Managing "socially admitted" patients in hospital: a qualitative study of health care providers' perceptions.

BACKGROUND: Emergency departments are a last resort for some socially vulnerable patients without an acute medical illness (colloquially known as "socially admitted" patients), resulting in their occupation of hospital beds typically designated for patients requiring acute medical care. In this study, we aimed to explore the perceptions of health care providers regarding patients admitted as "social admissions." METHODS: This qualitative study was informed by grounded theory and involved semistructured interviews at a Nova Scotia tertiary care centre. From October 2022 to July 2023, we interviewed eligible participants, including any health care clinician or administrator who worked directly with "socially admitted" patients. Virtual or in-person individual interviews were audio-recorded and transcribed, then independently and iteratively coded. We mapped themes on the 5 domains of the Quintuple Aim conceptual framework. RESULTS: We interviewed 20 nurses, physicians, administrators, and social workers. Most identified as female (n = 11) and White (n = 13), and were in their mid to late career (n = 13). We categorized 9 themes into 5 domains: patient experience (patient description, provision of care); care team well-being (moral distress, hierarchy of care); health equity (stigma and missed opportunities, prejudices); cost of care (wait-lists and scarcity of alternatives); and population health (factors leading to vulnerability, system changes). Participants described experiences caring for "socially admitted" patients, perceptions and assumptions underlying "social" presentations, system barriers to care delivery, and suggestions of potential solutions. INTERPRETATION: Health care providers viewed "socially admitted" patients as needing enhanced care but identified individual, institutional, and system challenges that impeded its realization. Examining perceptions of the people who care for "socially admitted" patients offers insights to guide clinicians and policy-makers in caring for socially vulnerable patients.

"Family doctors are also people": a qualitative analysis of how family physicians managed competing personal and professional responsibilities during the COVID-19 pandemic.

BACKGROUND: Family physicians (FPs) fill an essential role in public health emergencies yet have frequently been neglected in pandemic response plans. This exclusion harms FPs in their clinical roles and has unintended consequences in the management of concurrent personal responsibilities, many of which were amplified by the pandemic. The objective of our study was to explore the experiences of FPs during the first year of the COVID-19 pandemic to better understand how they managed their competing professional and personal priorities. METHODS: We conducted semi-structured interviews with FPs from four Canadian regions between October 2020 and June 2021. Employing a maximum variation sampling approach, we recruited participants until we achieved saturation. Interviews explored FPs' personal and professional roles and responsibilities during the pandemic, the facilitators and barriers that they encountered, and any gender-related experiences. Transcribed interviews were thematically analysed. RESULTS: We interviewed 68 FPs during the pandemic and identified four overarching themes in participants' discussion of their personal experiences: personal caregiving responsibilities, COVID-19 risk navigation to protect family members, personal health concerns, and available and desired personal supports for FPs to manage their competing responsibilities. While FPs expressed a variety of ways in which their personal experiences made their professional responsibilities more complicated, rarely did that affect the extent to which they participated in the pandemic response. CONCLUSIONS: For FPs to contribute fully to a pandemic response, they must be factored into pandemic plans. Failure to appreciate their unique role and circumstances often leaves FPs feeling unsupported in both their professional and personal lives. Comprehensive planning in anticipation of future pandemics must consider FPs' varied responsibilities, health concerns, and necessary precautions. Having adequate personal and practice supports in place will facilitate the essential role of FPs in responding to a pandemic crisis while continuing to support their patients' primary care needs.

Advice to future family physicians: findings from qualitative interviews with family medicine residents and early-career family physicians.

BACKGROUND: Canadians continue to report challenges accessing primary care. Practice choices made by primary care providers shape services available to Canadians. Although there is literature observing family medicine practice trends, there is less clarity on the reasoning underlying primary care providers' practice intentions. Advice offered by residents and early-career family physicians may reveal challenges they have experienced, how they have adapted to them, and strategies for new residents. In this paper, we examine advice family medicine residents and early-career family physicians would give to new family medicine residents. METHODS: Sixty early-career family physicians and thirty residents were interviewed as part of a mixed-methods study of practice patterns of family medicine providers in Canada. During qualitative interviews, participants were asked, "what advice would you give [a new family medicine resident] about planning their career as a family physician?" We inductively analyzed responses to this question. RESULTS: Advice consisted of understanding the current climate of family medicine (need for specialization, business management burden, physician burnout) and revealed reasons behind said challenges (lack of support for comprehensive clinic care, practical limitations of different practice models, and how payment models influence work-life balance). Subtheme analyses showed early-career family physicians being more vocal on understanding practical aspects of the field including practice logistics and achieving job security. CONCLUSION: Most advice mirrored current changes and challenges as well as revealing strategies on how primary care providers are handling the realities of practicing family medicine. Multi-modal systemic interventions may be needed to support family physicians throughout the changing reality of family medicine and ensure family medicine is an appealing specialty.

