Background: Chronic constipation is a common condition seen in family practice among the elderly and women. There is no consensus regarding its exact definition, and it may be interpreted differently by physicians and patients. Physicians prescribe various treatments, and patients often adopt different over-the-counter remedies. Chronic constipation is either caused by slow colonic transit or pelvic floor dysfunction, and treatment differs accordingly.Methods: To update our knowledge of chronic constipation and its etiology and best-evidence treatment, information was synthesized from articles published in PubMed, EMBASE, and Cochrane Database of Systematic Reviews. Levels of evidence and recommendations were made according to the Strength of Recommendation taxonomy.Results

Ontario's Family Health Team (FHT) model, implemented in 2005, may be North America's largest example of a patient-centered medical home. The model, based on multidisciplinary teams and an innovative incentive-based funding system, has been developed primarily from fee-for-service primary care practices. Nearly 2 million Ontarians are served by 170 FHTs. Preliminary observations suggest high satisfaction among patients, higher income and more gratifi cation for family physicians, and trends for more medical students to select careers in family medicine. Popular demand is resulting in expansion to 200 FHTs. We describe the development, implementation, reimbursement plan, and current status of this multidisciplinary model, relating it to the principles of the patient-centered medical home. We also identify its potential to provide an understanding of many aspects of primary care. 2011;9:165-171. doi:10.1370/afm.1228. Ann Fam Med INTRODUCTIONC anada, as does the United States, faces a crisis in primary care. In response, a number of primary care reform models have been developed across Canada during the past decade. Of these models, Ontario's Family Health Team (FHT) model, 1 begun in 2005, most closely mirrors the "Principles of the Patient-Centered Medical Home" as endorsed by the American Academy of Family Physicians, the American College of Physicians, the American Academy of Pediatrics, and the American Osteopathic Association. 2 We briefl y described this model in an online publication in the New England Journal of Medicine 3 and now provide a more complete description of FHTs' implementation, how FHTs achieve the joint principles of the patient-centered medical home, 2 and how the payment model provides incentives to achieve patient care goals. We further provide early fi ndings of their potential impact and discuss applicability of the model for the United States.Little information exists about wide implementation of medical homes or of their effi cacy in improving patient and physician satisfaction, increasing effi ciency, reducing costs, and improving outcomes. We believe a description of the FHT model provides useful information for the United States as it moves toward primary care reform. IMPLEMENTATION OF THE FHT MODEL IN ONTARIOIn 1969 Canada adopted a universal fi rst dollar health insurance program funded jointly by the provinces and the federal government. Each province assumed responsibility for its own health care system according to national guidelines. During its initial years, Ontario's health care system seemed well-funded and worked to the satisfaction of most Ontarians. By the mid 1980s, however, family physicians, the only primary care physician specialty in Canada, began to struggle to meet demands of their practices, and physician shortages began to appear. Most physicians were in solo or small-group fee-for-service practices. 166 ONTA RIO' S FA MILY HE A LT H T E A M M ODELto provide more visits in the face of costs rising and incomes static or falling. Many physicians began to...

An invitational conference led by the World Organization of Family Doctors (Wonca) involving selected delegates from 34 countries was held in Kingston, Ontario, Canada, March 8 to12, 2003. The conference theme was "Improving Health Globally: The Necessity of Family Medicine Research." Guiding conference discussions was the value that to improve health care worldwide, strong, evidencebased primary care is indispensable. Eight papers reviewed before the meeting formed the basic material from which the conference developed 9 recommendations. Wonca, as an international body of family medicine, was regarded as particularly suited to pursue these conference recommendations:1. Research achievements in family medicine should be displayed to policy makers, health (insurance) authorities, and academic leaders in a systematic way. 2. In all countries, sentinel practice systems should be developed to provide surveillance reports on illness and diseases that have the greatest impact on the population's health and wellness in the community. 3. A clearinghouse should be organized to provide a central repository of knowledge about family medicine research expertise, training, and mentoring. 4. National research institutes and university departments of family medicine with a research mission should be developed. 5. Practice-based research networks should be developed around the world. 6. Family medicine research journals, conferences, and Web sites should be strengthened to disseminate research fi ndings internationally, and their use coordinated. Improved representation of family medicine research journals in databases, such as Index Medicus, should be pursued. 7. Funding of international collaborative research in family medicine should be facilitated. 8. International ethical guidelines, with an international ethical review process, should be developed in particular for participatory (action) research, where researchers work in partnership with communities. 9. When implementing these recommendations, the specifi c needs and implications for developing countries should be addressed.The Wonca executive committee has reviewed these recommendations and the supporting rationale for each. They plan to follow the recommendations, but to do so will require the support and cooperation of many individuals, organizations, and national governments around the world. S6IMPROVING HEALTH CARE GLOBALLY health care system for most people-is important. Most people receive formal medical care in primary care, 2,3 and it is in that setting most episodes of illness are treated. Family medicine is a key discipline of primary care, and in many countries family physicians are the only physicians directly accessible to the public. 4 Clinical decisions made on fi rst encounters often determine whether health care resources are appropriately used. 2,[5][6][7] Strengthening the knowledge base in primary care will contribute to better medical care for all.Against this background an invitational conference was organized by the World Organization of...

