Primary Health Care Research & Development, Jul 1, 2005
, 2002). It is estimated that over 90% of personal health services are delivered in communitybase... more , 2002). It is estimated that over 90% of personal health services are delivered in communitybased primary care (White et al., 1961) and yet such services account for only about 35% of health service costs (Ontario Health Services Restructuring Commission, 2000). In international comparisons, a higher quality of primary care services has been shown to correlate with better health status indicators, higher satisfaction of the population, and lower costs of the health system (Starfield, 1994; 1998). Recent reviews (Macinko et al., 2003; Schoen et al., 2004) confirm the central role of primary care and indicate important issues to be addressed. Thus the rationale for developing a stronger and more integrated comprehensive primary health care system in Canada is on a firm foundation. Canadian family physicians/general practitioners (FPs/GPs) provide first contact or primary care services in their offices for patients who choose to access these services. Patients are not required to enrol or
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Aim: To review non-disease-specific predictors and causes of primary non-adherence of prescribed ... more Aim: To review non-disease-specific predictors and causes of primary non-adherence of prescribed pharmaceutical treatments and interventions. Method: A PubMed literature search (up to October 2015) using the terms primary, initial, first-fill and index with terms related to non-initiation, adherence, compliance, redemption and dispensing. The references, citations and similar articles for the identified articles were used to identify additional sources. Study selection and data extraction: Prescription record-based and survey-based studies considering at least four medication classes or diseases while evaluating factors (predictors and causes) associated with primary non-adherence were examined. Results: 53 articles were identified, including 16 specific to cost-related primary non-adherence. Regularly cited factors were age, gender, race and ethnicity, mental health, comorbidities, polypharmacy, medication beliefs, side effects, affordability, education, number of clinic, hospital and emergency department visits, patient-physician relationship, prescriber traits, forgetfulness and convenience. Issues related to affordability were raised most frequently, being brought up in 37of 53 sources. Many of the articles provided conflicting reports as to the direction of predictors and the importance of causes of primary non-adherence. Conclusion: To date, numerous factors have been identified and associated with primary non-adherence to medications. Some factors may appear to be more influential than others, though the relevance of each predictor and cause varied between studies. To date, discrepant data in the literature has prevented the homogeneous analysis of primary adherence to prescribed pharmaceutical treatments. By compiling the factors and barriers related to primary non-adherence, this investigative review will prompt and promote future research in this area. Ultimately, primary care physicians will be better equipped to understand, act and potentially prevent patients from avoiding treatment regimes at the outset.
Objective: To formulate recommendations for facilitating communication and helping prevent misund... more Objective: To formulate recommendations for facilitating communication and helping prevent misunderstandings during cross-cultural patient-physician interactions. Design: Qualitative study using content and semantic analyses of information supplied in focus groups. Setting: All family physician respondents were associated with departments of family medicine at two urban hospitals and had expressed interest in this study; all immigrant patients were recruited from the English-as-a-Second-Language program at a community agency. Participants: Thirteen immigrant patients, distributed in two groups (one of seven women and one man and one of three men and two women), and five family physicians (two women and three men). Main outcome measures: Responses to prepared questions asked in focus groups. Results: Family physicians thought that understanding patients' cultures better would improve quality of care. Patients did not always understand why their physicians asked questions about their culture, sometimes finding these questions irrelevant or intrusive. Comments were used to formulate recommendations for patient-physician interactions. Conclusions: Physicians and patients are aware of culture as a factor in their relationships but differ on its importance to quality of care.
OBJECTIVE To understand why Canadian adolescents go or do not go to see family physicians for ann... more OBJECTIVE To understand why Canadian adolescents go or do not go to see family physicians for annual checkups using the Theory of Planned Behavior as a conceptual framework. DESIGN Qualitative analysis of small group discussions. SETTING Edmonton, Alta, a large Canadian city. PARTICIPANTS Seventeen adolescents (6 male, 11 female) recruited from a medical clinic and an organized youth group. METHOD Two small group discussions and one validation focus group were held. A combination of category coding and thematic analysis was used to analyze the data transcribed. MAIN FINDINGS Adolescents reported that regular checkups, although uncomfortable, are a good idea. They also reported that going to a family doctor for a checkup is out of their control because of numerous barriers (eg, lack of time, not knowing how to set it up, or lack of transportation). Participants thought their parents' opinions on going for routine checkups were more important than the opinions of their peers. CONCLUSION Family physicians should recognize adolescents' attitudes toward visiting family physicians' offi ces and understand the potential barriers adolescents face in coming in for checkups in order to make visits to their offi ces more comfortable and benefi cial.
