What factors are associated with the research productivity of primary care researchers in Canada? A qualitative study.

BACKGROUND: Research evidence to inform primary care policy and practice is essential for building high-performing primary care systems. Nevertheless, research output relating to primary care remains low worldwide. This study describes the factors associated with the research productivity of primary care researchers. METHODS: A qualitative, descriptive key informant study approach was used to conduct semi-structured interviews with twenty-three primary care researchers across Canada. Qualitative data were analyzed using reflexive thematic analysis. RESULTS: Twenty-three primary care researchers participated in the study. An interplay of personal (psychological characteristics, gender, race, parenthood, education, spousal occupation, and support), professional (mentorship before appointment, national collaborations, type of research, career length), institutional (leadership, culture, resources, protected time, mentorship, type), and system (funding, systematic bias, environment, international collaborations, research data infrastructure) factors were perceived to be associated with research productivity. Research institutes and mentors facilitated collaborations, and mentors and type of research enabled funding success. Jurisdictions with fewer primary care researchers had more national collaborations but fewer funding opportunities. The combination of institutional, professional, and system factors were barriers to the research productivity of female and/or racialized researchers. CONCLUSIONS: This study illuminates the intersecting and multifaceted influences on the research productivity of primary care researchers. By exploring individual, professional, institutional, and systemic factors, we underscore the pivotal role of diverse elements in shaping RP. Understanding these intricate influencers is imperative for tailored, evidence-based interventions and policies at the level of academic institutions and funding agencies to optimize resources, promote fair evaluation metrics, and cultivate inclusive environments conducive to diverse research pursuits within the PC discipline in Canada.

The role of Canadian family physicians in the response to the COVID-19 pandemic.

Context: In Canada, most medical care is delivered through front line, first contact primary care. As nations traverse the most significant health event in a century, it is important to understand how primary care has been engaged in the challenge. Objective: Assess the patterns of direct clinical patient care involvement of Canadian family physicians (FPs) in the response to the COVID-19 pandemic by province, age, remuneration model, and practice setting. Study Design: Online, self-report survey administered between April 7 and May 10, 2021. Survey invitations sent via email, with three reminders following initial contact. Setting or Dataset: The College of Family Physicians of Canada (CFPC) membership list was used to reach family physicians in diverse practice settings in all Canadian provinces and territories. Population studied: All active CFPC family physician (FP) members were included. Family medicine trainees and members with primary addresses outside Canada were excluded. Most FPs in Canada are CFPC members; 39,991 FPs received survey invitations; 3,409 replied, for an overall response rate of 9%. Outcome Measures: Percent of FPs engaged in the pandemic response, including performing COVID-19 testing, administering COVID-19 vaccines, and caring for COVID-19 patients. Results: Almost all FPs (99%) were in some way involved in the COVID-19 response. Most FPs (77%) were involved in direct clinical patient care (eg vaccination, testing, and/or caring for COVID-19 patients). In particular, 54% cared for COVID-19 patients and 15% vaccinated patients at their practice. Older FPs, FPs receiving remuneration only via fee-for-service, and FPs practicing in family medicine clinics only were less likely to be involved in the COVID-19 response. The findings also vary across jurisdiction. Conclusions: While most family physicians have been involved in the COVID-19 response, discrepancies exist across jurisdiction, ages, remuneration types, and practice models. These results suggest that there were obstacles to the full involvement of Canada's primary care system in the response to the pandemic. Evidence generated by this study points to factors that could enable a more responsive future primary health care system.

Pandemic reflection: Significant change is needed to tap into the power of primary care during times of crisis.

Context: As a front-line resource, primary care could function as an indispensable health system resource during pandemic crises. However, throughout COVID-19, Canada's primary care providers expressed concern over their ability to respond. This study investigates factors related to these concerns, suggesting key areas for future primary care system development. Objective: Assess specific areas where robust, well-supported primary care could contribute significantly to the health system's pandemic response, & factors that may have prevented it from doing so. Study Design: Online, self-report survey administered over 3 weeks, April-May, 2021. Survey invitations sent via email, with three reminders following initial contact. Setting or Dataset: The College of Family Physicians of Canada (CFPC) membership list was used to reach family physicians in diverse practice settings in all Canadian provinces and territories. Population studied: All active CFPC family physician (FP) members were included. Most FPs in Canada are CFPC members; 39,991 FPs received survey invitations; 3,409 replied, for an overall response rate of 9%. Outcome Measures: Percent of FP engaged in systems level, pandemic response measures, including: 1) reporting COVID-19 cases to public health authorities, 2) identifying priority patients for vaccination, 3) participating in COVID-19 task forces, & 4) contributing to COVID-19 research/clinical studies. Results: Overall, one-third (34%) of FPs say that family practices in their region report COVID-19 cases to public health authorities. Most FPs (55%) say that their practices have not been asked to identify priority cases for COVID-19 vaccination. Less than 1-in-5 (19%) FPs have been involved in COVID-19 advisory/planning committees, task forces or groups. Very few FPs (6%) contribute to COVID-19 research/clinical studies. Half of FPs (50%) are highly concerned about the lack of clarity from government regarding FP response to the pandemic. These findings vary across jurisdictions and practice/remuneration models. Conclusions: Canada's primary care system has not been adequately engaged in important COVID-19 response measures, including monitoring viral spread in the population, pandemic planning, vaccination roll out, and therapeutic research. Practice models and remuneration arrangements are related to primary care's responsiveness to the COVID-19 pandemic,& should be considered in future primary care health system development.