Assessing the impact of Canadian primary care research and researchers: Citation analysis.

OBJECTIVE: To describe the citation impact and characteristics of Canadian primary care researchers and research publications. DESIGN: Citation analysis. SETTING: Canada. PARTICIPANTS: A total of 266 established Canadian primary care researchers. MAIN OUTCOME MEASURES: The 50 most cited primary care researchers in Canada were identified by analyzing data from the Scopus database. Various parameters, including the number of publications and citations, research themes, Scopus h index, content analysis, journal impact factors, and field-weighted citation impact for their publications, were assessed. Information about the characteristics of these researchers was collected using the Google search engine. RESULTS: On average, the 50 most cited primary care researchers produced 51.1 first-author publications (range 13 to 249) and were cited 1864.32 times (range 796 to 9081) over 29 years. Twenty-seven publications were cited more than 500 times. More than half of the researchers were men (60%). Most were clinician scientists (86%) with a primary academic appointment in family medicine (86%) and were affiliated with 5 universities (74%). Career duration was moderately associated with the number of first-author publications (0.35; P=.013). Most research focused on family practice, while some addressed health and health care issues (eg, continuing professional education, pharmaceutical policy). CONCLUSION: Canada is home to a cadre of primary care researchers who are highly cited in the medical literature, suggesting that their work is of high quality and relevance. Building on this foundation, further investments in primary care research could accelerate needed improvements in Canadian primary care policy and practice.

Care-seeking experiences of unattached patients in the Canadian health care system: Qualitative study.

OBJECTIVE: To understand how lack of attachment to a regular primary care provider influences patients' outlooks on primary care, ability to address their health care needs, and confidence in the health care system. DESIGN: Qualitative descriptive study using semistructured interviews. SETTING: Canadian provinces of Nova Scotia, Ontario, and Quebec. PARTICIPANTS: Patients aged 18 years or older who were unattached or had become attached within 1 year of being interviewed and who resided in the province in which they were interviewed. METHODS: Forty-one semistructured interviews were conducted, during which participants were asked to describe how they had become unattached, their searches to find new primary care providers, their perceptions of and experiences with the centralized waiting list in their province, their experiences seeking care while unattached, and the impact of being unattached on their health and on their perceptions of the health care system. Interviews were transcribed and analyzed using a thematic approach. MAIN FINDINGS: Two main themes were identified in interviews with unattached or recently attached patients: unmet needs of unattached patients and the impact of being unattached. Patients' perceived benefits of attachment included access to care, longitudinal relationships with health care providers, health history familiarity, and follow-up monitoring and care coordination. Being unattached was associated with negative effects on mental health, poor health outcomes, decreased confidence in the health care system, and greater pre-existing health inequities. CONCLUSION: Having a regular primary care provider is essential to having access to high-quality care and other health care services. Attachment also promotes health equity and confidence in the public health care system and has broader system-level, social, and policy implications.

Factors influencing practice choices of early-career family physicians in Canada: a qualitative interview study.

BACKGROUND: Comprehensiveness of primary care has been declining, and much of the blame has been placed on early-career family physicians and their practice choices. To better understand early-career family physicians' practice choices in Canada, we sought to identify the factors that most influence their decisions about how to practice. METHODS: We conducted a qualitative study using framework analysis. Family physicians in their first 10 years of practice were recruited from three Canadian provinces: British Columbia, Ontario, and Nova Scotia. Interview data were coded inductively and then charted onto a matrix in which each participant's data were summarized by code. RESULTS: Of the 63 participants that were interviewed, 24 worked solely in community-based practice, 7 worked solely in focused practice, and 32 worked in both settings. We identified four practice characteristics that were influenced (scope of practice, practice type and model, location of practice, and practice schedule and work volume) and three categories of influential factors (training, professional, and personal). CONCLUSIONS: This study demonstrates the complex set of factors that influence practice choices by early-career physicians, some of which may be modifiable by policymakers (e.g., policies and regulations) while others are less so (e.g., family responsibilities). Participants described individual influences from family considerations to payment models to meeting community needs. These findings have implications for both educators and policymakers who seek to support and expand comprehensive care.