Chronic Obstructive Pulmonary Disease (COPD) is a complex disease that is predicted to be the thi... more Chronic Obstructive Pulmonary Disease (COPD) is a complex disease that is predicted to be the third most common cause of death by 2030. In Canada, the care and management of chronic conditions is largely provided by primary care providers. Although there is emerging research and initiatives that describe the prevalence of COPD in Canadian primary care settings, to our knowledge, there have been no efforts to use a large pan-Canadian database to analyze COPD as a risk factor for other common chronic conditions managed in primary care. Since 2009, the Canadian Primary Care Sentinel Surveillance Network has assembled Canada’s first national electronic health record (EHR) data repository for primary care research and surveillance; it consists of ten primary care research networks with over 1,300 participating primary care sentinel clinicians (family physicians and nurse practitioners) contributing quarterly data on more than 1,700,000 patients across eight provinces and territories. This study will report the results of a series of descriptive and survival analyses compare an exposure of COPD in people over 40 years old (N=22,942) to predict the outcomes of: heart failure, depression, anxiety, coronary artery disease, diabetes, anemia, hypertension, ischemic heart disease, underweight, and osteoporosis while controlling for EHR status of: smoking, age, sex, and rurality. Results will be computed in March 2019. By the date of the ERS Congress 2019, we will be able to report the results of the aforementioned analyses, which will demonstrate the utility of using large EMR datasets to illustrate comorbid temporality managed by Canadian primary care providers.
Alpha-1 antitrypsin (A1AT) functions primarily to inhibit neutrophil elastase, and deficiency pre... more Alpha-1 antitrypsin (A1AT) functions primarily to inhibit neutrophil elastase, and deficiency predisposes individuals to the development of chronic obstructive pulmonary disease (COPD). Severe A1AT deficiency occurs in one in 5000 to one in 5500 of the North American population. While the exact prevalence of A1AT deficiency in patients with diagnosed COPD is not known, results from small studies provide estimates of 1% to 5%. The present document updates a previous Canadian Thoracic Society position statement from 2001, and was initiated because of lack of consensus and understanding of appropriate patients suitable for targeted testing for A1AT deficiency, and for the use of A1AT augmentation therapy. Using revised guideline development methodology, the present clinical practice guideline document systematically reviews the published literature and provides an evidence-based update. The evidence supports the practice that targeted testing for A1AT deficiency be considered in indivi...
Background: Since 1985, nurse-run asthma clinics have been developing and are now widespread in t... more Background: Since 1985, nurse-run asthma clinics have been developing and are now widespread in the United Kingdom, having been greatly stimulated by the New Contract for General Practice (1990). To
A very small percentage of the population receives its health care in teaching hospitals, yet thi... more A very small percentage of the population receives its health care in teaching hospitals, yet this is where most of the patient-focused health research takes place. 1 As such, the results are often not generalizable to the patients we see in family practice. 2 Recently, enlightened hospital-based researchers are beginning to address this issue and are turning their attention to family practices to recruit patients for their studies. 2 At the same time, family medicine physicians are also beginning to ask their own questions and participate in both clinical research and health services research. 3 Family physicians' participation in primary care research is one of the challenges with which family medicine researchers are struggling. 4 Residency training in family medicine is so short that research training gets little, if any, time in the curriculum. 5 Unlike our colleagues in other specialties, most FPs do not see research as part of their mandate as physicians. 6 Further, they are under constant workload pressures and do not have the support systems in place for office-based practice research. 7 For those FPs who are engaged in research, enlisting community-based FPs to be involved in any type of research can be a problem.
