbia and 70.8% in Nova Scotia to 28.9% in Ontario and 23.6% in Prince Edward Island. These proportions have remained relatively high and stable during the period studied in some provinces, such as British Columbia and Nova Scotia, and have declined steadily and notably in others. Data show that GP/FPs' involvement in vaginal births in most Canadian provinces is decreasing. This trend demonstrates a shift in GP/FPs' practice patterns and could indi...
The Institute of Medicine (IOM) framework has been used frequently to assess and monitor quality ... more The Institute of Medicine (IOM) framework has been used frequently to assess and monitor quality in secondary and tertiary care, but not in primary care. This article describes and proposes a conceptual framework for categorizing primary care indicators that align with the IOM's six aims for quality in healthcare performance (Safe, Effective, Patient-Centred, Timely, Efficient and Equitable.) Using an iterative process, the authors developed and compared a primary care framework for categorizing indicators in the Quality in Family Practice Book of Tools (QBT) with the IOM aims and other local healthcare systems frameworks (Integrated and Continuous, Appropriate Practice Resources). They also compared, cross-matched and analyzed their QBT categories and indicators with other international primary care assessment tools. And they compared the QBT titles and descriptions of groups of indicators with those published in the international tools.
Journal of the Canadian Association of Gastroenterology, 2019
Background Colorectal cancer (CRC) screening with guaiac fecal occult blood test (gFOBT) reduces ... more Background Colorectal cancer (CRC) screening with guaiac fecal occult blood test (gFOBT) reduces CRC-related death. Average risk individuals should be recalled for screening with gFOBT every 2 years in order to maximize effectiveness. However, adherence with repeated testing is often suboptimal. Our aim was to evaluate whether adding a gFOBT kit to a mailed recall letter improves participation compared with a mailed recall letter alone, among previous responders to a mailed invitation. Methods We conducted a cluster randomized controlled trial, with the primary care provider as the unit of randomization. Eligible patients had completed a gFOBT and tested negative in an earlier pilot study and were now due for recall. The intervention group received a mailed CRC screening recall letter from their primary care provider plus a gFOBT kit (n = 431) while the control group received a mailed CRC screening mailed recall letter alone (n = 452). The primary outcome was the uptake of gFOBT or ...
Canadian family physician Médecin de famille canadien, 1988
The authors surveyed 16 Canadian Family Medicine Departments to ascertain the availability and co... more The authors surveyed 16 Canadian Family Medicine Departments to ascertain the availability and content of faculty development activities. The majority of Departments sponsored some faculty development; they were limited, however, by financial constraints, a lack of available manpower, and time restrictions. Few departments had a specified plan for faculty development. No comprehensive orientation activities were available for new faculty, and little attention was paid to established part-time faculty. Although teaching workshops were the most popular faculty-development activity, most programs were planned on an ad hoc basis. A number of effective local programs were not shared nationally. The authors discuss the implications of these results and the need for greater national and regional co-ordination.
Objective: The objective of the Cardiovascular Health Awareness Program (CHAP) is to improve the ... more Objective: The objective of the Cardiovascular Health Awareness Program (CHAP) is to improve the processes of care related to the cardiovascular health of older adults. Participants: Two Ontario communities including family physicians (FP), pharmacists, public health units and nurses, volunteer peer health educators, older adult patients and community organizations. Setting: Community pharmacies and family physician offices. Intervention: CHAP is designed to close a process of care loop around cardiovascular health awareness that originates from, and returns to, the FP. Older patients are invited by their FP to attend pharmacy CHAP sessions. At these sessions, trained volunteer peer health educators (PHEs) assist patients both in recording their blood pressure using a calibrated automated device and in completing a cardiovascular risk profile. This information is relayed to their respective FP via an automated computerized database. Pharmacists and patients receive copies of the results. Based on these cumulative risk profiles, patients are advised to follow-up with their FP. Outcomes: Of the FPs and pharmacists asked, 47% and 79%, respectively, agreed to participate in the project. 39% of older adult patients invited by their FPs attended the CHAP community pharmacy sessions. Of these, 100% agreed to having their risk profile, including their blood pressure readings, forwarded to their FP. Positive feedback about CHAP was expressed by the volunteer PHEs, the FPs and the pharmacists. Conclusion: The community-based pharmacy CHAP sessions are a feasible way of improving patient, physician, and pharmacist access to reliable blood pressure measurements and to cardiovascular health information. A randomized trial is in progress that will assess the impact of CHAP on monitoring of blood pressure.
