Physician recruitment
All participating physicians provided written informed consent. The study was approved by Health Research Ethics Boards across Canada. The study was sponsored by research grants from the Ontario College of Family Physicians and Alliance for Better Bone Health (Procter & Gamble Pharmaceuticals Canada Inc. and Sanofi-Aventis Pharma Inc.).
Facilitators
A physician-facilitator was selected for each Quality Circle and trained to facilitate the management of the circle. Facilitators were local family physicians recruited to lead and initiate discussion at study meetings and were chosen because of their skills in small group facilitation and involvement in continuing professional development and were selected by the study's steering committee.
Osteoporosis specialist
An osteoporosis specialist was assigned to each quality circle. The specialist was recruited on the recommendation provided by the facilitator from the facilitator's local referral network. The role of the osteoporosis specialist was to attend each Quality Circle meeting to provide assistance in addressing clinical matters.
Members
Circle members were family physicians selected from specific geographical regions across Canada derived from a list developed by the facilitator of each Quality Circle, supplemented with physicians' names from the provincial College of Family Physician's membership list. All potential members received a written introductory letter from the local circle facilitator and were invited to participate in the study. A maximum of 15 physicians in each geographical area were enrolled into each circle in the study. Family physicians are defined as physicians who take professional responsibility for the comprehensive care of unselected patients with undifferentiated problems and are committed to the person regardless of gender, age, or illness [16].
Overview of project phases
The overall project consisted of five Quality Circle phases. Members committed to the first year of the project, which consist of Quality Circle phases one to three. Those who were interested and willing to commit to the second year of the project completed the remaining 2 project phases. The five phases include: 1) Introduction, Training & Baseline Data Collection, 2) First Educational Intervention & First Follow-Up Data Collection 3) First Strategy Implementation Session, 4) Final Educational Intervention & Final Follow-up Data Collection, and 5) Final Strategy Implementation Session (Figure 1). Participants received continuing professional development credits from the College of Family Physicians of Canada (12 MAINPRO-C credits (or 24 MAINPRO-M1 credits)) per year for participation.
This article describes the changes in physician behaviour during the first year of the project, but the over-all timeline of the Project is summarized in Figure 1, and the detailed description of all 5 phases follows.
Phase 1: introduction, training & baseline data collection
Project training was conducted via baseline circle meetings and involved a systematic examination of the study protocol, and a review of the project data collection form. Following training, each member collected baseline patient data from their own practice using a standardized baseline data collection form to ascertain current practice patterns for the diagnosis and treatment of osteoporosis. Once the data were evaluated, the Steering Committee met to review findings and determine key learnings that circle members should know. Key learnings were used to produce Physician Profiles. Profiles are "snapshots" of members' practice patterns showing how they managed osteoporosis including risk factor identification, bone mineral density testing, and therapies. Physician profiles were displayed graphically with a brief text summary. The profiles permitted anonymous comparisons of individual circle member data with their peers in their circle and with all the participating physicians in the project.
Phase 2: first educational intervention & first follow-up data collection
The educational intervention was initiated through a phase 2 Quality Circle meeting. The intervention consisted of two parts, 1) the presentation and discussion of baseline individual, group and overall Quality Circle Profiles. The profiles were provided to the members on-site. Then 2) educational materials related to the 2002 Osteoporosis Canada guidelines were distributed, discussed and an educational workshop was conducted. The facilitators led group discussions with their circles to identify barriers in managing osteoporosis as suggested by the guidelines and strategies to improve patient care. Following the educational intervention, a second phase of data collection was conducted by each member on additional patients using the follow-up Quality Circle collection form. Following the data collection period, the Steering Committee reviewed the findings, generated key learnings, and determined the next intervention.
Phase 3: first strategy implementation session
A strategy implementation meeting was conducted comparing individual, group and overall Quality Circle profiles from the baseline and first follow-up data collection periods. Discussions concerning the progress made by incorporating strategies identified in the prior phases of the project were shared among the group. Based on the major findings from the profiles, members discussed additional measures that should be implemented in their practices to increase alignment with the 2002 guidelines.
Phase 4: final educational intervention & final follow-up data collection
The final Quality Circle educational intervention meetings – phase 4 – were similarly designed to the first educational intervention meetings. However, the educational intervention focused on areas where the data showed physicians demonstrated suboptimal knowledge regarding the appropriate management of osteoporosis according the 2002 guidelines. Following the second educational intervention, data were collected by each physician on additional patients using the Quality Circle collection form.
Phase 5: final strategy implementation session
The final phase 5 strategy implementation meetings were similarly designed to the first strategy implementation meetings.
