Practice Facilitation to Support Family Physicians in Encouraging COVID-19 Vaccine Uptake: A Multimethod Process Evaluation.

PURPOSE: We offered a practice facilitation intervention to family physicians in Ontario, Canada, known to have large numbers of patients not yet vaccinated against coronavirus disease 2019 (COVID-19). METHODS: We conducted a multimethod process evaluation embedded within a randomized controlled trial (clinical trial #NCT05099497). We collected descriptive statistics regarding engagement and qualitative interview data from family physicians and practice facilitators, as well as data from facilitator field notes. We analyzed and triangulated the data using thematic analysis and mapped barriers to and enablers for implementation to structural, organizational, physician, and patient factors. RESULTS: Of the 300 approached, 90 family physicians (30%) accepted facilitation. Of these, 57% received technical support to identify unvaccinated patients, 29% used trained medical student volunteers to contact patients on their behalf, and 30% used automated calling to reach patients. Key factors affecting engagement with the intervention were staff shortages owing to COVID-19 (structural), clinic characteristics such as technical issues and gatekeeping by staff, which prevented facilitators from talking with physicians (organizational), burnout (physician), and specialized populations that required targeted resources (patient). The facilitator's ability to address technical issues and connect family physicians with medical students helped with engagement. CONCLUSIONS: Strategies to help underresourced family physicians serving high-needs populations for issues of public health importance, such as vaccine promotion, must acknowledge the scarcity of physicians' time and provide new resources. To successfully engage family physicians, practice facilitators should seek to build trust and relationships over time, including with front-office staff.

Family Physicians Stopping Practice During the COVID-19 Pandemic in Ontario, Canada.

We conducted 2 analyses using administrative data to understand whether more family physicians in Ontario, Canada stopped working during the COVID-19 pandemic compared with previous years. First, we found 3.1% of physicians working in 2019 (n = 385/12,247) reported no billings in the first 6 months of the pandemic; compared with other family physicians, a higher portion were aged 75 years or older (13.0% vs 3.4%, P <0.001), had fee-for-service reimbursement (37.7% vs 24.9%, P <0.001), and had a panel size under 500 patients (40.0% vs 25.8%, P <0.001). Second, a fitted regression line found the absolute increase in the percentage of family physicians stopping work was 0.03% per year from 2010 to 2019 (P = 0.042) but 1.2% between 2019 to 2020 (P <0.001). More research is needed to understand the impact of physicians stopping work on primary care attachment and access to care.

Patient perspectives on the vital primary care role of community pharmacists in Nova Scotia, Canada: qualitative findings from the PUPPY Study.

OBJECTIVES: Community pharmacists play an important role in primary care access and delivery for all patients, including patients with a family physician or nurse practitioner ("attached") and patients without a family physician or nurse practitioner ("unattached"). During the COVID-19 pandemic, community pharmacists were accessible care providers for unattached patients and patients who had difficulty accessing their usual primary care providers ("semi-attached"). Before and during the pandemic, pharmacist services expanded in several Canadian provinces. The aim of this qualitative study was to explore patient experiences receiving care from community pharmacists, and their perspectives on the scope of practice of community pharmacists. METHODS: Fifteen patients in Nova Scotia, Canada, were interviewed. Participant narratives pertaining to pharmacist care were analyzed thematically. KEY FINDINGS: Attached, "semi-attached," and unattached patients valued community pharmacists as a cornerstone of care and sought pharmacists for a variety of health services, including triaging and system navigation. Patients spoke positively about expanding the scope of practice for community pharmacists, and better optimization of pharmacists in primary care. CONCLUSIONS: System decision-makers should consider the positive role community pharmacists can play in achieving primary care across the Quintuple Aim (population health, patient and provider experiences, reducing costs, and supporting equity in health).

Trends in attachment to a primary care provider in Ontario, 2008-2018: an interrupted time-series analysis.