Background: Obesity is a pressing public health concern, which frequently presents in primary car... more Background: Obesity is a pressing public health concern, which frequently presents in primary care. With the explosive obesity epidemic, there is an urgent need to maximize effective management in primary care. The 5As of Obesity Management™ (5As) are a collection of knowledge tools developed by the Canadian Obesity Network. Low rates of obesity management visits in primary care suggest provider behaviour may be an important variable. The goal of the present study is to increase frequency and quality of obesity management in primary care using the 5As Team (5AsT) intervention to change provider behaviour. Methods/design: The 5AsT trial is a theoretically informed, pragmatic randomized controlled trial with mixed methods evaluation. Clinic-based multidisciplinary teams (RN/NP, mental health, dietitians) will be randomized to control or the 5AsT intervention group, to participate in biweekly learning collaborative sessions supported by internal and external practice facilitation. The learning collaborative content addresses provider-identified barriers to effective obesity management in primary care. Evidence-based shared decision making tools will be co-developed and iteratively tested by practitioners. Evaluation will be informed by the RE-AIM framework. The primary outcome measure, to which participants are blinded, is number of weight management visits/full-time equivalent (FTE) position. Patient-level outcomes will also be assessed, through a longitudinal cohort study of patients from randomized practices. Patient outcomes include clinical (e.g., body mass index [BMI], blood pressure), health-related quality of life (SF-12, EQ5D), and satisfaction with care. Qualitative data collected from providers and patients will be evaluated using thematic analysis to understand the context, implementation and effectiveness of the 5AsT program. Discussion: The 5AsT trial will provide a wide range of insights into current practices, knowledge gaps and barriers that limit obesity management in primary practice. The use of existing resources, collaborative design, practice facilitation, and integrated feedback loops cultivate an applicable, adaptable and sustainable approach to increasing the quantity and quality of weight management visits in primary care. Trial registration: NCT01967797.
Research CMAJ OPEN C hronic obstructive pulmonary disease (COPD) is a substantial source of morbi... more Research CMAJ OPEN C hronic obstructive pulmonary disease (COPD) is a substantial source of morbidity and mortality in Canada and globally. Estimates place the worldwide prevalence at 9%-10% from physiologic-based studies and 3%-8% from studies based on physician-or patient-reported diagnosis or symptoms. 1,2 Globally, COPD is rated as the fifth leading cause of death, and ninth in contributions to loss of disability-adjusted life years. 3,4 A recent systematic review of COPD epidemiology worldwide identified 12 Canadian studies, which produced prevalence estimates that ranged from 3% to 12%, depending on the method used. 5 Canadian data from a study using spirometry to screen a populationbased sample suggest a rate of about 10%. 6 There are limited data on COPD either alone or in combination with other chronic diseases from primary care settings. In other countries, the limited reports on COPD prevalence in primary care settings show marked variation depending on the method of identification of illness. A study from the United Kingdom based on electronic records in the Computerized Patient Records Database found the prevalence of physician-diagnosed COPD to be less than 1% for women and only 1.35% for men. 7 Another practice-based research network study from the UK that invited participants in a postal survey to come for spirometry if they had either symptoms or a smoking history found a much higher prevalence (4.1% overall, 9.6% in patients over 40 yr). 8 A recent Spanish study using data from electronic medical records (EMRs) found a physician-diagnosed prevalence of 3.2%, 90% of whom were also found to have at least 1 comorbid condition. 9
Advances in medical education and practice, May 1, 2011
The scope of practice by general practitioners and family physicians in North America has been ch... more The scope of practice by general practitioners and family physicians in North America has been changing over time. Are academic practices providing residents the same scope of practice as the urban practices into which they are going? Methods: A survey describing the activities and scope of general practice/family practice was constructed from the literature and checked with general practitioners/family physicians for face validity. It was administered by mail to academic family physicians at the University of Alberta Department of Family Medicine in Edmonton and to all practicing general practitioners/family physicians in the city and Capital Region around Edmonton. There was a response rate of 78% and 50.9%, respectively. Results: Academic physicians' practices differed from those of their urban colleagues. The former were all certified by the College of Family Physicians of Canada, worked in group practices, and included more males and fewer immigrants. They worked as many hours, but did less clinical work than their urban colleagues. Even so, 25% did more than 40 hours of clinical work each week compared with 68% of urban physicians. There was a wide scope of services and procedures provided by both groups and other services that were different from group to group. There was no difference between groups in intention to add or remove services in the next two years, but academic physicians had removed more services in the last two years. Conclusion: General practitioners/family physicians still provide a wide range of services. Although both academic and urban general practitioners/family physicians have reduced some services in the last two years, they have both added others to their repertoire. Although the teaching and urban general practitioners/family physicians practices have many similarities, they also have differences, which may have implications for the training of future urban family physicians.
