Screening for hypertension in adults: protocol for evidence reviews to inform a Canadian Task Force on Preventive Health Care guideline update.

PURPOSE: To inform updated recommendations by the Canadian Task Force on Preventive Health Care on screening in a primary care setting for hypertension in adults aged 18 years and older. This protocol outlines the scope and methods for a series of systematic reviews and one overview of reviews. METHODS: To evaluate the benefits and harms of screening for hypertension, the Task Force will rely on the relevant key questions from the 2021 United States Preventive Services Task Force systematic review. In addition, a series of reviews will be conducted to identify, appraise, and synthesize the evidence on (1) the association of blood pressure measurement methods and future cardiovascular (CVD)-related outcomes, (2) thresholds for discussions of treatment initiation, and (3) patient acceptability of hypertension screening methods. For the review of blood pressure measurement methods and future CVD-related outcomes, we will perform a de novo review and search MEDLINE, Embase, CENTRAL, and APA PsycInfo for randomized controlled trials, prospective or retrospective cohort studies, nested case-control studies, and within-arm analyses of intervention studies. For the thresholds for discussions of treatment initiation review, we will perform an overview of reviews and update results from a relevant 2019 UK NICE review. We will search MEDLINE, Embase, APA PsycInfo, and Epistemonikos for systematic reviews. For the acceptability review, we will perform a de novo systematic review and search MEDLINE, Embase, and APA PsycInfo for randomized controlled trials, controlled clinical trials, and observational studies with comparison groups. Websites of relevant organizations, gray literature sources, and the reference lists of included studies and reviews will be hand-searched. Title and abstract screening will be completed by two independent reviewers. Full-text screening, data extraction, risk-of-bias assessment, and GRADE (Grading of Recommendations Assessment, Development and Evaluation) will be completed independently by two reviewers. Results from included studies will be synthesized narratively and pooled via meta-analysis when appropriate. The GRADE approach will be used to assess the certainty of evidence for outcomes. DISCUSSION: The results of the evidence reviews will be used to inform Canadian recommendations on screening for hypertension in adults aged 18 years and older. SYSTEMATIC REVIEW REGISTRATION: This protocol is registered on PROSPERO and is available on the Open Science Framework (osf.io/8w4tz).

Characteristics of patients attached to near-retirement family physicians: a population-based serial cross-sectional study in Ontario, Canada.

OBJECTIVES: Population ageing is a global phenomenon. Resultant healthcare workforce shortages are anticipated. To ensure access to comprehensive primary care, which correlates with improved health outcomes, equity and costs, data to inform workforce planning are urgently needed. We examined the medical and social characteristics of patients attached to near-retirement comprehensive primary care physicians over time and explored the early-career and mid-career workforce's capacity to absorb these patients. DESIGN: A serial cross-sectional population-based analysis using health administrative data. SETTING: Ontario, Canada, where most comprehensive primary care is delivered by family physicians (FPs) under universal insurance. PARTICIPANTS: All insured Ontario residents at three time points: 2008 (12 936 360), 2013 (13 447 365) and 2019 (14 388 566) and all Ontario physicians who billed primary care services (2008: 11 566; 2013: 12 693; 2019: 15 054). OUTCOME MEASURES: The number, proportion and health and social characteristics of patients attached to near-retirement age comprehensive FPs over time; the number, proportion and characteristics of near-retirement age comprehensive FPs over time. SECONDARY OUTCOME MEASURES: The characteristics of patients and their early-career and mid-career comprehensive FPs. RESULTS: Patient attachment to comprehensive FPs increased over time. The overall FP workforce grew, but the proportion practicing comprehensiveness declined (2008: 77.2%, 2019: 70.7%). Over time, an increasing proportion of the comprehensive FP workforce was near retirement age. Correspondingly, an increasing proportion of patients were attached to near-retirement physicians. By 2019, 13.9% of comprehensive FPs were 65 years or older, corresponding to 1 695 126 (14.8%) patients. Mean patient age increased, and all physicians served markedly increasing numbers of medically and socially complex patients. CONCLUSIONS: The primary care sector faces capacity challenges as both patients and physicians age and fewer physicians practice comprehensiveness. Nearly 15% (1.7 million) of Ontarians may lose their comprehensive FP to retirement between 2019 and 2025. To serve a growing, increasingly complex population, innovative solutions are needed.

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.

The Feasibility of a Primary Care Based Navigation Service to Support Access to Health and Social Resources: The Access to Resources in the Community (ARC) Model.