Procedures for data collection
Criteria for patient selection, screening & completion of the quality circle collection forms
Eligible patients met the following criteria: women 55 years of age and older, known to the physician, and attended at least two visits to the physician's clinic in the 24 months prior to enrollment. The screening of eligible patients was conducted by the clinic nurse to overcome the possibility of physician bias. At the end of each recruitment day, the nurse used the day's visit schedule to randomly select three or four medical charts of patients that met the study's eligibility criteria. After making the selection, the nurse placed the patient questionnaire into each patient chart and the family physician completed the form. Each form was one page and took approximately 5 minutes to complete. All forms were faxed to a central site and the information was incorporated in an electronic database for analysis. For each data collection period (phases one, two and four), a total of 25 different patients were randomly selected for evaluation. Over the course of the study, the forms were slightly modified to better capture important clinical data.
Multifaceted educational intervention
The educational intervention consisted of eight key components: 1) audit and feedback, where standardized Quality Circle Data Collection Forms were used to audit physicians' practices and physicians profiles were generated to provide feedback; 2) interactive small group discussions at all 5 Quality Circle meetings, where participants could safely reflect on their own practice patterns compared to their peers and compared to a gold standard; 3) use of opinion leaders who were local primary care physicians who not only served as meeting facilitators but as peers who thought the information being discussed was important; 4) reminders, where the standardized collection forms, being filled out repeatedly over a number of weeks, triggered thought on a patient's risk factors for fracture, bone mineral density utilization, and therapies; 5) multi-professional collaboration and community building where osteoporosis specialists attended each Quality Circle meeting to provide assistance in addressing clinical matters but also become personally known by circle members; 6) financial intervention of $10 for each completed standardized patient form; 7) patient directed interventions where the primary care physicians distributed Osteoporosis Canada information and educational tools for patient use; 8) and educational workshops built on needs assessments of the participants as defined by the data collected from participants own practices and focus group feedback from a cross-section of circle members. These interventions have been shown to be effective in changing behaviour [17–21].
A series of five Quality Circle Educational Intervention Workshops were developed by the Core Educational Committee consisting of members of the Osteoporosis Canada, Ontario College of Family physicians, leading physicians and scientists, and industry partners. The 2002 Osteoporosis Canada guidelines were used as the main evidence-based reference for the workshops. The workshops were developed to meet the identified needs of the cohort and required 60–90 minutes to administer during the circle meetings.
Risk factor assessment and bone densitometry
According to the Osteoporosis Canada 2002 guidelines, all postmenopausal women over the age of 50 years should be assessed for the presence of risk factors for osteoporosis. A patient was considered to be at high risk if they had one major or 2 or more minor risk factors for fracture. Low risk patients had at most one minor risk factor for fracture [9].
For individuals under the age of 65 years, a bone mineral density measurement is recommended for those who have at least one major, or 2 minor risk factors for future fracture (high risk). In addition, all women 65 years of age and older should have a bone mineral density test conducted because of the high risk of osteoporosis and fracture in this group [9].
Statistical analysis
The generalized estimating equations [22] approach was used to model differences in physician perceived certainty of risk factors for osteoporosis and appropriate utilization of bone mineral density testing pre and post educational intervention (first year of the study). An exchangeable correlation matrix was used for the analyses. Physicians' awareness of the following risk factors were examined: age 65 years and older; prior fragility fracture after age 40 years at the hip wrist, or spine; family history of fracture; menopause before age 45 years; any other major risk factor; and two or more minor risk factors. Generalized estimating equations method was used to take into account the clustered nature of the data; given that patients treated within a primary care physician should be correlated (clustered variable is the physician). For the model, the unit of analysis is the patient and the unit of inference is the physician. Separate models were conducted for the dependent variables, risk factor certainty and appropriate bone mineral density testing. Unadjusted and adjusted odds ratios (OR) and corresponding 95% confidence intervals (CI) are reported.
A physician was certain about a patient's particular risk factor if the physician indicate on the standardized form that the patient had (yes) or did not have (no) the risk factor. If the physician was unsure, the physician indicated uncertain on the standardized form. Appropriate bone mineral density testing was defined, based on the Osteoporosis Canada guidelines, as testing in those who have at least one major, or 2 minor risk factors for future fracture (high risk) or not testing in patients with one minor or no risk factors. Given that only those who were interested and willing to commit to the second year of the project completed year two of the study, the analyses were conducted for only the first year. Goodness-of-fit of each model was assessed using the method developed by Horton et al. [23].
All statistical analyses were performed using the SAS/STAT (version 9.1; SAS Institute Inc., Cary, North Carolina, USA) software package running on Windows XP Professional. The criterion for statistical significance was set at α 0.05.