Primary Health Care Research & Development, Jul 1, 2005
, 2002). It is estimated that over 90% of personal health services are delivered in communitybase... more , 2002). It is estimated that over 90% of personal health services are delivered in communitybased primary care (White et al., 1961) and yet such services account for only about 35% of health service costs (Ontario Health Services Restructuring Commission, 2000). In international comparisons, a higher quality of primary care services has been shown to correlate with better health status indicators, higher satisfaction of the population, and lower costs of the health system (Starfield, 1994; 1998). Recent reviews (Macinko et al., 2003; Schoen et al., 2004) confirm the central role of primary care and indicate important issues to be addressed. Thus the rationale for developing a stronger and more integrated comprehensive primary health care system in Canada is on a firm foundation. Canadian family physicians/general practitioners (FPs/GPs) provide first contact or primary care services in their offices for patients who choose to access these services. Patients are not required to enrol or
This article is an open access article distributed under the terms and conditions of the Creative... more This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY
Aim: To review non-disease-specific predictors and causes of primary non-adherence of prescribed ... more Aim: To review non-disease-specific predictors and causes of primary non-adherence of prescribed pharmaceutical treatments and interventions. Method: A PubMed literature search (up to October 2015) using the terms primary, initial, first-fill and index with terms related to non-initiation, adherence, compliance, redemption and dispensing. The references, citations and similar articles for the identified articles were used to identify additional sources. Study selection and data extraction: Prescription record-based and survey-based studies considering at least four medication classes or diseases while evaluating factors (predictors and causes) associated with primary non-adherence were examined. Results: 53 articles were identified, including 16 specific to cost-related primary non-adherence. Regularly cited factors were age, gender, race and ethnicity, mental health, comorbidities, polypharmacy, medication beliefs, side effects, affordability, education, number of clinic, hospital and emergency department visits, patient-physician relationship, prescriber traits, forgetfulness and convenience. Issues related to affordability were raised most frequently, being brought up in 37of 53 sources. Many of the articles provided conflicting reports as to the direction of predictors and the importance of causes of primary non-adherence. Conclusion: To date, numerous factors have been identified and associated with primary non-adherence to medications. Some factors may appear to be more influential than others, though the relevance of each predictor and cause varied between studies. To date, discrepant data in the literature has prevented the homogeneous analysis of primary adherence to prescribed pharmaceutical treatments. By compiling the factors and barriers related to primary non-adherence, this investigative review will prompt and promote future research in this area. Ultimately, primary care physicians will be better equipped to understand, act and potentially prevent patients from avoiding treatment regimes at the outset.
Objective: To formulate recommendations for facilitating communication and helping prevent misund... more Objective: To formulate recommendations for facilitating communication and helping prevent misunderstandings during cross-cultural patient-physician interactions. Design: Qualitative study using content and semantic analyses of information supplied in focus groups. Setting: All family physician respondents were associated with departments of family medicine at two urban hospitals and had expressed interest in this study; all immigrant patients were recruited from the English-as-a-Second-Language program at a community agency. Participants: Thirteen immigrant patients, distributed in two groups (one of seven women and one man and one of three men and two women), and five family physicians (two women and three men). Main outcome measures: Responses to prepared questions asked in focus groups. Results: Family physicians thought that understanding patients' cultures better would improve quality of care. Patients did not always understand why their physicians asked questions about their culture, sometimes finding these questions irrelevant or intrusive. Comments were used to formulate recommendations for patient-physician interactions. Conclusions: Physicians and patients are aware of culture as a factor in their relationships but differ on its importance to quality of care.
OBJECTIVE To understand why Canadian adolescents go or do not go to see family physicians for ann... more OBJECTIVE To understand why Canadian adolescents go or do not go to see family physicians for annual checkups using the Theory of Planned Behavior as a conceptual framework. DESIGN Qualitative analysis of small group discussions. SETTING Edmonton, Alta, a large Canadian city. PARTICIPANTS Seventeen adolescents (6 male, 11 female) recruited from a medical clinic and an organized youth group. METHOD Two small group discussions and one validation focus group were held. A combination of category coding and thematic analysis was used to analyze the data transcribed. MAIN FINDINGS Adolescents reported that regular checkups, although uncomfortable, are a good idea. They also reported that going to a family doctor for a checkup is out of their control because of numerous barriers (eg, lack of time, not knowing how to set it up, or lack of transportation). Participants thought their parents' opinions on going for routine checkups were more important than the opinions of their peers. CONCLUSION Family physicians should recognize adolescents' attitudes toward visiting family physicians' offi ces and understand the potential barriers adolescents face in coming in for checkups in order to make visits to their offi ces more comfortable and benefi cial.