Introduction: We established a patient centric navigation model embedded in primary care (PC) to support access to the broad range of health and social resources; the Access to Resources in the Community (ARC) model. Methods: We evaluated the feasibility of ARC using the rapid cycle evaluations of the intervention processes, patient and PC provider surveys, and navigator log data. PC providers enrolled were asked to refer patients in whom they identified a health and/or social need to the ARC navigator. Results: Participants: 26 family physicians in four practices, and 82 of the 131 patients they referred. ARC was easily integrated in PC practices and was especially valued in the non-interprofessional practices. Patient overall satisfaction was very high (89%). Sixty patients completed the post-intervention surveys, and 33 reported accessing one or more service(s). Conclusion: The ARC Model is an innovative approach to reach and support a broad range of patients access needed resources. The Model is feasible and acceptable to PC providers and patients, and has demonstrated potential for improving patients' access to health and social resources. This study has informed a pragmatic randomized controlled trial to evaluate the ARC navigation to an existing web and telephone navigation service (Ontario 211).

Primary care bonus payments and patient-reported access in urban Ontario: a cross-sectional study.

BACKGROUND: Rurality strongly correlates with higher pay-for-performance access bonuses, despite higher emergency department use and fewer primary care services than in urban settings. We sought to evaluate the relation between patient-reported access to primary care and access bonus payments in urban settings. METHODS: We conducted a cross-sectional, secondary data analysis using Ontario survey and health administrative data from 2013 to 2017. We used administrative data to calculate annual access bonuses for eligible urban family physicians. We linked this payment data to adult (≥ 16 yr) patient data from the Health Care Experiences Survey to examine the relation between access bonus achievement (in quintiles of the proportion of bonus achieved, from lowest [Q1, reference category] to highest [Q5]) and 4 patient-reported access outcomes. The average survey response rate to the patient survey during the study period was 51%. We stratified urban geography into large, medium and small settings. In a multilevel regression model, we adjusted for patient-, physician- and practice-level covariates. We tested linear trends, adjusted for clustering, for each outcome. RESULTS: We linked 18 893 respondents to 3940 physicians in 414 bonus-eligible practices. Physicians in small urban settings earned the highest proportion of their maximum potential access bonuses. Access bonus achievement was positively associated with telephone access (Q2 odds ratio [OR] 1.18, 95% confidence interval [CI] 0.98-1.42; Q3 OR 1.34, 95% CI 1.10-1.63; Q4 OR 1.46, 95% CI 1.19-1.79; Q5 OR 1.87, 95% CI 1.50-2.33), after hours access (Q2 OR 1.26, 95% CI 1.09-1.47; Q3 OR 1.46, 95% CI 1.23-1.74; Q4 OR 1.77, 95% CI 1.46-2.15; Q5 OR 1.88, 95% CI 1.52-2.32), wait time for care (Q2 OR 1.01, 95% CI 0.85-1.20; Q3 OR 1.17, 95% CI 0.97-1.41; Q4 OR 1.27, 95% CI 1.05-1.55; Q5 OR 1.63, 95% CI 1.32-2.00) and timeliness (Q2 OR 1.29, 95% CI 0.98-1.69; Q3 OR 1.29, 95% CI 0.94-1.77; Q4 OR 1.58, 95% CI 1.16-2.13; Q5 OR 1.98, 95% CI 1.38-2.82). When stratified by geography, we observed several of these associations in large urban settings, but not in small urban settings. Trend tests were statistically significant for all 4 outcomes. INTERPRETATION: Although the access bonus correlated with access in larger urban settings, it did not in smaller settings, aligning with previous research questioning its utility in smaller geographies. The access bonus may benefit from a redesign that considers geography and patient experience.

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.

Do Incentive Payments Reward The Wrong Providers? A Study Of Primary Care Reform In Ontario, Canada.

Primary care payment reform in the US and elsewhere usually involves capitation, often combined with bonuses and incentives. In capitation systems, providing care within the practice group is needed to contain costs and ensure continuity of care, yet this is challenging in settings that allow patient choice in access to services. We used linked population-based administrative databases in Ontario, Canada, to examine a substantial payment called the "access bonus" designed to incentivize primary care access and to minimize primary care visits outside of capitation practices. We found that the access bonus flowed disproportionately to physicians outside large cities and to those whose patients made fewer primary care visits, received less after-hours care, made more emergency department visits, and had higher adjusted ambulatory costs. Our findings indicate a lack of alignment between these payments and their intended purpose. Financial incentives should be prospectively evaluated and frequently revisited to ensure relevance, alignment with system goals, efficiency, and equity.

Serial liver transaminases have no prognostic value in non-alcoholic fatty liver disease.

Background: Routine measurement of liver transaminases is common in the general monitoring of patients with non-alcoholic fatty liver disease (NAFLD), but there is little data to support the utility of this practice. The aims of this study were to determine how alanine aminotransferase (ALT) results vary over time in patients with NAFLD; and to determine if serial measurement of ALT is a useful clinical marker for progression of NAFLD. Methods: Consecutive adult patients with NAFLD were followed prospectively in a tertiary liver disease clinic over a 15-year period. Clinicodemographic characteristics and the change in liver enzymes, liver function, and histopathology were followed over time. Paired t test, chi-square test, analysis of variance (ANOVA), and logistic regression were performed to assess the relationship between ALT and severity of NAFLD, or development of cirrhosis or hepatocellular carcinoma (HCC). Results/Conclusion: A change in liver transaminases over time is not a useful metric in predicting outcomes in patients with NAFLD. Additionally, all stages of NAFLD are equally responsive to standard medical interventions of advocating for weight loss and correcting metabolic disturbances.