BACKGROUND: Attachment to a regular primary care provider is associated with better health outcomes, but 15% of people in Canada lack a consistent source of ongoing primary care. We sought to evaluate trends in attachment to a primary care provider in Ontario in 2008-2018, through an equity lens and in relation to policy changes in implementation of payment reforms and team-based care. METHODS: Using linked, population-level administrative data, we conducted a retrospective observational study to calculate rates of patients attached to a regular primary care provider from Apr. 1, 2008, to Mar. 31, 2019. We evaluated the association of patient characteristics and attachment in 2018 using sex-stratified, adjusted, multivariable logistic regression models and used segmented piecewise regression to evaluate changing trends before and after implementation of a policy that restricted physician entry to alternate models. RESULTS: Attachment increased from 80.5% (n = 10 352 385) in 2008 to 88.9% of the population (n = 12 537 172) in 2018, but was lower among people with low comorbidity, high residential instability, material deprivation, rural residence and recent immigrants. Inequities narrowed for recent immigrants, males and people with lower incomes over the study period, but disparities persisted for these groups. Attachment grew by 1.47% annually until 2014 (p < 0.0001), but was stagnant thereafter (annual percent change of 0.13, p = 0.16). INTERPRETATION: Lack of sustained progress in attachment followed reduced levels of physician entry to alternate funding models. Although disparities narrowed for many groups over the study period, persistent gaps remained for immigrants and people with lower incomes; targeted interventions and policy changes are needed to address these persistent gaps.

Relational Continuity, Physician Payment, and Team-Based Primary Care in the Canadian Health Care System.

PURPOSE: Continuity is a core component of primary care and known to differ by patient characteristics. It is unclear how primary care physician payment and organization are associated with continuity. METHODS: We analyzed administrative data from 7,110,036 individuals aged 16+ in Ontario, Canada who were enrolled to a physician and made at least 2 visits between October 1, 2017 and September 30, 2019. Continuity with physician and practice group was quantified using the usual provider of care index. We used log-binomial regression to assess the relationship between enrollment model and continuity adjusting for patient characteristics. RESULTS: Mean physician and group continuity were 67.3% and 73.8%, respectively, for patients enrolled in enhanced fee-for-service, 70.7% and 76.2% for nonteam capitation, and 70.6% and 78.7% for team-based capitation. These differences were attenuated in regression models for physician-level continuity and group-level continuity. Older age was the most notable factor associated with continuity. Compared with those 16 to 34, those 80 and older had 1.45 times higher continuity with their physician. CONCLUSION: Our results suggest that continuity does not differ substantially by physician payment or organizational model among primary care patients who are formally enrolled with a physician in a setting with universal health insurance.

Development and validation of an algorithm using health administrative data to define patient attachment to primary care providers.

PURPOSE: The authors developed and validated an algorithm using health administrative data to identify patients who are attached or uncertainly attached to a primary care provider (PCP) using patient responses to a survey conducted in Ontario, Canada. DESIGN/METHODOLOGY/APPROACH: The authors conducted a validation study using as a reference standard respondents to a community-based survey who indicated they did or did not have a PCP. The authors developed and tested health administrative algorithms against this reference standard. The authors calculated the sensitivity, specificity positive predictive value (PPV) and negative predictive value (NPV) on the final patient attachment algorithm. The authors then applied the attachment algorithm to the 2017 Ontario population. FINDINGS: The patient attachment algorithm had an excellent sensitivity (90.5%) and PPV (96.8%), though modest specificity (46.1%) and a low NPV (21.3%). This means that the algorithm assigned survey respondents as being attached to a PCP and when in fact they said they had a PCP, yet a significant proportion of those found to be uncertainly attached had indicated they did have a PCP. In 2017, most people in Ontario, Canada (85.4%) were attached to a PCP but 14.6% were uncertainly attached. RESEARCH LIMITATIONS/IMPLICATIONS: Administrative data for nurse practitioner's encounters and other interprofessional care providers are not currently available. The authors also cannot separately identify primary care visits conducted in walk in clinics using our health administrative data. Finally, the definition of hospital-based healthcare use did not include outpatient specialty care. PRACTICAL IMPLICATIONS: Uncertain attachment to a primary health care provider is a recurrent problem that results in inequitable access in health services delivery. Providing annual reports on uncertainly attached patients can help evaluate primary care system changes developed to improve access. This algorithm can be used by health care planners and policy makers to examine the geographic variability and time trends of the uncertainly attached population to inform the development of programs to improve primary care access. SOCIAL IMPLICATIONS: As primary care is an essential component of a person's medical home, identifying regions or high need populations that have higher levels of uncertainly attached patients will help target programs to support their primary care access and needs. Furthermore, this approach will be useful in future research to determine the health impacts of uncertain attachment to primary care, especially in view of a growing body of the literature highlighting the importance of primary care continuity. ORIGINALITY/VALUE: This patient attachment algorithm is the first to use existing health administrative data validated with responses from a patient survey. Using patient surveys alone to assess attachment levels is expensive and time consuming to complete. They can also be subject to poor response rates and recall bias. Utilizing existing health administrative data provides more accurate, timely estimates of patient attachment for everyone in the population.

