Web references [as supplied by authors]

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Family medicine certification examination

Successful completion of family medicine certification examination is required for licensure as a primary care doctor in Quebec. Examination comprises the Canadian family physician certification examination and the Quebec objective structured clinical examination, both of which are completed at end of an accredited two year postgraduate training programme in family medicine.

Geographical area of residence

Urban (regions of Montréal, Québec, Laval, Montérégie), intermediate (regions of Lanaudière, Estrie, Saguenay-Lac-St-Jean, Laurentides, Mauricie-Bois-Francs, Outaouais) or rural-remote (regions of Chaudières-Appalaches, Abitibi-Témiscamingue, Gaspésie, Bas-Saint-Laurent, Côte-Nord, Nord-du-Québec, Kativik Terres-cries-de la Baie-James).

Table 3

Covariates significantly associated with mammography screening rates

Covariates that were significantly (P<0.05) associated with mammography screening rates, before inclusion of characteristics of doctor�s training, included being female (55.6/1000, 95% confidence interval 43.0 to 68.3), certification examination score (158/1000 per SD increase in score, 99 to 217), average household income (- 4.0/1000 per $10<thin>000 increase in income, - 6.2 to - 1.8), number of doctors seen in previous year compared with 1-5 doctors: (6-10 doctors, - 164.2/1000, 95% confidence interval - 205.3 to - 123.1), 11-15 doctors, - 226.8/1000, - 282.3 to - 171.3), 16-20 doctors, - 262.7/1000, - 353.9 to - 171.5), >20 doctors, - 295.6/1000, - 399.1 to 192.2), and ambulatory diagnostic group: chronic specialty unstable (- 650.3/1000, - 1241.9 to - 58.7). Practice population of graduates from different medical schools differed primarily in proportion of female graduates and number of doctors involved in medical management before first contact with study doctor in year.

Additional information

When certification examination score was excluded from model, to assess potential effect of adjusting for differences between graduates in period before and after transition that may have been due to differences in effectiveness of curriculum, only substantial changes in estimates were for Montreal graduates for mammography screening rate (difference in rates before and after transition: 12.5 (95% confidence interval - 19.8 to 44.9 ), as Montreal graduates in period after transition had lower certification examination scores (see table 1) than graduates in period before transition. Neither adjusted nor unadjusted differences in mammography screening rate were statistically significant.

Individual schools fitted by transitional period interactions to test whether differences before and after transition at Sherbrooke were significantly greater than differences at the three other medical schools. Change in mammography rates at Laval (- 42.7/1000, P=0.01) and Montreal (- 46.8/1,000, P=0.005) was significantly less than those at Sherbrooke in conventional multivariate regression analyses, but these interaction effects became non-significant after adjusting for clustering in generalised estimated equations analysis (Laval: - 37.5/1000, P=0.17; Montreal: - 36.0/1,000, P=0.19). Change in outcomes in period before and after transition was less at McGill than at Sherbrooke, but this difference was not statistically significant in cluster adjusted or conventional analyses.

Table 4

Covariates significantly associated with continuity of care and additional information

Covariates that were significantly (P<0.05) associated with continuity of care, before inclusion of characteristics of doctor�s training, included age and sex distribution of the practice; compared with women aged <20: women aged 21-40 (7.9%, 95% confidence interval 1.8% to 14.0%), women aged 41-65 (14.1%, 6.2% to 22.0%), women aged >65 (30.0%, 5.1% to 54.9%); compared with men aged <20: men aged 41-65 (26.5%, 15.9% to 37.1%), geographical access to care, proportion of patients more than 50 km from tertiary care centre (6.7%, 5.4% to 8.0%), average household income (- 0.3% per $10<thin>000 increase in income, 95% confidence interval - 0.5 to - 0.2), comorbidity values >1 (12.6%, 9.3% to 15.8%), ambulatory diagnostic groups: acute minor conditions (- 12.5%, - 16.6% to - 8.4%) acute major conditions (- 10.5%, - 15.4% to - 5.7%), conditions likely to recur (- 7.4%, - 12.3% to - 2.5%), eye or dental conditions (- 24.7%, - 35.6% to - 13.8%), prevention (18.6%, 15.5% to 21.7%), and admissions to hospital in year before first visit to study doctor (- 30.2%, - 3.8% to - 22.4%). Practice population of graduates from different medical schools differed primarily in access to health care, comorbidity of patients seen in practice population, and prior rates of admission to hospital.

Individual schools fitted by transitional period interactions to test whether differences before and after transition at Sherbrooke were significantly greater than differences at the other three medical schools. Change in continuity of care at Laval (- 2.5%, P=0.01) and Montreal (- 3.1%, P=0.001) was significantly less than at Sherbrooke in conventional multivariate regression analyses, but these interaction effects became non-significant after adjusting for clustering in generalised estimated equations analysis (Laval: - 2.5%, P=0.13; Montreal: - 2.5%, P=0.11). Change in outcomes in period before and after transition was less at McGill than at Sherbrooke, but this difference was not statistically significant in cluster adjusted or conventional analyses.

Table 5

Covariates significantly associated with prescribing and additional information

Covariates that were significantly (P<0.05) associated with disease specific minus symptom relief prescribing, before inclusion of characteristics of doctor�s training, included age and sex distribution of practice; compared with women aged 65-70, women age 70-5 (108.5/1000, 95% confidence interval 41.5 to 175.5), women aged >75 (63.4/1000, 16.5 to 110.3), compared with men aged 65-70, men aged 70-5 (94.1/1000, 18.4 to 169.9), Charlson comorbidity values >1 (40.6/1000, 8.3 to 72.8), and ambulatory diagnostic groups: chronic stable conditions (620.9/1000, 363.0 to 878.7), prevention (376.3/1000, 144.9 to 607.7). Practice population of graduates from different medical schools differed primarily in age distribution and comorbidity of patients seen in practice population.

Annual prescribing rates adjusted for doctor characteristics (sex, certification examination score, cumulative months of practice). Certification examination score was significantly (P<0.05) associated with contraindicated prescribing (- 2.3/1000 per SD increase in examination score, 95% confidence interval - 4.7 to 0). No adjustments were made for differences in practice population because prescription of relatively contraindicated drug is rarely justified by patient characteristics.

When certification examination score was excluded from model, to assess the potential effect of adjusting for differences between graduates in the period before and after transition that may have been due to differences in effectiveness of curriculum, estimated difference in outcome rates was only changed for Montreal graduates for disease specific compared with symptom relief prescribing rate (21.6/1000, 95% confidence interval 7.6 to 36.1), as Montreal graduates in period after transition had lower certification examination scores (see table 1) than graduates in period before transition.

Individual schools fitted by transitional period interactions to test whether differences before and after transition at Sherbrooke were significantly greater than differences at the other three medical schools for difference in disease specific and symptom relief prescribing rates. Change in Laval (- 25.3/1000, p=0.002) and McGill (- 24.1/1,000, p=0.05) was significantly less than at Sherbrooke in conventional multivariate regression analyses. After adjusting for clustering in generalised estimated equations analysis, these interaction effects were only significant for Laval (Laval: 25.9/1000, P=0.03; McGill: - 24.1, P=0.12).