"There's nothing like a good crisis for innovation": a qualitative study of family physicians' experiences with virtual care during the COVID-19 pandemic.

BACKGROUND: Prior to the pandemic, Canada lagged behind other Organisation for Economic Cooperation and Development countries in the uptake of virtual care. The onset of COVID-19, however, resulted in a near-universal shift to virtual primary care to minimise exposure risks. As jurisdictions enter a pandemic recovery phase, the balance between virtual and in-person visits is reverting, though it is unlikely to return to pre-pandemic levels. Our objective was to explore Canadian family physicians' perspectives on the rapid move to virtual care during the COVID-19 pandemic, to inform both future pandemic planning for primary care and the optimal integration of virtual care into the broader primary care context beyond the pandemic. METHODS: We conducted semi-structured interviews with 68 family physicians from four regions in Canada between October 2020 and June 2021. We used a purposeful, maximum variation sampling approach, continuing recruitment in each region until we reached saturation. Interviews with family physicians explored their roles and experiences during the pandemic, and the facilitators and barriers they encountered in continuing to support their patients through the pandemic. Interviews were audio-recorded, transcribed, and thematically analysed for recurrent themes. RESULTS: We identified three prominent themes throughout participants' reflections on implementing virtual care: implementation and evolution of virtual modalities during the pandemic; facilitators and barriers to implementing virtual care; and virtual care in the future. While some family physicians had prior experience conducting remote assessments, most had to implement and adapt to virtual care abruptly as provinces limited in-person visits to essential and urgent care. As the pandemic progressed, initial forays into video-based consultations were frequently replaced by phone-based visits, while physicians also rebalanced the ratio of virtual to in-person visits. Medical record systems with integrated capacity for virtual visits, billing codes, supportive clinic teams, and longitudinal relationships with patients were facilitators in this rapid transition for family physicians, while the absence of these factors often posed barriers. CONCLUSION: Despite varied experiences and preferences related to virtual primary care, physicians felt that virtual visits should continue to be available beyond the pandemic but require clearer regulation and guidelines for its appropriate future use.

Changes in comprehensiveness of services delivered by Canadian family physicians: Analysis of population-based linked data in 4 provinces.

OBJECTIVE: To describe changes in the comprehensiveness of services delivered by family physicians across service settings and service areas in 4 Canadian provinces, to identify which settings and areas have changed the most, and to compare the magnitude of changes by physician characteristics. DESIGN: Descriptive analysis of province-wide, population-based billing data linked to population and physician registries. SETTING: British Columbia, Manitoba, Ontario, and Nova Scotia. PARTICIPANTS: Family physicians registered to practise in the 1999-2000 and 2017-2018 fiscal years. MAIN OUTCOME MEASURES: Comprehensiveness was measured across 7 service settings (home care, long-term care, emergency departments, hospitals, obstetric care, surgical assistance, anesthesiology) and in 7 service areas consistent with office-based practice (prenatal and postnatal care, Papanicolaou testing, mental health, substance use, cancer care, minor surgery, palliative home visits). The proportion of physicians with activity in each setting and area are reported and the average number of service settings and areas by physician characteristics is described (years in practice, sex, urban or rural practice setting, and location of medical degree training). RESULTS: Declines in comprehensiveness were observed across all provinces studied. Declines were greater for comprehensiveness of settings than for areas consistent with office-based practice. Changes were observed across all physician characteristics. On average across provinces, declines in the number of service settings and service areas were highest among physicians in practice 20 years or longer, male physicians, and physicians practising in urban areas. CONCLUSION: Declining comprehensiveness was observed across all physician characteristics, pointing to changes in the practice and policy contexts in which all family physicians work.

Influences on intentions for obstetric practice among family physicians and residents in Canada: an explorative qualitative inquiry.

