Accepting new patients who require opioids into family practice: results from the MAAP-NS census survey study.

BACKGROUND: Acceptance to a family practice is key to access and continuity of care. While Canadian patients increasingly report not being able to acquire acceptance to a family practice, little is known about the association between requiring opioids and acceptance. We aim to determine the proportion of family physicians who would accept new patients who require opioids and describe physician and practice characteristics associated with willingness to accept these patients. METHODS: Census telephone survey of family physicians' practices in Nova Scotia, Canada. MEASURES: physician (i.e., age, sex, years in practice) and practice (i.e., number/type of provider in the practice, care hours/week) characteristics and practice-reported willingness to accept new patients who require opioids. RESULTS: The survey was completed for 587 family physicians (83.7% response rate). 354 (60.3%) were taking new patients unconditionally or with conditions; 326 provided a response to whether they would accept new patients who require opioids; 91 (27.9%) reported they would not accept a new patient who requires opioids. Compared to family physicians who would not accept patients who require opioids, in bivariate analysis, those who would, tended to work in larger practices; had fewer years in practice; are female; and provided more patient care. The relationship to number of providers in the practice, having a nurse, and experience persisted in multivariate analysis. CONCLUSIONS: The strongest predictors of willingness to accept patients who require opioids are fewer years in practice (OR = 0.96 [95% CI 0.93, 0.99]) and variables indicating a family physician has support of a larger (OR = 1.19 [95% CI 1.00, 1.42]), interdisciplinary team (e.g., nurses, mental health professionals) (OR = 1.15 [95% CI 1.11, 5.05]). Almost three-quarters (72.1%) of surveyed family physicians would accept patients requiring opioids.

Practice patterns among early-career primary care (ECPC) physicians and workforce planning implications: protocol for a mixed methods study.

INTRODUCTION: Canadians report persistent problems accessing primary care despite an increasing per-capita supply of primary care physicians (PCPs). There is speculation that PCPs, especially those early in their careers, may now be working less and/or choosing to practice in focused clinical areas rather than comprehensive family medicine, but little evidence to support or refute this. The goal of this study is to inform primary care planning by: (1) identifying values and preferences shaping the practice intentions and choices of family medicine residents and early career PCPs, (2) comparing practice patterns of early-career and established PCPs to determine if changes over time reflect cohort effects (attributes unique to the most recent cohort of PCPs) or period effects (changes over time across all PCPs) and (3) integrating findings to understand the dynamics among practice intentions, practice choices and practice patterns and to identify policy implications. METHODS AND ANALYSIS: We plan a mixed-methods study in the Canadian provinces of British Columbia, Ontario and Nova Scotia. We will conduct semi-structured in-depth interviews with family medicine residents and early-career PCPs and analyse survey data collected by the College of Family Physicians of Canada. We will also analyse linked administrative health data within each province. Mixed methods integration both within the study and as an end-of-study step will inform how practice intentions, choices and patterns are interrelated and inform policy recommendations. ETHICS AND DISSEMINATION: This study was approved by the Simon Fraser University Research Ethics Board with harmonised approval from partner institutions. This study will produce a framework to understand practice choices, new measures for comparing practice patterns across jurisdictions and information necessary for planners to ensure adequate provider supply and patient access to primary care.

Case management in primary care for frequent users of healthcare services with chronic diseases and complex care needs: an implementation and realist evaluation protocol.

INTRODUCTION: Significant evidence in the literature supports case management (CM) as an effective intervention to improve care for patients with complex healthcare needs. However, there is still little evidence about the facilitators and barriers to CM implementation in primary care setting. The three specific objectives of this study are to: (1) identify the facilitators and barriers of CM implementation in primary care clinics across Canada; (2) explain and understand the relationships between the actors, contextual factors, mechanisms and outcomes of the CM intervention; (3) identify the next steps towards CM spread in primary care across Canada. METHODS AND ANALYSIS: We will conduct a multiple-case embedded mixed methods study. CM will be implemented in 10 primary care clinics in five Canadian provinces. Three different units of analysis will be embedded to obtain an in-depth understanding of each case: the healthcare system (macro level), the CM intervention in the clinics (meso level) and the individual/patient (micro level). For each objective, the following strategy will be performed: (1) an implementation analysis, (2) a realist evaluation and (3) consensus building among stakeholders using the Technique for Research of Information by Animation of a Group of Experts method. ETHICS AND DISSEMINATION: This study, which received ethics approval, will provide innovative knowledge about facilitators and barriers to implementation of CM in different primary care jurisdictions and will explain how and why different mechanisms operate in different contexts to generate different outcomes among frequent users. Consensual and prioritised statements about next steps for spread of CM in primary care from the perspectives of all stakeholders will be provided. Our results will offer context-sensitive explanations that can better inform local practices and policies and contribute to improve the health of patients with complex healthcare needs who frequently use healthcare services. Ultimately, this will increase the performance of healthcare systems and specifically mitigate ineffective use and costs.

