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Research

Wait times to rheumatology care for patients with rheumatic diseases: a data linkage study of primary care electronic medical records and administrative data

Jessica Widdifield, Sasha Bernatsky, J. Carter Thorne, Claire Bombardier, R. Liisa Jaakkimainen, Laura Wing, J. Michael Paterson, Noah Ivers, Debra Butt, Anne Lyddiatt, Catherine Hofstetter, Vandana Ahluwalia and Karen Tu
May 13, 2016 4 (2) E205-E212; DOI: https://doi.org/10.9778/cmajo.20150116
Jessica Widdifield
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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Sasha Bernatsky
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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J. Carter Thorne
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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Claire Bombardier
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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R. Liisa Jaakkimainen
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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Laura Wing
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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J. Michael Paterson
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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Noah Ivers
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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Debra Butt
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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Anne Lyddiatt
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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Catherine Hofstetter
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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Vandana Ahluwalia
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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Karen Tu
Department of Clinical Epidemiology (Widdifield, Bernatsky), McGill University Health Centre, Montréal, Que.; Department of Epidemiology, Biostatistics and Occupational Health (Widdifield, Bernatsky), McGill University, Montréal, Que.; Department of Rheumatology (Thorne), Southlake Regional Health Centre, Newmarket, Ont.; Departments of Family and Community Medicine (Jaakkimainen, Ivers, Butt, Tu) and Rheumatology (Bombardier), University of Toronto, Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.; Department of Family Medicine (Butt), Scarborough Hospital, Toronto, Ont.; Patient representative (Lyddiatt), Ingersoll, Ont.; Patient representative (Hofstetter), Toronto, Ont.; Department of Rheumatology (Ahluwalia), William Osler Health Centre, Brampton, Ont.
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Article Figures & Tables

Tables

    • View popup
    Table 1: Comparison of EMRALD study physicians and all primary care physicians in Ontario as of Mar. 31, 2014
    CharacteristicNo. (%) of physicians*
    EMRALD physicians
    n = 168
    All primary care physicians in Ontario†
    n = 8054
    Sex
        Female94 (56.0)3333 (41.4)
        Male74 (44.0)4721 (58.6)
    Age, yr
        < 3525 (14.9)500 (6.2)
        35-4457 (33.9)1643 (20.4)
        45-5436 (21.4)2425 (30.1)
        55-7946 (27.4)3471 (43.1)
        Unknown4 (2.4)15 (0.2)
    Medical training location
        Canada150 (89.3)5967 (74.1)
        Elsewhere/unknown18 (10.7)2087 (25.9)
    Practice location
        Rural32 (19.0)608 (7.5)
        Suburban39 (23.2)1313 (16.3)
        Urban97 (57.7)6133 (76.1)
    Practice model
        FHG or FHN18 (10.7)2795 (34.7)
        FHO136 (81.0)3525 (43.8)
        Other/unknown14 (8.3)1734 (21.5)
    Age, yr, mean (range)46.6 (28-69)52.2 (27-79)
    Years in practice, mean (range)15.2 (1-36)18.5 (0-45)
    Years since graduation, mean (range)19.9 (3-43)26.3 (2-65)

    Note: EMRALD = Electronic Medical Record Administrative data Linked Database, FHG = Family Health Group, FHN = Family Health Network, FHO = Family Health Organization.

    *Unless stated otherwise.

    †Primary care physicians whose practice was focused on primary care were defined as having a main specialty of general practice/family practice or community medicine/public health.