Mental health impact of COVID-19 on family doctors in Canada: one year after.

Context: A year after the pandemic outbreak, primary care providers continue to face extreme psychological pressure. This study gauges the mental health and burnout levels of family physicians during the third wave of the COVID-19 pandemic in Canada. Objective: Assess the levels of personal, professional and patient-related burnout of family physicians (FPs) in the response to the pandemic and explore demographic and work-related factors that may influence burnout levels. Study Design: Online, self-report survey administered between April 7 and May 10, 2021. Setting or Dataset: The College of Family Physicians of Canada's (CFPC) list of all active members was used to reach family physicians in diverse practice settings in all Canadian provinces and territories. Population studied: All active CFPC family physician (FP) members were included. Family medicine trainees and members with primary addresses outside Canada were excluded. Most FPs in Canada are CFPC members; 39,991 FPs received survey invitations; 3,409 replied, for an overall response rate of 9%. Outcome Measures: The study used the Copenhagen Burnout Inventory (CBI) which measures the level of personal, work-related and patient-related burnout. As well, question asking about FP's overall sense of well being and personal wellness which were asked in a previous survey, a year prior, were incorporated to allow for longitudinal comparison. Results: 15% of FPs reported feeling burned out and thinking of, or have taken, a break from work, three times more than last year. More than one-fifth of FPs currently experience high or severe personal (22%) and work-related (21%) burnout, while 13% report the same levels of patient-related burnout. Female FPs report higher levels of personal burnout (26%, 17%) and work-related burnout (23%, 16%) than male FPs. Generations Y (30%) and X (25%) are experiencing higher levels of personal burnout than Baby Boomers (14%) and Traditionalists (2%). Conclusions: Roughly 1-in-4 FPs in Canada are currently experiencing high or severe personal and work-related burnout. Compared with the survey results a year prior, the numbers are climbing rapidly, reflecting the serious challenges FPs facing during the pandemic. This study was designed to contribute to a better understanding of the extent of the problem, contributing factors and to assist in considering approaches to build effective support systems to improve the mental health of FPs.

Nurturing a culture of curiosity in family medicine and primary care: The Section of Researchers' Blueprint 2 (2018-2023).

OBJECTIVE: To describe Blueprint 2 (2018-2023), the 5-year strategic plan launched in 2018 by the Section of Researchers (SOR), as well as its guiding principles and the process used to develop it. COMPOSITION OF THE COMMITTEE: Blueprint 2 was co-created by many stakeholders from across Canada and led by the SOR Council (SORC). The process started with an external, commissioned program evaluation in 2017 of the effect of the first SOR Blueprint (2012-2017). The findings and recommendations arising from the evaluation were presented in a day-long facilitated invitational retreat, hosted by the SORC in September 2017 and involving 40 key stakeholders. METHODS: Blueprint 2 was created using a multi-pronged, participatory, and iterative process to ensure broad input and alignment with current and future opportunities and priorities. REPORT: Blueprint 2 incorporates 4 strategic priority areas, each supported by objectives and actions. The strategic priority areas are membership, capacity building, advocacy, and partnerships. This updated Blueprint provides a useful, membership-driven strategic plan specifically for the SOR. The implementation of its objectives will promote research and quality improvement and contribute to building a culture of curiosity. Blueprint 2 emphasizes research and quality improvement that emanate from the realities of everyday practice and are rooted in everyday work. At its core are patient- and community-oriented approaches; it also contributes to achieving the Quadruple Aim. These outcomes will further the integration of the scholar role into daily practice for family physicians and primary care clinicians and teams. CONCLUSION: The ability of family physicians to identify, study, and cite their own evidence is essential to establishing the value and effect of primary care, including family medicine, in relation to Canadians' health and the Canadian health care system.

Fracture risk and areal bone mineral density in adolescent females with anorexia nervosa.