Objective. High blood pressure is an important and modifiable cardiovascular disease risk factor ... more Objective. High blood pressure is an important and modifiable cardiovascular disease risk factor that remains under-detected and under-treated. Community-level interventions that address high blood pressure and other modifiable risk factors are a promising strategy to improve cardiovascular health in populations. The present study is a community cluster-randomised trial testing the effectiveness of CHAP (Cardiovascular Health Awareness Program) on the cardiovascular health of older adults. Methods. Thirty-nine mid-sized communities in Ontario, Canada were stratified by geographic location and size of the population aged ≥ 65 years and randomly allocated to receive CHAP or no intervention. In CHAP communities, residents aged ≥65 years were invited to attend cardiovascular risk assessment sessions held in pharmacies over 10 weeks in Fall, 2006. Sessions included blood pressure measurement and feedback to family physicians. Trained volunteers delivered the program with support from pharmacists, community nurses and local organisations. Results. The primary outcome measure is the relative change in the mean annual rate of hospital admission for acute myocardial infarction, congestive heart failure and stroke (composite end-point) among residents aged ≥65 years in intervention and control communities, using routinely collected, population-based administrative health data. Conclusion. This paper highlights considerations in design, implementation and evaluation of a large-scale, community-wide cardiovascular health promotion initiative.
Objective To evaluate the effectiveness of the community based Cardiovascular Health Awareness Pr... more Objective To evaluate the effectiveness of the community based Cardiovascular Health Awareness Program (CHAP) on morbidity from cardiovascular disease. Design Community cluster randomised trial. Setting 39 mid-sized communities in Ontario, Canada, stratified by location and population size. Participants Community dwelling residents aged 65 years or over, family physicians, pharmacists, volunteers, community nurses, and local lead organisations. Intervention Communities were randomised to receive CHAP (n=20) or no intervention (n=19). In CHAP communities, residents aged 65 or over were invited to attend volunteer run cardiovascular risk assessment and education sessions held in community based pharmacies over a 10 week period; automated blood pressure readings and self reported risk factor data were collected and shared with participants and their family physicians and pharmacists. Main outcome measure Composite of hospital admissions for acute myocardial infarction, stroke, and congestive heart failure among all community residents aged 65 and over in the year before compared with the year after implementation of CHAP. Results All 20 intervention communities successfully implemented CHAP. A total of 1265 three hour long sessions were held in 129/145 (89%) pharmacies during the 10 week programme. 15 889 unique participants had a total of 27 358 cardiovascular assessments with the assistance of 577 peer volunteers. After adjustment for hospital admission rates in the year before the intervention, CHAP was associated with a 9% relative reduction in the composite end point (rate ratio 0.91, 95% confidence interval 0.86 to 0.97; P=0.002) or 3.02 fewer annual hospital admissions for cardiovascular disease per 1000 people aged 65 and over. Statistically significant reductions favouring the intervention communities were seen in hospital admissions for acute myocardial infarction (rate ratio 0.87, 0.79 to 0.97; P=0.008) and congestive heart failure (0.90, 0.81 to 0.99; P=0.029) but not for stroke (0.99, 0.88 to 1.12; P=0.89). Conclusions A collaborative, multi-pronged, community based health promotion and prevention programme targeted at older adults can reduce cardiovascular morbidity at the population level. Trial registration Current controlled trials ISRCTN50550004.
Objective. High blood pressure is an important and modifiable cardiovascular disease risk factor ... more Objective. High blood pressure is an important and modifiable cardiovascular disease risk factor that remains under-detected and under-treated. Community-level interventions that address high blood pressure and other modifiable risk factors are a promising strategy to improve cardiovascular health in populations. The present study is a community cluster-randomised trial testing the effectiveness of CHAP (Cardiovascular Health Awareness Program) on the cardiovascular health of older adults. Methods. Thirty-nine mid-sized communities in Ontario, Canada were stratified by geographic location and size of the population aged ≥ 65 years and randomly allocated to receive CHAP or no intervention. In CHAP communities, residents aged ≥65 years were invited to attend cardiovascular risk assessment sessions held in pharmacies over 10 weeks in Fall, 2006. Sessions included blood pressure measurement and feedback to family physicians. Trained volunteers delivered the program with support from pharmacists, community nurses and local organisations. Results. The primary outcome measure is the relative change in the mean annual rate of hospital admission for acute myocardial infarction, congestive heart failure and stroke (composite end-point) among residents aged ≥65 years in intervention and control communities, using routinely collected, population-based administrative health data. Conclusion. This paper highlights considerations in design, implementation and evaluation of a large-scale, community-wide cardiovascular health promotion initiative.