Patients' perceptions of access to primary care: Analysis of the QUALICOPC Patient Experiences Survey.

OBJECTIVE: To gain a more comprehensive understanding of patients' perceptions of access to their primary care practice and how these relate to patient characteristics. DESIGN: Cross-sectional study. SETTING: Ontario. PARTICIPANTS: Adult primary care patients in Ontario (N = 1698) completing the Quality and Costs of Primary Care (QUALICOPC) Patient Experiences Survey. MAIN OUTCOME MEASURES: Responses to 11 access-related survey items, analyzed both individually and as a Composite Access Score (CAS). RESULTS: The mean (SD) CAS was 1.78 (0.16) (the highest possible CAS was 2 and the lowest was 1). Most patients (68%) waited more than 1 day for their appointment. By far most (96%) stated that it was easy to obtain their appointment and that they obtained that appointment as soon as they wanted to (87%). There were no statistically significant relationships between CAS and sex, language fluency, income, education, frequency of emergency department use, or chronic disease status. A higher CAS was associated with being older and being born in Canada, better self-reported health, and increased frequency of visits to a doctor. CONCLUSION: Despite criticisms of access to primary care, this study found that Ontario patients belonging to primary care practices have favourable impressions of their access. There were few statistically significant relationships between patient characteristics and access, and these relationships appeared to be weak.

Do First Generation Immigrant Adolescents Face Higher Rates of Bullying, Violence and Suicidal Behaviours Than Do Third Generation and Native Born?

We conducted a systematic review to examine first generation immigrant adolescents' likelihood of experiencing bullying, violence, and suicidal behaviours compared to their later-generation and native born counterparts, and to identify factors that may underlie these risks. Eighteen studies met full inclusion criteria. First generation immigrant adolescents experience higher rate of bullying and peer aggression compared to third generation and native counterparts. Refugee status and advanced parental age were associated with increased parent to child aggression among South East Asians. Family cohesion was associated with lower rates of violence. Suicidal ideation was lower across most immigrant adolescents' ethnicities, with the exception of Turkish and South Asian Surinamese female adolescents in the Netherlands. Bullying and peer aggression of immigrant children and adolescents and potential mitigating factors such as family cohesion warrant research and program attention by policymakers, teachers and parents.

The physical, developmental, and mental health needs of young children in child welfare by initial placement type.

The American Academy of Pediatrics recommends comprehensive assessments for children entering foster care. These children may be placed with biological parents, kin, or in nonrelative foster care. It is not known whether health-related needs differ by placement. Chart abstractions were conducted of child welfare and medical records of 1542 children, ages 3 months to 5 years 11 months, admitted to San Diego's sole emergency shelter/receiving facility from April 1, 1998, through June 30, 1999, for investigation of alleged maltreatment. Children were discharged to three placement types: biological parents (28.5%), kinship caregivers (28.4%), or nonrelative foster parents (43.1%). Overall, 86.7% of children studied demonstrated physical, developmental, or mental health needs, with more than half displaying two or more problems. More than half of the children had a "Suspect" score on the Denver-II; 70.3% of children with "Suspect" scores were found to have delay on a developmental evaluation. Almost one tenth of the sample were diagnosed with one or more mental health conditions. Few differences were found for physical, developmental, or mental health concerns by placement. Results suggest that young children placed with biological parents or in kinship care have similar needs to those of children placed with foster parents. This study confirms the importance of comprehensive assessments for young children removed from their homes, regardless of placement. It also illustrates a need for standardized assessment criteria, particularly for developmental and mental health status, and for collaborative care models for all young children entering the child welfare system, regardless of their placement following investigation.

Addressing the developmental and mental health needs of young children in foster care.

Research over the past two decades has consistently documented the high rates of young children entering the child protective services/child welfare system with developmental and mental health problems. There is an emerging evidence base for the role of early intervention services in improving outcomes for children with developmental and mental health problems in the general population that heavily relies on accurate and appropriate screening and assessment practices. The Child Welfare League of America, the American Academy of Pediatrics, and the American Academy of Child and Adolescent Psychiatry have all published guidelines concerning the importance of comprehensive assessments and appropriate referral to early intervention services for children entering out-of-home care. Recent federal legislation (P.L. 108-36) calls for increased collaboration between child welfare and public agencies to address the developmental and mental health needs of young children in foster care. This paper provides a framework for health, developmental, and mental health professionals seeking to partner with child welfare to develop and implement programs addressing these critical issues.