PURPOSE In 2004, we undertook a consultation with Canadian primary health care experts to defi ne the attributes that should be evaluated in predominant and proposed models of primary health care in the Canadian context. METHOD Twenty persons considered to be experts in primary health care or recommended by at least 2 peers responded to an electronic Delphi process. The expert group was balanced between clinicians (principally family physicians and nurses), academics, and decision makers from all regions in Canada. In 4 iterative rounds, participants were asked to propose and modify operational defi nitions. Each round incorporated the feedback from the previous round until consensus was achieved on most attributes, with a fi nal consensus process in a face-to-face meeting with some of the experts. RESULTSOperational defi nitions were developed and are proposed for 25 attributes; only 5 rate as specifi c to primary care. Consensus on some was achieved early (relational continuity, coordination-continuity, family-centeredness, advocacy, cultural sensitivity, clinical information management, and quality improvement process). The defi nitions of other attributes were refi ned over time to increase their precision and reduce overlap between concepts (accessibility, quality of care, interpersonal communication, community orientation, comprehensiveness, multidisciplinary team, responsiveness, integration).CONCLUSION This description of primary care attributes in measurable terms provides an evaluation lexicon to assess initiatives to renew primary health care and serves as a guide for instrument selection. Med;5:336-344. DOI: 10.1370/afm.682. Ann Fam INTRODUCTIONH ealth systems based on a strong primary health care system are more effective and effi cient than those centered on specialty and tertiary care.1 In Canada, various national and provincial commissions on health care [2][3][4][5][6][7][8] concluded that strengthening and expanding primary health care will meet Canadians' needs for prompt access to comprehensive evidence-based services. Major initiatives have also been undertaken in New Zealand and the United Kingdom to strengthen primary health care. 9,10 As health systems worldwide engage in evaluation efforts to assess the impacts of primary health care renewal initiatives, there is a critical need to provide evaluation frameworks and tools to facilitate these efforts.An important starting point for evaluation is an operational defi nition of the dimension being evaluated. An operational defi nition is a description of a concept in measurable terms. It is used to remove ambiguity, to serve as a guide for the selection of measurement tools, and to reduce the likelihood of disparate results between different data collections. 337 AT T R IBU T ES O F PR IM A RY HE A LT H C A R Edevelop a common lexicon of operational defi nitions of attributes to be evaluated in predominant and emerging models of primary health care in Canada, but many of these defi nitions will be relevant to primary health care mode...

Given this significant association between family physician continuity of care and ED visits during the end-of-life, and given international trends to reform primary care, active planning of strategies to facilitate such continuity should be encouraged.

This study is concerned with methods to measure population-based indicators of quality end-oflife care. Using a retrospective cohort approach, we assessed the feasibility, validity and reliability of using administrative databases to measure quality indicators of end-of-life care in two Canadian provinces. The study sample consisted of all females who died of breast cancer between 1 January 1998 and 31 December 2002, in Nova Scotia or Ontario, Canada. From an initial list of 19 quality indicators selected from the literature, seven were determined to be fully measurable in both provinces. An additional seven indicators in one province and three in the other province were partially measurable. Tests comparing administrative and chart data show a high level of

This study demonstrates an association between family physician continuity of care and the location of death for those with advanced cancer. Such continuity should be fostered in the development of models of integrated service delivery for end-of-life care.

BACKGROUND Quality indicators (QIs) are tools designed to measure and improve quality of care. The objective of this study was to assess stakeholder acceptability of QIs of end‐of‐life (EOL) care that potentially were measurable from population‐based administrative health databases. METHODS After a literature review, the authors identified 19 candidate QIs that potentially were measurable through administrative databases. A modified Delphi methodology, consisting of multidisciplinary panels of cancer care health professionals in Nova Scotia and Ontario, was used to assess agreement on acceptable QIs of EOL care (n = 21 professionals; 2 panels per province). Focus group methodology was used to assess acceptability among patients with metastatic breast cancer (n = 16 patients; 2 groups per province) and bereaved family caregivers of women who had died of metastatic breast cancer (n = 8 caregivers; 1 group per province). All sessions were audiotaped, transcribed verbatim, and audited, and thematic analyses were conducted. RESULTS Through the Delphi panels, 10 QIs and 2 QI subsections were identified as acceptable indicators of quality EOL care, including those related to pain and symptom management, access to care, palliative care, and emergency room visits. When Delphi panelists did not agree, the principal reasons were patient preferences, variation in local resources, and benchmarking. In the focus groups, patients and family caregivers also highlighted the need to consider preferences and local resources when examining quality EOL care. CONCLUSIONS The findings of this study should be considered when developing quality monitoring systems. QIs will be most useful when stakeholders perceive them as measuring quality care. Cancer 2008. © 2008 American Cancer Society.