      • View popup
      Table 2: Patients' mean age and sex, by diagnosis at time of referral
      DiagnosisNo. of patientsAge, yr,
      mean ± SD
      Female,
      no. (%)
      All patients243053.0 ± 16.31682 (69.2)
      Osteoarthritis78756.4 ± 15.6554 (70.4)
      Systemic inflammatory rheumatic disease74553.4 ± 17.0427 (57.3)
          Rheumatoid arthritis12055.4 ± 15.884 (70.0)
          Inflammatory arthritis, other16750.9 ± 16.295 (56.9)
          Crystal arthropathy12261.3 ± 15.333 (27.0)
          Spondylitis/spondyloarthropathy7641.5 ± 15.231 (40.8)
          Psoriatic arthritis4452.9 ± 12.626 (59.1)
          Polymyalgia rheumatica6671.2 ± 9.241 (62.1)
          Vasculitis1952.7 ± 23.510 (52.6)
         Other systemic autoimmune rheumatic disease13145.3 ± 13.9107 (81.7)
      Regional musculoskeletal syndrome39552.2 ± 15.8286 (72.4)
      Chronic pain condition34646.5 ± 14.3298 (86.1)
      Osteoporosis4562.3 ± 15.238 (84.4)
      Other11246.3 ± 16.379 (70.5)
      • View popup
      Table 3: Main reasons for declined referrals
      ReasonNo. (%) of patients
      n = 2430
      Patient declined or missed consultation after first referral sent68 (2.8)
      Symptoms resolved6 (8.8)
      Patient choice21 (30.9)
      Patient unavailable/missed appointment26 (38.2)
      Rheumatologist declined consultation after first referral sent87 (3.6)
      Consulted only for certain conditions23 (26.4)
      Rheumatologist suggested alternative plan (e.g., pain clinic, another specialist)21 (24.1)
      No reason provided19 (21.8)
      Not accepting new patients10 (11.5)
      • View popup
      Table 4: Wait time from date of referral to rheumatologist consultation
      DiagnosisNo. of patientsNo. (%) seen by rheumatologist within:Wait time, d, median (IQR)Wait time percentile, d*
      4 wk6 wk3 mo6 mo9 mo12 mo50th90th
      All patients2430579 (23.8)846 (34.8)1414 (58.2)1839 (75.7)1963 (80.8)2015 (82.9)74 (27-101)57170
      Osteoarthritis787168 (21.3)249 (31.6)454 (57.7)601 (76.4)640 (81.3)661 (84.0)73 (30-103)62174
      Systemic inflammatory rheumatic disease745242 (32.5)333 (44.7)496 (66.6)597 (80.1)629 (84.4)643 (86.3)66 (18-84)43155
          Rheumatoid arthritis12046 (38.3)†57 (47.5)85 (70.8)95 (79.2)101 (84.2)104 (86.7)66 (15-81)37166
          Inflammatory arthritis, other16759 (35.3)†85 (50.9)117 (70.1)133 (79.6)139 (83.2)143 (85.6)55 (17-71)38128
          Crystal arthropathy12233 (27.0)51 (41.8)78 (63.9)101 (82.8)107 (87.7)108 (88.5)69 (24-93)52156
          Spondylitis/
          spondyloarthropathy
      7617 (22.4)24 (31.6)48 (63.2)†63 (82.9)65 (85.5)65 (85.5)62 (29-91)58146
          Psoriatic arthritis4411 (25.0)15 (34.1)†26 (59.1)38 (86.4)42 (95.4)43 (97.7)88 (30-117)56189
          Polymyalgia rheumatica6631 (47.0)36 (54.5)47 (71.2)54 (81.8)57 (86.4)58 (87.9)53 (11-64)27131
          Vasculitis1910 (52.6)12 (63.2)14 (73.7)14 (73.7)15 (78.9)15 (78.9)28 (11-39)1671
          Other systemic autoimmune rheumatic disease13135 (26.7)53 (40.5)81 (61.8)99 (75.6)103 (78.6)107 (81.7)62 (22-83)46137
      Regional musculoskeletal syndrome39599 (25.1)145 (36.7)240 (60.8)307 (77.7)323 (81.8)330 (83.5)68 (26-94)53152
      Chronic pain condition34651 (14.7)88 (25.4)161 (46.5)236 (68.2)263 (76.0)271 (78.3)90 (35-125)72204
      Osteoporosis45NR‡NR‡9 (20.0)24 (53.3)28 (62.2)28 (62.2)82 (74-156)118183
      Other11216 (14.3)27 (24.1)54 (48.2)74 (66.1)80 (71.4)82 (73.2)69 (40-110)69175

      Note: IQR = interquartile range, NR = not reportable.

      *The 50th percentile reflects that 50% of the patients had seen a rheumatologist within this time frame and 50% were still waiting; the 90th percentile reflects that 90% of patients had seen a rheumatologist within this time frame and 10% were still waiting.

      †Benchmark target = 100%.

      ‡Suppressed to protect privacy.