Closing the indigenous health gap in Canada: Results from the TransFORmation of IndiGEnous PrimAry HEAlthcare delivery (FORGE AHEAD) program.

AIMS: TransFORmation of IndiGEnous PrimAry HEAlthcare Delivery (FORGE AHEAD) partnered with local clinical and community teams in 11 First Nations (FN) communities across Canada to develop quality improvement (QI) initiatives aimed at improving T2DM. METHODS: Pre-post mixed-methods case study design was used. The 18-month intervention included community and clinical readiness, development of a community diabetes registry and clinical system, and QI activities. Participants consisted of community members, 18 yrs and older, with diabetes. Changes in clinical outcomes and clinical practice guideline (CPG) recommendations were assessed pre and post intervention using multilevel regression (patients nested within communities) adjusted forindividual andcommunity baseline characteristics. RESULTS: No significant change in HbA1c orsBP, but a small reduction indBP(-0.75 mmHg, p < 0.05) and LDL (-0.09 mmol/L, p < 0.05) was observed in 2008 adults with T2DM (mean age: 60·5 (SD:14·6) years; female: 57·2%). Individuals not at CPG targets at baseline had significant reductions in: %HbA1c (N = 616): -0.40 (95%CI:-0·55,-0·24),sBP (N = 561): -7·67 mmHg (95%CI:-9·23, -5·72),dBP (N = 291): -7·46 mmHg (95%CI:-8·69, -6·26), LDL (N = 450): -0·37mmo/l (95%CI:-0·44, -0·29).Annual HbA1c (OR: 1·95; 95%CI:1·66, 2·29), BP (OR: 1·78; 95%CI:1·52, 2·09), LDL (OR: 1·27; 95%CI:1·10, 1·47) and CKD screening (OR: 6·37; 95%CI:5·16, 7·92)increased but retinopathy screening decreased (OR: 0·68; 95%CI:0·57, 0·82). No significant change in foot exams (OR: 0·97; 95%CI:0·76, 1·23) or BMI recordings (OR: 0·96; 95%CI:0·82, 1·12) was seen. Overall, individualsweremorelikely to receive ≥75% of CPG recommended services compared to baseline (OR: 1·51; 95%CI:1·27, 1·80). CONCLUSIONS: FORGE AHEAD is the first Canadian study to demonstrate that a FN community-led QI intervention can lead to diabetes improvements.

Response of rural physicians in a non-fee-for-service environment to acute increases in demand due to physician shortages.

INTRODUCTION: The Weeneebayko Health Ahtuskaywin (WHA) is an Aboriginal regional health authority serving a large remote region on the west coast of James Bay. The physicians are all paid on a non-fee-for-service basis. There are periods of acute shortage, periods of relative stability and periods when much of the care is provided by locum physicians. As a closed system, it is ideal for the investigation of physician response to periods of acute increases in demand for service. PURPOSE: This study investigated the relationships between staffing levels and service provision to describe the response of physicians to increased demand due to an acute shortage of physicians. It also looked at whether payment options affected these relationships. METHODS: Using an existing administrative database from WHA for the period 1999 to 2002, relationships between staffing levels and service provision were investigated. We looked at the relationship between total physician levels and the number of patients seen per family medicine clinic. We also studied the relationships between total physician staffing levels and the number of patients seen in clinic, in the emergency department (ED), and per ED shift. We also looked at some proxy measures for the level of intensity of the work, including the number of hospital inpatients, the number of medevacs per ED shift and the number of ED shifts per physician. Exploratory graphical analysis was conducted and was followed by linear regression for associations of interest. RESULTS AND CONCLUSION: During periods of decreased staffing, physicians saw more patients per clinic and ED shift, despite the lack of financial incentives. The study also clearly demonstrates the increased intensity of the workloads carried by rural physicians in times of staffing shortages as noted by increased numbers of ED shifts, increased numbers of medevacs per ED shift and the lack of a decline in inpatient numbers. This highlights the need for ongoing recruitment and retention efforts in rural and remote locations to ensure adequate physician staffing levels, if burnout is to be avoided.

