This project involved collaboration between the BETTER Program and the TAPESTRY (Teams Advancing Patient Experience: Strengthening Quality) Project. The goal of TAPESTRY is to promote optimal aging. Optimal aging within the TAPESTRY program means supporting people to move through life with good health in the best possible way: Being Alive Well.

The aim of this collaboration was to refine and integrate electronic versions of the BETTER Program tools (i.e. the BETTER App) into the TAPESTRY Application (or TAP-App) platform developed for use in the McMaster personal health record. Three primary care clinics, one in Alberta and two in Newfoundland & Labrador, will be asked pilot the e-tool enhanced BETTER approach and designate one or more personnel to undertake the role of Prevention Practitioner.

The Prevention Practitioner is a member of the team who receives training on the BETTER approach to chronic disease prevention and screening (CDPS), including shared decision-making and motivational interviewing. Using the BETTER App, and existing TAP-App tools as appropriate, the Prevention Practitioner worked directly with patients by inviting them to a special prevention visit at which an individualized “prevention prescription” was developed and patients were able to set their own CDPS goals. The Prevention Practitioner followed patients over time to assess their progress on their goals and their achievement/completion of the CDPS manoeuvers they were eligible to receive.

This project provided an opportunity to:

  1. Determine how CDPS information should be best collected from patients through the BETTER App, and TAP-App tools as appropriate,
  2. Understand the feasibility and usability of the BETTER App and TAP App tools from the perspectives of patients and primary care providers, and
  3. Explore how the BETTER and TAP Apps and processes can help inform the care delivered to patients.

The desired long-term goals of the TAPESTRY-BETTER collaboration are to enhance patients’ care by:

  1. Informing patients about their CDPS status through the use of the BETTER App and TAP App tools,
  2. Enhancing primary care providers/teams’ processes of care through the personalization of the CDPS care delivered to patients, and
  3. Increasing and streamlining the collaboration between patients and primary care.

For more information about the TAPESTRY project, please visit their website.

Through the BETTER Trial, we developed and tested a unique, comprehensive and integrated approach to chronic disease prevention and screening at the patient level.

To assess the adaptability, sustainability and effectiveness of the Prevention Practitioner intervention in other settings, including rural and remote settings, the BETTER approach was expanded into the Northwest Territories and Newfoundland & Labrador, and disseminated in Alberta, Ontario and Nova Scotia.

The BETTER 2 Program engaged patients, clinicians, researchers and policy-makers to develop an integrated, comprehensive, longitudinal and sustainable approach to chronic disease prevention and screening within the various settings. The BETTER 2 team also adapted and refined the BETTER tools, maneuvers, and training resources in order to increase feasibility and sustainability of the approach.

The specific aims of the BETTER 2 Program were:

  1. To expand the BETTER approach into three new jurisdictions and deepen the impact in the existing provinces by providing a framework, tools and resources to do chronic disease prevention and screening.
  2. To further adapt, revise and tailor the BETTER individual patient-level chronic disease prevention and screening intervention including the survey, tools, maneuvers and resources to each setting including remote, rural and disadvantaged populations (such as aboriginal populations and populations with mental illness and substance abuse).
  3. Evaluate the adapted BETTER individual patient intervention including a qualitative program evaluation of perceived effectiveness, facilitators and barriers, benefits and disadvantages in varied settings including remote, rural and disadvantaged populations.
  4. Synthesize BETTER knowledge products for translation, dissemination and exchange.
  5. To develop a sustainable coalition and linkages between primary care clinicians, researchers and policy-makers and evaluate the efforts of the Coalition for sustained work on chronic disease prevention and screening in primary care.

Each primary care setting wishing to implement the BETTER approach to chronic disease prevention and screening adapted the BETTER tools and approach to their setting and/or identified one or more personnel available to the practice to take on the role Prevention Practitioner. This individual:

  • Developed skills in chronic disease prevention and screening
  • Adapted the BETTER maneuvers and tools to their setting so that they are culturally relevant and sensitive
  • Identified resources to integrate into the practice
  • Developed a process within their setting for chronic disease prevention and screening
  • Identified which patients are ideal to target in their setting
  • Met with patients to develop individualized chronic disease prevention and screening prescriptions

More information about this implementation phase of the BETTER Program, can be found in our publications section.

For a downloadable version of the BETTER 2 Program Executive Summary, please click here.

The BETTER 2 Program Team (2012 – 2015)

Principal Investigators: Dr. Donna Manca and Dr. Eva Grunfeld
Co-Investigators: Dr. Kris Aubrey-Bassler and Dr. Kami Kandola
Dissemination Leads: Dr. Catherine Cervin, Dr. Emily Marshall, Dr. Nandini Natarajan, Dr. Sarah Newbery.
Collaborators: P. Corcoran-Mooney, D. Gallant.
Methodology Working Group: E. Grunfeld (Co-Chair), D. Manca (Co-Chair), K. Aubrey-Bassler, V. Faria, K. Kandola, P. Krueger, C. Meaney, R. Moineddin, C. Nykiforuk, N. Sopcak.
Qualitative Methodology Working Group: N. Sopcak (Lead), C. Aguilar, L. Green, E. Grunfeld, P. Krueger, D. Manca, E. Marshall, C. Nykiforuk, M.A. O’Brien, G. Salvalaggio.
Clinical Working Group: D. Campbell-Scherer (Chair), K. Aubrey-Bassler, J. Carroll, V. Faria, E. Grunfeld, J. Inman, K. Kandola, D. Klein, C. Korownyk, L. Lyall, D. Manca, J. Mercer, J. Neudorf, G. Salvalaggio, G. Stagg-Sturge, M. Wilson.
Statistical Analysis: R. Moineddin, C. Meaney.
Program Coordination: C. Fernandes, J. Baxter, R. Cullen, V. Faria.
Research Assistant: M. Heatherington.
Students/Trainees: Y. Khakhuda, M. Lukasewich.