OBJECTIVE: To (i) compare fracture prevalence in adolescent females with anorexia nervosa (AN) versus normal-weight controls and (ii) examine whether reductions in areal bone mineral density (aBMD) predict fracture risk in females with AN. METHOD: Four-hundred eighteen females (310 with active AN and 108 normal-weight controls) 12- to 22-years-old were studied cross-sectionally. Lifetime fracture history was recorded by a physician during participant interviews. Body composition and aBMD measurements of the whole body, whole body less head, lumbar spine, and hip were assessed by dual-energy X-ray absorptiometry, and bone mineral apparent density (BMAD) was calculated for the lumbar spine. RESULTS: Participants with AN and normal-weight controls did not differ for chronological age, sexual maturity, or height. The lifetime prevalence of prior fracture was 59.8% higher in those with AN as compared to controls (31.0% vs. 19.4%, p = 0.02), and the fracture incidence rate peaked in our cohort after the diagnosis of AN. Lower aBMD and lumbar BMAD were not associated with a higher prevalence of fracture in the AN or control group on univariate or multivariate analyses. Compared to controls, fracture prevalence was significantly higher in the subgroup of girls with AN who had normal aBMD or only modest reductions of aBMD (Z-scores > -1 or -1.5). DISCUSSION: This is the first study to show that the risk of fracture during childhood and adolescence is significantly higher in patients with AN than in normal-weight controls. Fracture prevalence is increased in this cohort of participants with AN even without significant reductions in aBMD.

Hip structural analysis in adolescent boys with anorexia nervosa and controls.

CONTEXT: We have reported lower hip bone mineral density (BMD) in adolescent boys with anorexia nervosa (AN) compared with controls. Although studies have described bone structure in girls with AN, these data are not available for boys. Hip structural analysis (HSA) using dual-energy x-ray absorptiometry is a validated technique to assess hip geometry and strength while avoiding radiation associated with quantitative computed tomography. OBJECTIVE: We hypothesized that boys with AN would have impaired hip structure/strength (assessed by HSA) compared with controls. DESIGN AND SETTING: We conducted a cross-sectional study at a clinical research center. SUBJECTS AND INTERVENTION: We used HSA techniques on hip dual-energy x-ray absorptiometry scans in 31 previously enrolled boys, 15 with AN and 16 normal-weight controls, 12 to 19 years old. RESULTS: AN boys had lower body mass index SD score (P < .0001), testosterone (P = .0005), and estradiol (P = .006) than controls. A larger proportion of AN boys had BMD Z-scores <-1 at the femoral neck (60% vs 12.5%, P = 0008). Using HSA, at the narrow neck and trochanter region, boys with AN had lower cross-sectional area (P = .03, 0.02) and cortical thickness (P = .02, 0.03). Buckling ratio at the trochanter region was higher in AN (P = .008). After controlling for age and height, subperiosteal width at the femoral shaft, cross-sectional moment of inertia (narrow neck and femoral shaft), and section modulus (all sites) were lower in AN. The strongest associations of HSA measures were observed with lean mass, testosterone, and estradiol. On multivariate analysis, lean mass remained associated with most HSA measures. CONCLUSIONS: Boys with AN have impaired hip geometric parameters, associated with lower lean mass.

Physiologic estrogen replacement increases bone density in adolescent girls with anorexia nervosa.

Anorexia nervosa (AN) is prevalent in adolescents and is associated with decreased bone mineral accrual at a time critical for optimizing bone mass. Low BMD in AN is a consequence of nutritional and hormonal alterations, including hypogonadism and low estradiol levels. Effective therapeutic strategies to improve BMD in adolescents with AN have not been identified. Specifically, high estrogen doses given as an oral contraceptive do not improve BMD. The impact of physiologic estrogen doses that mimic puberty on BMD has not been examined. We enrolled 110 girls with AN and 40 normal-weight controls 12 to 18 years of age of similar maturity. Subjects were studied for 18 months. Mature girls with AN (bone age [BA] ≥15 years, n = 96) were randomized to 100 µg of 17ß-estradiol (with cyclic progesterone) or placebo transdermally for 18 months. Immature girls with AN (BA < 15 years, n = 14) were randomized to incremental low-dose oral ethinyl-estradiol (3.75 µg daily from 0 to 6 months, 7.5 µg from 6 to 12 months, 11.25 µg from 12 to 18 months) to mimic pubertal estrogen increases or placebo for 18 months. All BMD measures assessed by dual-energy X-ray absorptiometry (DXA) were lower in girls with AN than in control girls. At baseline, girls with AN randomized to estrogen (AN E + ) did not differ from those randomized to placebo (AN E-) for age, maturity, height, BMI, amenorrhea duration, and BMD parameters. Spine and hip BMD Z-scores increased over time in the AN E+ compared with the AN E- group, even after controlling for baseline age and weight. It is concluded that physiologic estradiol replacement increases spine and hip BMD in girls with AN.