BACKGROUND: Many family medicine residency graduates indicate a desire to provide obstetric care, but a low proportion of family physicians (FPs) provide obstetric care within their practice. This suggests personal preference alone may not account for the low proportion of FPs who ultimately provide full obstetric care. If decisionmakers plan to augment the number of FPs providing obstetric care, barriers to the provision of such care must first be identified. Within this paper, we explore the perspectives of both family practice residents and early-career FPs on the factors that shaped their decision to provide obstetric care. METHODS: In this qualitative study, we analyzed a subset of interview data from three Canadian provinces: British Columbia, Ontario, and Nova Scotia (n = 18 family practice residents; n = 39 early-career FPs). We used thematic analysis to analyze data relevant to obstetric care practice, applying the socio-ecological model and comparing themes across participant types, gender, and province. RESULTS: Participants described influences affecting their decision about providing obstetric care. Key influencing factors aligned with the levels of the socio-ecological model of public policy (i.e., liability), community (i.e., community needs), organizational (e.g., obstetric care trade-offs, working in teams, sufficient exposure in training), interpersonal practice preferences (i.e., impact on family life, negative interactions with other healthcare professionals), and individual factors (i.e., defining comprehensive care as "everything but obstetrics"). Many participants were interested in providing obstetric care within their practice but did not provide such care. Participants' decision-making around providing or not providing obstetric care included considerations of personal preferences and outside influences. CONCLUSIONS: Individual-level factors alone do not account for the decrease in the type and amount of obstetric care offered by FPs. Instead, FPs' choice to provide or not provide obstetric care is influenced by factors at higher levels of the socio-ecological model. Policymakers who want to encourage obstetric practice by FPs should implement interventions at the public policy, community, organizational, interpersonal, and individual levels.

"At the mercy of some of the regulations": the impact of the residency match and return of service requirement on the early-career decisions of international medical graduates in Canada.

BACKGROUND: Return-of-service (ROS) agreements require international medical graduates (IMGs) who accept medical residency positions in Canada to practice in specified geographic areas following completion of training. However, few studies have examined how ROS agreements influence career decisions. We examined IMG resident and early-career family physicians' perceptions of the residency matching process, ROS requirements, and how these factors shaped their early career decisions. METHODS: As part of a larger project, we conducted semi-structured qualitative interviews with early-career family physicians and family medicine residents in British Columbia, Ontario and Nova Scotia. We asked participants about their actual or intended practice characteristics (e.g., payment model, practice location) and factors shaping actual or intended practice (e.g., personal/professional influences, training experiences, policy environments). Interviews were transcribed verbatim and a thematic analysis approach was employed to identify recurring patterns and themes. RESULTS: For this study, we examined interview data from nine residents and 15 early-career physicians with ROS agreements. We identified three themes: IMGs strategically chose family medicine to increase the likelihood of obtaining a residency position; ROS agreements limited career choices; and ROS agreements delayed preferred practice choice (e.g., scope of practice and location) of an IMGs' early-career practice. CONCLUSIONS: The obligatory nature of ROS agreements influences IMG early-career choices, as they necessitate strategically tailoring practice intentions towards available residency positions. Existing analyses of IMGs' early-career practice choices neglect to distinguish between ROS and practice choices made independently of ROS requirements. Further research is needed to understand how ROS influences longer term practice patterns of IMGs in Canada.

Family physicians' perspectives on the impact of COVID-19 on preventative care in primary care: findings from a qualitative study.

INTRODUCTION: Health system disruptions, caused by unexpected emergencies such as disease outbreaks, natural disasters, and cybercrimes, impact the delivery of routine preventative care. As comprehensive care providers, family physicians (FPs) devote significant time to prevention. However, without emergency and pandemic plans in place in primary care, FPs face added barriers to prioritizing and sustaining preventative care when health systems are strained, which was evident during the COVID-19 pandemic. This study aims to describe FPs' experiences providing preventative care during the COVID-19 pandemic and their perceptions of the impacts of disrupted preventative care in primary care settings. METHODS: Using a qualitative descriptive approach, we conducted semistructured interviews with FPs across 4 provinces in Canada (i.e. Newfoundland and Labrador, Nova Scotia, Ontario, British Columbia) between October 2020 and June 2021 as part of a larger multiple case study. These interviews broadly explored the roles and responsibilities of FPs during the COVID-19 pandemic. Interviews were coded thematically and codes from the larger study were analysed further using an iterative, phased process of thematic analysis. RESULTS: Interviews averaged 58 min in length (range 17-97 min) and FPs had a mean of 16.9 years of experience. We identified 4 major themes from interviews with FPs (n = 68): (i) lack of capacity and coordination across health systems, (ii) patient fear, (iii) impacts on patient care, and (iv) negative impacts on FPs. Physicians voiced concerns with managing patients' prevention needs when testing availability and coordination of services was limited. Early in the pandemic, patients were also missing or postponing their own primary care appointments. Change in the provision and coordination of routine preventative care had negative impacts on both patients and physicians, affecting disease incidence/progression, physician workload, and psychological wellbeing. CONCLUSION: During the COVID-19 pandemic, upstream care efforts were impacted, and FPs were forced to reduce their provision of preventative care. FPs contribute direct insight to primary care delivery that can support pandemic planning to ensure preventative care is sustained during future emergencies.