Chronic Obstructive Pulmonary Disease (COPD) is a complex disease that is predicted to be the thi... more Chronic Obstructive Pulmonary Disease (COPD) is a complex disease that is predicted to be the third most common cause of death by 2030. In Canada, the care and management of chronic conditions is largely provided by primary care providers. Although there is emerging research and initiatives that describe the prevalence of COPD in Canadian primary care settings, to our knowledge, there have been no efforts to use a large pan-Canadian database to analyze COPD as a risk factor for other common chronic conditions managed in primary care. Since 2009, the Canadian Primary Care Sentinel Surveillance Network has assembled Canada’s first national electronic health record (EHR) data repository for primary care research and surveillance; it consists of ten primary care research networks with over 1,300 participating primary care sentinel clinicians (family physicians and nurse practitioners) contributing quarterly data on more than 1,700,000 patients across eight provinces and territories. This study will report the results of a series of descriptive and survival analyses compare an exposure of COPD in people over 40 years old (N=22,942) to predict the outcomes of: heart failure, depression, anxiety, coronary artery disease, diabetes, anemia, hypertension, ischemic heart disease, underweight, and osteoporosis while controlling for EHR status of: smoking, age, sex, and rurality. Results will be computed in March 2019. By the date of the ERS Congress 2019, we will be able to report the results of the aforementioned analyses, which will demonstrate the utility of using large EMR datasets to illustrate comorbid temporality managed by Canadian primary care providers.
Alpha-1 antitrypsin (A1AT) functions primarily to inhibit neutrophil elastase, and deficiency pre... more Alpha-1 antitrypsin (A1AT) functions primarily to inhibit neutrophil elastase, and deficiency predisposes individuals to the development of chronic obstructive pulmonary disease (COPD). Severe A1AT deficiency occurs in one in 5000 to one in 5500 of the North American population. While the exact prevalence of A1AT deficiency in patients with diagnosed COPD is not known, results from small studies provide estimates of 1% to 5%. The present document updates a previous Canadian Thoracic Society position statement from 2001, and was initiated because of lack of consensus and understanding of appropriate patients suitable for targeted testing for A1AT deficiency, and for the use of A1AT augmentation therapy. Using revised guideline development methodology, the present clinical practice guideline document systematically reviews the published literature and provides an evidence-based update. The evidence supports the practice that targeted testing for A1AT deficiency be considered in indivi...
Background: Since 1985, nurse-run asthma clinics have been developing and are now widespread in t... more Background: Since 1985, nurse-run asthma clinics have been developing and are now widespread in the United Kingdom, having been greatly stimulated by the New Contract for General Practice (1990). To
A very small percentage of the population receives its health care in teaching hospitals, yet thi... more A very small percentage of the population receives its health care in teaching hospitals, yet this is where most of the patient-focused health research takes place. 1 As such, the results are often not generalizable to the patients we see in family practice. 2 Recently, enlightened hospital-based researchers are beginning to address this issue and are turning their attention to family practices to recruit patients for their studies. 2 At the same time, family medicine physicians are also beginning to ask their own questions and participate in both clinical research and health services research. 3 Family physicians' participation in primary care research is one of the challenges with which family medicine researchers are struggling. 4 Residency training in family medicine is so short that research training gets little, if any, time in the curriculum. 5 Unlike our colleagues in other specialties, most FPs do not see research as part of their mandate as physicians. 6 Further, they are under constant workload pressures and do not have the support systems in place for office-based practice research. 7 For those FPs who are engaged in research, enlisting community-based FPs to be involved in any type of research can be a problem.