Objective: The objective of the Cardiovascular Health Awareness Program (CHAP) is to improve the ... more Objective: The objective of the Cardiovascular Health Awareness Program (CHAP) is to improve the processes of care related to the cardiovascular health of older adults. Participants: Two Ontario communities including family physicians (FP), pharmacists, public health units and nurses, volunteer peer health educators, older adult patients and community organizations. Setting: Community pharmacies and family physician offices. Intervention: CHAP is designed to close a process of care loop around cardiovascular health awareness that originates from, and returns to, the FP. Older patients are invited by their FP to attend pharmacy CHAP sessions. At these sessions, trained volunteer peer health educators (PHEs) assist patients both in recording their blood pressure using a calibrated automated device and in completing a cardiovascular risk profile. This information is relayed to their respective FP via an automated computerized database. Pharmacists and patients receive copies of the results. Based on these cumulative risk profiles, patients are advised to follow-up with their FP. Outcomes: Of the FPs and pharmacists asked, 47% and 79%, respectively, agreed to participate in the project. 39% of older adult patients invited by their FPs attended the CHAP community pharmacy sessions. Of these, 100% agreed to having their risk profile, including their blood pressure readings, forwarded to their FP. Positive feedback about CHAP was expressed by the volunteer PHEs, the FPs and the pharmacists. Conclusion: The community-based pharmacy CHAP sessions are a feasible way of improving patient, physician, and pharmacist access to reliable blood pressure measurements and to cardiovascular health information. A randomized trial is in progress that will assess the impact of CHAP on monitoring of blood pressure.
An approach to preconception health promotion by obtaining a history and through physical examina... more An approach to preconception health promotion by obtaining a history and through physical examination and laboratory investigation is outlined. The controversies are explained, and the current programs that have been developed in the United Kingdom, Canada, and the United States are described. All women of childbearing age should have access to prepregnancy intervention; however, presently, barriers to its comprehensive implementation exist.
Canadian family physician Médecin de famille canadien, 1988
Gestational diabetes mellitus is a relatively common complication of pregnancy. The incidence var... more Gestational diabetes mellitus is a relatively common complication of pregnancy. The incidence varies from 1.6% to 13%, depending on the criteria used for evaluating glucose tolerance in studies where universal screening was employed. The glucose-challenge screening test produces many false-positive results; the patients thus identified are then subjected to further unpleasant oral glucose-tolerance tests to make the diagnosis. The diagnosis labels many pregnant patients as "high risk" and exposes them to a cascade of interventions. The author examines the basis in the literature for universal screening practices. The recommendations of the Second International Workshop-Conference on Gestational Diabetes Mellitus are presented. The author discusses risks and benefits of alternative screening approaches, diagnosis, control, and reviews the current literature.
Canadian family physician Médecin de famille canadien, 1989
There is no Canadian literature on training family physicians in emergency medicine. The author r... more There is no Canadian literature on training family physicians in emergency medicine. The author reviews the content of the current programs at the undergraduate and postgraduate levels. He questions whether the curriculum of family-medicine programs adequately fulfills the trainee's or the community's needs. Increased competence, as well as greatly increased confidence, should result from a four-month emergency medicine rotation. The teaching should be done by full-time specialists in emergency medicine.
Canadian family physician Médecin de famille canadien, 2000
To determine provincial trends in provision of intrapartum care by general practitioners and fami... more To determine provincial trends in provision of intrapartum care by general practitioners and family physicians (GP/FPs) for the 11 years from 1984 to 1995. Analyses of provincial Medical Care Fee-for-Service Utilization data for births from 1984-1985 to 1994-1995. 10 provinces of Canada. Proportion of vaginal births billed by GP/FPs (expressed as total number of vaginal births billed by GP/FPs divided by total number of vaginal births). In 1994-1995, the proportion of vaginal births billed by GP/FPs ranged from 77.2% in British Columbia and 70.8% in Nova Scotia to 28.9% in Ontario and 23.6% in Prince Edward Island. These proportions have remained relatively high and stable during the period studied in some provinces, such as British Columbia and Nova Scotia, and have declined steadily and notably in others. Data show that GP/FPs' involvement in vaginal births in most Canadian provinces is decreasing. This trend demonstrates a shift in GP/FPs' practice patterns and could indi...
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