'Meet and greet' intake appointments in primary care: a new pattern of patient intakes?

Background: Family physicians (FPs) are expected to take on new patients fairly and equitably and to not discriminate based on medical or social history. 'Meet and greet' appointments are initial meetings between physicians and prospective patients to establish fit between patient needs and provider scope of practice. The public often views these appointments as discriminatory; however, there is no empirical evidence regarding their prevalence or outcomes. Objectives: To determine the proportion of FPs conducting 'meet and greets' and their outcomes. Methods: Study design and setting: Census telephone survey of all FP practices in Nova Scotia (NS). Participants: Person who answers the FP office telephone. Main Outcomes: Proportion of FPs holding 'meet and greets'; proportion of FPs conducting 'meet and greets' who have ever decided not to continue seeing a patient after the meeting. Results: 9.2% of FPs accept new patients unconditionally; 51.1% accept new patients under certain conditions. Of those accepting patients unconditionally or with conditions, 46.9% require a 'meet and greet'; 41.8% have a first-come, first-serve policy. Among FPs who require a 'meet and greet', 44.0% decided, at least once, not to continue seeing a patient after the first meeting. Conclusion: 'Meet and greets' are common among FPs in NS and result in some patients not being accepted into practice. More research is needed to understand the intentions, processes, and outcomes of 'meet and greets'. We recommend that practice scope be made clear to prospective patients before their first visit, which may eliminate the need for 'meet and greets'.

Protocol for determining primary healthcare practice characteristics, models of practice and patient accessibility using an exploratory census survey with linkage to administrative data in Nova Scotia, Canada.

INTRODUCTION: There is little evidence on how primary care providers (PCPs) model their practices in Nova Scotia (NS), Canada, what services they offer or what accessibility is like for the average patient. This study will create a database of all family physicians and primary healthcare nurse practitioners in NS, including information about accessibility and the model of care in which they practice, and will link the survey data to administrative health databases. METHODS AND ANALYSIS: 3 census surveys of all family physicians, primary care nurse practitioners (ie, PCPs) and their practices in NS will be conducted. The first will be a telephone survey conducted during typical daytime business hours. At each practice, the person answering the telephone will be asked questions about the practice's accessibility and model of care. The second will be a telephone survey conducted after typical daytime business hours to determine what out-of-office services PCP practices offer their patients. The final will be a tailored fax survey that will collect information that could not be obtained in the first 2 surveys plus new information on scope of practice, practice model and willingness to participate in research. Survey data will be linked with billing data from administrative health databases. Multivariate regression analysis will be employed to assess whether access and availability outcome variables are associated with PCP and model of practice characteristics. Negative binomial regression analysis will be employed to assess the association between independent variables from the survey data and health system use outcomes from administrative data. ETHICS AND DISSEMINATION: This study has received ethical approval from the Nova Scotia Health Authority and the Health Data Nova Scotia Data Access Committee. Dissemination approached will include stakeholder engagement at local and national levels, conference presentations, peer-reviewed publications and a public website.

Does socio-economic status or having a chronic condition affect whether family physicians accept a new patient? A Nova Scotia population study.

OBJECTIVES: To determine whether socio-economic status (SES) and presence of a chronic condition are associated with the response a prospective patient receives when seeking a family physician (FP). METHODS: Scripted telephone calls (indicating higher or lower SES and presence or absence of a chronic condition) were made to all 327 FP offices in Nova Scotia (NS) requesting an appointment. The main outcome measures were the responses to callers seeking a FP: being accepted for an appointment or being offered further assistance if not accepted (e.g., walk-in clinic, alternative provider, and telehealth), as well as the callers' perception of the experience as positive, negative, or neutral. RESULTS: Only 9.9% of offices accepted callers as new patients. There were no statistically significant differences by SES or chronic condition in the proportion of calls resulting in an appointment. Callers indicating high SES were more likely to be provided further assistance than those with low SES (p = 0.06), and callers indicating a chronic condition reported a better overall experience than those without (p = 0.03). CONCLUSION: First contact accessibility for prospective new patients was low across NS. Lower SES was associated with fewer offers of additional assistance than higher SES. This is particularly troubling since those with lower SES may need additional support as they may have less access to resources and networks that could provide support. This study signals the need to improve general and equitable accessibility to primary care providers.