Background: Obesity is a pressing public health concern, which frequently presents in primary car... more Background: Obesity is a pressing public health concern, which frequently presents in primary care. With the explosive obesity epidemic, there is an urgent need to maximize effective management in primary care. The 5As of Obesity Management™ (5As) are a collection of knowledge tools developed by the Canadian Obesity Network. Low rates of obesity management visits in primary care suggest provider behaviour may be an important variable. The goal of the present study is to increase frequency and quality of obesity management in primary care using the 5As Team (5AsT) intervention to change provider behaviour. Methods/design: The 5AsT trial is a theoretically informed, pragmatic randomized controlled trial with mixed methods evaluation. Clinic-based multidisciplinary teams (RN/NP, mental health, dietitians) will be randomized to control or the 5AsT intervention group, to participate in biweekly learning collaborative sessions supported by internal and external practice facilitation. The learning collaborative content addresses provider-identified barriers to effective obesity management in primary care. Evidence-based shared decision making tools will be co-developed and iteratively tested by practitioners. Evaluation will be informed by the RE-AIM framework. The primary outcome measure, to which participants are blinded, is number of weight management visits/full-time equivalent (FTE) position. Patient-level outcomes will also be assessed, through a longitudinal cohort study of patients from randomized practices. Patient outcomes include clinical (e.g., body mass index [BMI], blood pressure), health-related quality of life (SF-12, EQ5D), and satisfaction with care. Qualitative data collected from providers and patients will be evaluated using thematic analysis to understand the context, implementation and effectiveness of the 5AsT program. Discussion: The 5AsT trial will provide a wide range of insights into current practices, knowledge gaps and barriers that limit obesity management in primary practice. The use of existing resources, collaborative design, practice facilitation, and integrated feedback loops cultivate an applicable, adaptable and sustainable approach to increasing the quantity and quality of weight management visits in primary care. Trial registration: NCT01967797.
Research CMAJ OPEN C hronic obstructive pulmonary disease (COPD) is a substantial source of morbi... more Research CMAJ OPEN C hronic obstructive pulmonary disease (COPD) is a substantial source of morbidity and mortality in Canada and globally. Estimates place the worldwide prevalence at 9%-10% from physiologic-based studies and 3%-8% from studies based on physician-or patient-reported diagnosis or symptoms. 1,2 Globally, COPD is rated as the fifth leading cause of death, and ninth in contributions to loss of disability-adjusted life years. 3,4 A recent systematic review of COPD epidemiology worldwide identified 12 Canadian studies, which produced prevalence estimates that ranged from 3% to 12%, depending on the method used. 5 Canadian data from a study using spirometry to screen a populationbased sample suggest a rate of about 10%. 6 There are limited data on COPD either alone or in combination with other chronic diseases from primary care settings. In other countries, the limited reports on COPD prevalence in primary care settings show marked variation depending on the method of identification of illness. A study from the United Kingdom based on electronic records in the Computerized Patient Records Database found the prevalence of physician-diagnosed COPD to be less than 1% for women and only 1.35% for men. 7 Another practice-based research network study from the UK that invited participants in a postal survey to come for spirometry if they had either symptoms or a smoking history found a much higher prevalence (4.1% overall, 9.6% in patients over 40 yr). 8 A recent Spanish study using data from electronic medical records (EMRs) found a physician-diagnosed prevalence of 3.2%, 90% of whom were also found to have at least 1 comorbid condition. 9
Advances in medical education and practice, May 1, 2011
The scope of practice by general practitioners and family physicians in North America has been ch... more The scope of practice by general practitioners and family physicians in North America has been changing over time. Are academic practices providing residents the same scope of practice as the urban practices into which they are going? Methods: A survey describing the activities and scope of general practice/family practice was constructed from the literature and checked with general practitioners/family physicians for face validity. It was administered by mail to academic family physicians at the University of Alberta Department of Family Medicine in Edmonton and to all practicing general practitioners/family physicians in the city and Capital Region around Edmonton. There was a response rate of 78% and 50.9%, respectively. Results: Academic physicians' practices differed from those of their urban colleagues. The former were all certified by the College of Family Physicians of Canada, worked in group practices, and included more males and fewer immigrants. They worked as many hours, but did less clinical work than their urban colleagues. Even so, 25% did more than 40 hours of clinical work each week compared with 68% of urban physicians. There was a wide scope of services and procedures provided by both groups and other services that were different from group to group. There was no difference between groups in intention to add or remove services in the next two years, but academic physicians had removed more services in the last two years. Conclusion: General practitioners/family physicians still provide a wide range of services. Although both academic and urban general practitioners/family physicians have reduced some services in the last two years, they have both added others to their repertoire. Although the teaching and urban general practitioners/family physicians practices have many similarities, they also have differences, which may have implications for the training of future urban family physicians.
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