Effectiveness of registered nurses on patient outcomes in primary care: a systematic review.

BACKGROUND: Globally, registered nurses (RNs) are increasingly working in primary care interdisciplinary teams. Although existing literature provides some information about the contributions of RNs towards outcomes of care, further evidence on RN workforce contributions, specifically towards patient-level outcomes, is needed. This study synthesized evidence regarding the effectiveness of RNs on patient outcomes in primary care. METHODS: A systematic review was conducted in accordance with Joanna Briggs Institute methodology. A comprehensive search of databases (CINAHL, MEDLINE Complete, PsycINFO, Embase) was performed using applicable subject headings and keywords. Additional literature was identified through grey literature searches (ProQuest Dissertations and Theses, MedNar, Google Scholar, websites, reference lists of included articles). Quantitative studies measuring the effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN) that reported related outcomes were included. Articles were screened independently by two researchers and assessed for bias using the Integrated Quality Criteria for Review of Multiple Study Designs tool. A narrative synthesis was undertaken due to the heterogeneity in study designs, RN-led interventions, and outcome measures across included studies. RESULTS: Forty-six patient outcomes were identified across 23 studies. Outcomes were categorized in accordance with the PaRIS Conceptual Framework (patient-reported experience measures, patient-reported outcome measures, health behaviours) and an additional category added by the research team (biomarkers). Primary care RN-led interventions resulted in improvements within each outcome category, specifically with respect to weight loss, pelvic floor muscle strength and endurance, blood pressure and glycemic control, exercise self-efficacy, social activity, improved diet and physical activity levels, and reduced tobacco use. Patients reported high levels of satisfaction with RN-led care. CONCLUSIONS: This review provides evidence regarding the effectiveness of RNs on patient outcomes in primary care, specifically with respect to satisfaction, enablement, quality of life, self-efficacy, and improvements in health behaviours. Ongoing evaluation that accounts for primary care RNs' unique scope of practice and emphasizes the patient experience is necessary to optimize the delivery of patient-centered primary care. PROTOCOL REGISTRATION ID: PROSPERO: International Prospective Register of Systematic Reviews. 2018. ID=CRD42 018090767 .

Effectiveness of registered nurses on system outcomes in primary care: a systematic review.

BACKGROUND: Internationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of registered nurses (RNs) within primary care teams. Although existing literature provides some information regarding RN contributions, further evidence on the impact of RNs towards quality and cost of care is necessary to demonstrate the contribution of this role on health system outcomes. In this study we synthesize international evidence on the effectiveness of RNs on care delivery and system-level outcomes in primary care. METHODS: A systematic review was conducted in accordance with Joanna Briggs Institute methodology. Searches were conducted in CINAHL, MEDLINE Complete, PsycINFO, and Embase for published literature and ProQuest Dissertations and Theses and MedNar for unpublished literature between 2019 and 2022 using relevant subject headings and keywords. Additional literature was identified through Google Scholar, websites, and reference lists of included articles. Studies were included if they measured effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN within the context of an independent or interdependent role) and reported outcomes of these interventions. Included studies were published in English; no date or location restrictions were applied. Risk of bias was assessed using the Integrated Quality Criteria for Review of Multiple Study Designs tool. Due to the heterogeneity of included studies, a narrative synthesis was undertaken. RESULTS: Seventeen articles were eligible for inclusion, with 11 examining system outcomes (e.g., cost, workload) and 15 reporting on outcomes related to care delivery (e.g., illness management, quality of smoking cessation support). The studies suggest that RN-led care may have an impact on outcomes, specifically in relation to the provision of medication management, patient triage, chronic disease management, sexual health, routine preventative care, health promotion/education, and self-management interventions (e.g. smoking cessation support). CONCLUSIONS: The findings suggest that primary care RNs impact the delivery of quality primary care, and that RN-led care may complement and potentially enhance primary care delivered by other primary care providers. Ongoing evaluation in this area is important to further refine nursing scope of practice policy, determine the impact of RN-led care on outcomes, and inform improvements to primary care infrastructure and systems management to meet care needs. PROTOCOL REGISTRATION ID: PROSPERO: International prospective register of systematic reviews. 2018. ID= CRD42018090767 .