Hospital admission rates and emergency department use in relation to glycated hemoglobin in people with diabetes mellitus: a linkage study using electronic medical record and administrative data in Ontario.

BACKGROUND: The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) collects extensive data on primary care patients but it currently does not gather reliable information on outcomes in other settings. The objectives of this study were to link electronic medical record (EMR) data from Ontario patients in the CPCSSN with administrative data from the Institute for Clinical Evaluative Sciences (ICES), to assess the representativeness of the CPCSSN population, and to identify people with diabetes in the CPCSSN data and describe their emergency department (ED) visits and hospital admissions over a 2-year period (2010-2012) by HbA1c level. METHODS: We conducted a cross-sectional study linking 2014 Ontario CPCSSN data with ICES administrative data and a retrospective cohort study using the 2014 data extraction linked with data from the Ontario health care registry, hospital discharge abstracts and a database of emergency department visits. Demographics of CPCSSN patients were compared with those of the Ontario population. Patients with a CPCSSN diagnosis of diabetes were compared by HbA1c category for ED visits, hospital admissions and diagnosis of diabetes-related complications. RESULTS: The linkage rate was 99%. We identified 12 358 patients with diabetes, 2356 of whom were missing data on HbAIc, for a final sample of 10 002. Patients with diabetes had a mean age of 64 years. Those with a higher HbA1c were younger, more likely to be male, had a lower income, had more comorbidities and were more likely to live in rural or suburban areas than patients with a lower HbA1c. Over the study period 31.8% of patients had 1 or more ED visits and 13.7% had a hospital admission for a diabetes-related complication. Patients with HbA1c greater than 8 had significantly more hospital admissions, ED visits and diabetes-related complications than patients with a lower HbA1c . INTERPRETATION: The linkage between EMR and administrative data was successful. In this study population, higher HbA1c values were associated with increased ED visits and hospital admissions, with an increasing gradient as HbA1c increased from less than 7% to greater than 8%.

Impact of a provincial quality-improvement program on primary health care in Ontario: a population-based controlled before-and-after study.

BACKGROUND: In Ontario, a province-wide quality-improvement program (Quality Improvement and Innovation Partnership [QIIP]) was implemented between 2008 and 2010 to support improved outcomes in Family Health Teams, a care model that includes many features of the patient-centred medical home. We assessed the impact of this program on diabetes management, colorectal and cervical cancer screening and access to health care. METHODS: We used comprehensive linked administrative data sets to conduct a population-based controlled before-and-after study. Outcome measures included diabetes process-of-care measures (test ordering, retinal examination, medication prescribing and completion of billing items specific to diabetes management), colorectal and cervical cancer screening measures and use of health care services (emergency department visits, hospital admission for ambulatory-care-sensitive conditions and rates of readmission to hospital). The control group consisted of Family Health Team physicians with at least 100 assigned patients during the study follow-up period (November 2009-February 2013). RESULTS: There were 53 physicians in the intervention group and 1178 physicians in the control group. Diabetes process-of-care measures improved more in the intervention group than in the control group: hemoglobin A1c testing 4.3% (95% confidence interval [CI] 1.2-7.5) more, retinal examination 2.5% (95% CI 0.8-4.4) more and preventive care visits 8.9% (95% CI 2.9-14.9) more. Medication prescribing also improved for use of statins (3.4% [95% CI 0.8-6.0] more) and angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers (4.1% [95% CI 1.8-6.4] more). Colorectal cancer screening improved 5.4% (95% CI 3.1-7.8) more in the intervention group than in the control group, and cervical cancer screening improved 2.7% (95% CI 0.9-4.6) more. There were no significant differences in any of the measures of use of health care services. INTERPRETATION: This large controlled evaluation of a broadly implemented quality-improvement initiative showed improvement for diabetes process of care and cancer screening outcomes, but not for proxy measures of access related to use of health care services.

Prevalence and management of osteoarthritis in primary care: an epidemiologic cohort study from the Canadian Primary Care Sentinel Surveillance Network.