BackgroundUsing the Internet may prove useful in providing nutrition counselling and social support for patients with chronic diseases.ObjectiveWe evaluated the impact of Web-based nutrition counselling and social support on social support measures, anthropometry, blood pressure, and serum cholesterol in patients at increased cardiovascular risk.MethodsWe conducted a randomized controlled trial among patients with increased cardiovascular risk in Canadian family practices. During 8 months, patients in the intervention group and control groups received usual care. Patients in the intervention group also had access to a Web-based nutrition counselling and social support tool (Heartweb). Site use during the study was monitored. We measured social support, body mass index, waist/hip ratio, blood pressure, and cholesterol levels at baseline and at 4 and 8 months to assess the effectiveness of the intervention.ResultsWe randomized 146 patients into the Web-based intervention (n=73) or the control group (n=73). Within the Web-based intervention group, Heartweb was used by only 33% (24/73) of patients, with users being significantly younger than nonusers (P=.03). There were no statistically significant differences between the intervention group and the control group in changes in social support, anthropometry, blood pressure, and serum cholesterol levels.ConclusionsUptake of the Web-based intervention was low. This study showed no favourable effects of a Web-based nutrition counselling and social support intervention on social support, anthropometry, blood pressure, and serum cholesterol. Improvements in reach and frequency of site use are needed to increase the effectiveness of Web-based interventions.

A strong primary health care system is essential to provide effective and efficient health care in both resource-rich and resource-poor countries. Although a direct link has not been proven, we can reasonably expect better economic status when the health of the population is improved. Research in primary care is essential to inform practice and to develop better health systems and health policies. Among the challenges for primary care, especially in countries with limited resources, is the need to enhance the research capacity and to engage primary care clinicians in the research enterprise. These caregivers need to be an integral part of the research enterprise so the right questions will be asked, the results from research will be used in practice, and a scholarly and evidence-based approach to primary care will become the norm.The challenge of developing research in primary care can be met only by creating a strong infrastructure. This will include strengthening academic departments, enhancing links to researchers in other fields, improving training programs for future primary care researchers, developing more practicebased primary care research networks, and increasing funding for research in primary care. A greatly increased commitment on the part of international organizations both within and outside of primary care is needed, in particular those organizations involved with funding research. We provide suggestions to improve the global primary care research enterprise for the benefit of the world's population. A strong primary health care system is essential to provide effective and efficient health care in both resource-rich and in resource-poor countries. To improve equity in health it is vitally important to improve health services for the world's poorest and least healthy people.1 Among the challenges for developing a strong primary care system, especially in countries with limited resources, is that of developing research capacity in primary care. This capacity is needed to inform practice and to improve health systems and policies. This paper reviews the evidence supporting the role of the primary care system in providing effective and efficient health care, the need for primary care research to be part of this system, a description of the primary care research, and recommendations to strengthen the primary care research enterprise. The Strength of Primary Care Predicts a Population's Health StatusStudies of the value of health services have concluded that approximately half of the improvements in the health of populations in the past half century are attributable to health services, with other factors (geography, nutrition, public health measures) accounting for the remainder.2-4 Within the last 2 decades, several researchers have shown that the strength of the primary care component of health systems is positively related to most common indicators of population health status, including birth outcomes, potential years of life lost, ageadjusted death rates, and age-specific mortality rates. The benef...