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada).

BACKGROUND: COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. METHODS: We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. RESULTS: We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults - pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. CONCLUSION: COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

Retention of visa-trainee post-graduate residents in Canada: a retrospective cohort study.

BACKGROUND: Visa trainees (international medical graduates [IMG] who train in Canada under a student or employment visa) are expected to return home after completing their training. We examine the retention patterns of visa trainee residents funded by Canadian (regular ministry and other), foreign, or mixed sources. METHODS: We linked data from the Canadian Post-MD Medical Education Registry with Scott's Medical Database for a retrospective cohort study. Eligible trainees were IMG visa trainees as of their first year of training, started their residency program no earlier than 2000, and exited training between 2006 and 2016. We used Cox regression to compare the retention of visa trainees by funding source. RESULTS: Of 1,913 visa trainees, 431(22.5%), 1353 (70.7%) and 129 (6.8%) had Canadian, foreign, or mixed funding, respectively. The proportion of trainees remaining in Canada decreased over time, with 35.5% (679/1913); 17.7% (186/1052); 10.8% (11/102) in Canada one, five, and ten years, respectively after their exit from PGME training. Trainees who remained on visas (HR: 1.91; [95% CI 1.59, 2.30]), were funded exclusively by foreign sources (HR: 1.46; [95% CI 1.25, 1.69]), and who had graduated from 'Western' countries (HR: 1.39; [95% CI 1.06, 1.84]) were more likely to leave Canada compared to trainees who became citizens/permanent residents, were funded by Canadian sources, or were visa graduates of Canadian medical schools, respectively. CONCLUSIONS: Most visa trainees leave Canada following their training. Trainees with Canadian connections (funding and/or change in legal status) were more likely to remain in Canada.

"Meet and greets" in family practice: Who, why, and to what end?

OBJECTIVE: To understand physician acceptance of new patients, specifically the use of "meet and greets"; and to explore FPs' rationale, beliefs, and processes regarding these appointments. DESIGN: Exploratory qualitative interviews. SETTING: Nova Scotia. PARTICIPANTS: A purposive sample of 12 FPs who had previously participated in the Models and Access to Primary Care Providers in Nova Scotia study. METHODS: In-depth, semistructured, 1-on-1 qualitative interviews. Interview transcripts were coded using Atlas.ti and analyzed for typologies and common themes regarding accepting practices. MAIN FINDINGS: Four typologies of accepting practices emerged: no form of meet and greet; nonscreening meet and greet to gather a history; meet and greet to assess alignment of patient needs and provider scope; and meet and greet to screen out undesirable patients. Typology 1 was subdivided: accepting first-come, first-served and accepting with previous patient knowledge. Rationale for each varied. Family physicians employing typologies 1 and 2 emphasized the importance of equitable access to primary care. Family physicians employing typologies 3 and 4 highlighted the challenges of meeting the needs of specific populations within the context of professional and systemic constraints. CONCLUSION: Meet and greets before accepting new patients are purposed differently across providers. Some FPs incorporate these meetings ethically; others present challenges to the principles of equity and nondiscrimination. Policy implications exist for how providers admit new patients and what resources might support more equitable access.

Health check guidelines and billing for family physicians caring for adults with intellectual and developmental disabilities: Incentives to improve care.

OBJECTIVE: To examine the degree to which Canadian consensus guideline recommendations for annual comprehensive preventive care assessments of adults with intellectual and developmental disabilities (IDD) are being taken up by Nova Scotia family physicians since the introduction of incentive billing codes; and to discuss the importance of complete physical examinations for this patient population, extra time needed in clinic encounters, and challenges for practitioners providing care. DESIGN: Analysis of family physicians' billing of codes 03.04C and 03.03E from April 2012 to December 2016. SETTING: Nova Scotia. PARTICIPANTS: Family physicians. MAIN OUTCOME MEASURES: Number of billings through fee-for-service and alternative payment plans, and number of providers who used these fee codes. RESULTS: Analysis yielded 3 key results. Use of incentivized billing codes for adult IDD visits and complete examinations in Nova Scotia has steadily increased for patients since the introduction of the modified codes. There is measurable uptake of the IDD adult visit code in total numbers and numbers of providers billing the code. There is poor uptake of the complete examination code. CONCLUSION: Enhanced billing codes will provide Nova Scotia family physicians with an incentive to employ the newly revised 2018 Canadian consensus guidelines in the care of adults with IDDs. With continued discussion and promotion of annual physical examinations for patients with IDD, more patients and caregivers might make this proactive care item a priority.