BACKGROUND: Osteoarthritis is a common chronic condition that affects many older Canadians and is a considerable cause of disability. Our objective was to describe the epidemiology of osteoarthritis in patients aged 30 years and older using electronic medical records (EMRs) in a Canadian primary care population. METHODS: In this retrospective cohort study, we analyzed the EMRs of 207 610 patients over 30 years of age (extracted on December 31, 2012) who had at least one clinic visit during the preceding 2 years. We calculated the age-sex standardized prevalence of diagnosed osteoarthritis and its association with comorbidities and covariates available in the Canadian Primary Care Sentinel Surveillance Network database. RESULTS: The estimated prevalence of diagnosed osteoarthritis was 14.2% (15.6% among women, 12.4% among men). The diagnosis of osteoarthritis was associated with several comorbidities: hypertension (prevalence ratio [PR] 1.17, 95% confidence interval [CI] 1.15-1.18), depression (PR 1.26, 95% CI 1.22-1.3), chronic obstructive pulmonary disease (COPD) (PR 1.16, 95% CI 1.11-1.21) and epilepsy (PR 1.27, 95% CI 1.13-1.43). In addition, 56.6% of patients had received a prescription for a range of nonsteroidal anti-inflammatory drugs, 45% of which were topical. Opioid medications were prescribed to 33% of patients for pain management. CONCLUSION: Osteoarthritis is a common disease in middle-aged and older Canadians. It is more common in women than in men and is associated with comorbid conditions. Most patients with osteoarthritis received pharmacotherapy for inflammation and pain management. As the Canadian population ages, osteoarthritis will become an increasing burden for individuals and the health care system.

Chronic obstructive pulmonary disease in primary care: an epidemiologic cohort study from the Canadian Primary Care Sentinel Surveillance Network.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is mostly managed within primary care, but there is little Canadian evidence from this setting. This study was undertaken to determine the prevalence of physician-diagnosed COPD in primary care practices, and the degree of comorbidity with other chronic conditions, and to assess patterns of medication prescribing. METHODS: The Canadian Primary Care Sentinel Surveillance Network is a national "network of networks" whose member practices use electronic medical records (EMRs). At the time of the study, it included data from 444 physicians from 10 networks in 8 provinces. We conducted an epidemiologic cohort study of all patients who had EMR data collected by the network at the end of 2012. Validated case-finding algorithms were used to identify cases of COPD. We used descriptive statistics and multivariate modelling analyses to calculate the prevalence of COPD, its association with key demographic factors and comorbidities, and patterns of medication prescribing. RESULTS: The observed prevalence of COPD was 4.0% (10 043/250 346), which represents a population prevalence of 3.4% using age-sex standardization. Comorbidity was common, with prevalence ratios ranging from 1.1 for the presence of a single comorbid condition to 1.9 for 4 or more comorbid conditions. Anticholinergic agents (63%), short- (48%) and long-acting (38%) ß-agonists and inhaled corticosteroids (41%) were the most commonly used medications. INTERPRETATION: The prevalence of physician-diagnosed COPD in Canadian primary care practices was similar to that reported in other practice-based studies at about 3%-4%. Most patients had comorbid conditions and were taking multiple medications. EMR data may be useful to assess both the epidemiology and management of COPD in primary care practices.

Financial and work satisfaction: impacts of participation in primary care reform on physicians in ontario.

Governments in Ontario have promised family physicians (FPs) that participation in primary care reform would be financially as well as professionally rewarding. We compared work satisfaction, incomes and work patterns of FPs practising in different models to determine whether the predicted benefits to physicians really materialized. Study participants included 332 FPs in Ontario practising in five models of care. The study combined self-reported survey data with administrative data from ICES and income data from the Canada Revenue Agency. FPs working in non-fee-for-service (FFS) models had higher levels of work satisfaction than those in FFS models. Incomes were similar across groups prior to the advent of primary care reform. Incomes of family health network FPs rose by about 30%, while family health group FPs saw increases of about 10% and those in FFS experienced minimal changes or decreases. Self-reported change in income was not reliable, with only 47% of physicians correctly identifying whether their income remained stable, increased or decreased. The availability of a variety of FFS- and non-FFS-based payment options, each designed to accommodate physicians with different types or styles of practice, may be a useful tool for governments as they grapple with issues of physician recruitment and retention.