The purpose of the BETTER Trial was to determine whether prevention and screening for cancer and other chronic diseases such as diabetes and heart disease could be improved in the family practice setting.

BETTER was a pragmatic cluster randomized controlled trial (RCT) predicated on the Ontario Ministry of Health and Long Term Care’s Chronic Disease Prevention and Management Framework.

The setting for the BETTER Trial was eight, urban, Primary Care Team (PCT) practices in two Canadian jurisdictions (Toronto, Ontario and Edmonton, Alberta). PCTs are integrated primary care delivery models that include an inter-professional team. They work collaboratively to provide comprehensive, accessible, and coordinated primary healthcare to their rostered patients. The team typically comprises a combination of primary care physician (PCP), nurse practitioner, nurse, dietitian, pharmacist and other healthcare professional members.

Eight PCTs participated in BETTER, 4 in each jurisdiction, and 4 primary care physicians (PCPs) within each PCT participated as well, for a total of 32 PCPs (16 in each jurisdiction). Two PCTs in each jurisdiction were randomly allocated to the practice-level intervention arm. Within each PCT, two of the four participating Primary Care Physicians (PCPs) were randomly allocated to the patient-level intervention arm, for a total of 16 PCPs between both jurisdictions.

Better Trial Design Schema

Therefore, the two-way factorial design produced:

Patient-level Intervention – Internal Facilitation

The patient-level facilitation intervention involved 8 Prevention Practitioners (1 per PCT), who were healthcare professionals available within each PCT and chosen by the practice to undertake the role. The Prevention Practitioners received specialized training in the BETTER approach to evidence-based prevention and screening maneuvers and was responsible for meeting with patients one-on-one to assess their risk for chronic disease and helping them set chronic disease prevention and screening (CDPS) goals (i.e. the “Prevention Visit”). Through shared decision-making, the Prevention Practitioner and the patient developed a “Prevention Prescription” tailored specifically to that patient based on their medical and family history, and chronic disease risk. This personalized Prescription may have included referrals for screening procedures and/or referrals for lifestyle modification programs as appropriate.

Practice-level Intervention – External Facilitation

The practice-level facilitation intervention involved 2 Practice Facilitators (1 per jurisdiction), who were individuals from outside the practice, trained in the BETTER approach to CDPS. Each Practice Facilitator was trained by the Centre for Effective Practice (CEP) and Quality Improvement and Innovation Partnership (QIIP) to work with representatives of each PCT to develop CDPS care paths for each maneuver used in BETTER. Each Practice Facilitator assessed the practices’ use of their electronic medical record (EMR) and prepared a “Prevention Prescription” aimed to better enable the EMR for CDPS (e.g. patient invitation letters, audit and feedback, decision support) and tailored to the needs of each PCT, with a focus on optimizing the use of information tools and resources available to the practice.

BETTER Results

Recruitment for BETTER started in August 2010 and ended in March 2011, resulting in the enrollment of 789 patients aged 40-65. Analysis shows a strong positive effect of the patient-level facilitation intervention and a minor effect of the practice-level facilitation intervention.

Several outputs were also generated as a result of the BETTER Trial:

More information about the BETTER cluster randomized controlled trial, can be found in our publications section.

The BETTER trial was made possible through a financial contribution from Health Canada, through the Canadian Partnership Against Cancer’s Coalitions Linking Action & Science for Prevention (CLASP) initiative, and from the Heart and Stroke Foundation of Canada.

The BETTER Trial Team (2009 – 2012)

Principal Investigators: Dr. Eva Grunfeld and Dr. Donna Manca
Methodology Working Group: E. Grunfeld (Chair), D. Manca, R. Moineddin, K. Thorpe, M. Mamdani, P. Krueger.
Clinical Working Group: D. Campbell-Scherer (Chair), R. Barrett, S. Bell, S. Bible, S. Buchman, J. Carroll, M. Dhaliwal, S. Dunn, M. Griever, E. Grunfeld, C. Harrison, L. Hosford, M. Kahan, D. Klein, C. Korownyk, K. Lang-Robertson, D. Manca, J. Meuser, V. Mozgala, J. Pencharz, L. Radmanovich, J. Rogers, G. Salvalaggio, L. Schaar, R. Stoller, D.L. Vesik, R. Wymer, M. Yan.
Statistical Analysis: R. Moineddin, K. Thorpe, C. Meaney.
Trial Coordination: Applied Health Research Centre, L. Patterson, C. Fernandes.
Economic Analysis: J. Hoch, J. Beca.
Research Assistants: T.K. Dallman, K. Kam, M. Leyland, P. Patel, D. Sanderson, C. Wright.