Family doctors providing home visits in Nova Scotia: Who are they and how often does it happen?

OBJECTIVE: To examine how FP and practice characteristics relate to the provision of home visits. DESIGN: Census survey linked to administrative billing data. SETTING: Nova Scotia, 2014 to 2015. PARTICIPANTS: Respondents to the family physician practice survey (N = 740; 84.5% response rate), the FP provider survey (N = 677; 56.7% response rate), and the nurse practitioner provider survey (N = 45; 68.9% response rate). MAIN OUTCOME MEASURES: Provision of home visits. Family physician characteristics included age, sex, and proximity to retirement; practice characteristics included patient age and practice rurality. RESULTS: Overall, 84.4% of surveyed FPs reported that they did home visits. In both survey data and billing data, older FPs were more likely to do home visits (P < .01). In multivariate analyses, older FP age, older patient age, rural practice location, and male FP sex were all independently associated with provision of any home visits and with the number of home visits (all P < .0001). Among FPs who had billed for home visits in the study year, the median (interquartile range [IQR]) number of visits was 16 (2 to 42); the range was 1 to 1265. Male FPs billed for more home visits (median [IQR] = 21 [7 to 54] visits) than female FPs (median [IQR] = 12 [4 to 30]) did (P < .001). Rural FPs had performed more home visits (median [IQR] = 29 [8 to 83]) than their urban counterparts (median [IQR] = 14 [5 to 36]) had (P < .001). CONCLUSION: Most FPs in Nova Scotia who responded to our survey reported doing home visits. This is an encouraging finding for the care of vulnerable older adults and runs counter to the widely held view that home visits are a dying art. Nevertheless, given that older male FPs are more likely to do home visits, there could be work force implications as these FPs retire. As the population ages, strategies to support home visits will be an important area for further research and policy development.

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.

Falls and long-term care: a report from the care by design observational cohort study.

BACKGROUND: Falls and the resulting complications are common among frail older adults. We aimed to explore risk factors and potential prevention strategies for falls in elderly residents of Long-Term Care Facilities (LTCF). METHODS: This was a cross sectional study design using data from the Care by Design (CBD) study, within Nova Scotia's Capital District Health Authority. This observational time series cohort study collected data before, during and after the implementation of CBD, a new model of coordinated primary care in LTCF. Here, we analyzed data collected after the implementation of CBD (September 1, 2011- February 28, 2012). RESULTS: Falls were frequent; 56.2% of our sample of 395 residents fell at least once. In univariate analyses, male gender (p = 0.009), dementia (p = 0.005), and use of Selective Serotonin Reuptake Inhibitors or Selective Serotonin-Norepinepherine Reuptake Inhibitors (SSRI/SNRI) (p = 0.084) showed statistically significant associations with having fallen. Benzodiazepine use appeared to be protective for falls (p = 0.058). In a fully adjusted multivariable linear regression model, dementia (ß coefficient 0.96, 95% CI: 0.83,1.84; p = 0.032), visual impairment (ß 0.84, 95% CI: 0.13,1.56; p = 0.021), and use of any PIMs (ß 0.34, 95% CI: 0.037,0.65; p = 0.028) were associated with increased risk of having fallen. Benzodiazepine use remained associated with reduced numbers of falls (p = 0.009), and SSRI/SNRI use was associated with increased numbers of falls (p = 0.007). Male gender was associated with increased falls in the model which excluded frailty (p = 0.022), though gender lost statistical significance once frailty was added to the model (p = 0.06). CONCLUSIONS: In our sample of LTCF residents, falls were common. Cognitive impairment, male gender, visual impairment, PIM use and use of SSRI/SNRI medications were associated with increased risk of falls, while benzodiazepine use appeared to be associated with a decreased risk of having fallen. Falls remain an important problem among LTC residents. Screening for falls during patient encounters is recommended, along with further research to identify risk factors and target interventions.