        • View popup
        Table 5: Median wait time from symptom onset to rheumatologist consultation for systemic inflammatory rheumatic diseases*
        VariableRheumatoid arthritis
        n = 101
        Inflammatory arthritis, other
        n = 147
        Crystal arthropathy
        n = 97
        Spondylitis/ spondylo-arthropathy
        n = 56
        Psoriatic arthritis
        n = 35
        Polymyalgia rheumatica
        n = 60
        Vasculitis
        n = 18
        Other systemic autoimmune rheumatic disease
        n = 96
        Median wait time (IQR), d
        Symptom onset to primary care visit†173
        (16-189)
        102
        (10-112)
        188
        (4-192)
        716
        (14-730)
        228
        (17-245)
        63
        (14-77)
        128
        (3-131)
        208
        (14-222)
        Primary care visit to referral‡115
        (14-128)
        125
        (11-136)
        353
        (20-373)
        173
        (7-181)
        513
        (15-528)
        123
        (15-138)
        73
        (7-80)
        181
        (7-188)
        Symptom onset to referral326
        (49-375)
        259
        (41-300)
        1326
        (48-1374)
        1342
        (63-1405)
        627
        (90-7167)
        238
        (55-293)
        293
        (33-325)
        855
        (44-899)
        Referral to rheumatologist consultation§66
        (15-81)
        55
        (17-71)
        69
        (24-93)
        62
        (29-91)
        88
        (30-117)
        53
        (11-64)
        28
        (11-39)
        62
        (22-83)
        Symptom onset to rheumatologist consultation327
        (83-410)
        260
        (91-350)
        1312
        (111-1423)
        1262
        (112-1374)
        680
        (125-805)
        240
        (81-321)
        608
        (59-667)
        940
        (113-1053)
        No. (%) of patients seen by rheumatologist within:
        3 mo from symptom onset24 (24)31 (21)15 (15)8 (14)NR¶17 (28)NR¶16 (17)
        6 mo from symptom onset42 (42)67 (46)34 (35)19 (34)12 (34)32 (53)7 (39)29 (30)
        9 mo from symptom onset50 (50)86 (59)44 (45)22 (39)15 (43)38 (63)8 (44)40 (42)
        12 mo from symptom onset60 (59)97 (66)46 (47)23 (41)17 (49)43 (72)10 (56)45 (47)

        Note: IQR = interquartile range, NR = not reportable.

        *Analyses confined to patients with date of symptom onset captured in their medical record.

        †Defined as first documentation of the complaint within the primary care medical record.

        ‡Defined as the date the referral was sent to the rheumatologist.

        §Defined as the first visit to the rheumatologist.

        ¶Suppressed to protect privacy.

          • View popup
          Table 6: Median wait time from referral to rheumatologist consultation, by patient's health service planning region (LHIN)
          LHIN no.LHINNo. (%) of patientsMedian wait time (IQR), dNo. of rheumatologists in 2009/10No. of rheumatologists per 100 000
          13North East190 (7.8)55.0 (37.0-92.0)< 60.2
          3Waterloo Wellington405 (16.7)77.5 (28.0-105.5)< 60.5
          1Erie St. ClairNR*NR*< 60.7
          5Central West90 (3.7)103.0 (41.0-144.0)< 60.8
          12North Simcoe Muskoka224 (9.2)77.5 (25.5-103.0)< 60.8
          9Central East184 (7.6)46.3 (32.0-78.3)120.9
          14North WestNR*NR*< 61.0
          2South West182 (7.5)146.5 (34.3-180.8)91.1
          6Mississauga Halton29 (1.2)65.0 (17.0-82.0)111.2
          8Central365 (15.0)72.3 (27.0-99.3)181.3
          10South East13 (0.5)125.2 (30.8-156.0)61.4
          4Hamilton Niagara Haldimand Brant67 (2.8)71.2 (24.3-95.5)191.6
          11Champlain166 (6.8)112.2 (49.8-162.0)191.8
          7Toronto Central509 (20.9)59.0 (15.0-74.0)505.2
          -All Ontario regions2430 (100.0)74.0 (27.0-101.0)1621.5

          Note: IQR = interquartile range, LHIN = Local Health Integration Network, NR = not reportable.

          *Suppressed to protect privacy.

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          Vol. 4, Issue 2
          23 Jun 2016
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          Wait times to rheumatology care for patients with rheumatic diseases: a data linkage study of primary care electronic medical records and administrative data
          Jessica Widdifield, Sasha Bernatsky, J. Carter Thorne, Claire Bombardier, R. Liisa Jaakkimainen, Laura Wing, J. Michael Paterson, Noah Ivers, Debra Butt, Anne Lyddiatt, Catherine Hofstetter, Vandana Ahluwalia, Karen Tu
          May 2016, 4 (2) E205-E212; DOI: 10.9778/cmajo.20150116

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          Wait times to rheumatology care for patients with rheumatic diseases: a data linkage study of primary care electronic medical records and administrative data
          Jessica Widdifield, Sasha Bernatsky, J. Carter Thorne, Claire Bombardier, R. Liisa Jaakkimainen, Laura Wing, J. Michael Paterson, Noah Ivers, Debra Butt, Anne Lyddiatt, Catherine Hofstetter, Vandana Ahluwalia, Karen Tu
          May 2016, 4 (2) E205-E212; DOI: 10.9778/cmajo.20150116
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