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

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

The stable isotope hydrology of Sable Island, Nova Scotia, Canada with implications for evaluating the water budget of wild horses.

We investigated the stable isotope hydrology of Sable Island, Nova Scotia, Canada over a five year period from September, 2017 to August, 2022. The δ2H and δ18O values of integrated monthly precipitation were weakly seasonal and ranged from -66 to -15 ‰ and from -9.7 to -1.9 ‰, respectively. Fitting these monthly precipitation data resulted in a local meteoric water line (LMWL) defined by: δ2H = 7.22 ± 0.21 · δ18O + 7.50 ± 1.22 ‰. Amount-weighted annual precipitation had δ2H and δ18O values of -36 ± 11 ‰ and -6.1 ± 1.4 ‰, respectively. Deep groundwater had more negative δ2H and δ18O values than mean annual precipitation, suggesting recharge occurs mainly in the winter, while shallow groundwater had δ2H and δ18O values more consistent with mean annual precipitation or mixing of freshwater with local seawater. Surface waters had more positive values and showed evidence of isolation from the groundwater system. The stable isotopic compositions of plant (leaf) water, on the other hand, indicate plants use groundwater as their source. Fog had δ2H and δ18O values that were significantly more positive than those of local precipitation, yet had similar 17O-excess values. δ2H values of horsehair from 4 individuals lacked seasonality, but had variations typical to those of precipitation on the island. Differences in mean δ2H values of horsehair were statistically significant and suggest variations in water use may exist between spatially disparate horse communities. Our results establish an important initial framework for ongoing isotope studies of feral horses and other wildlife on Sable Island.

Reducing wait times and avoiding unnecessary use of high-cost mental health services through a Rapid Access and Stabilization Program: protocol for a program evaluation study.

BACKGROUND: Emergency psychiatric care, unplanned hospital admissions, and inpatient health care are the costliest forms of mental health care. According to Statistics Canada (2018), almost 18% (5.3 million) of Canadians reported needing mental health support. However, just above half of this figure (56.2%) have reported their needs were fully met. In light of this evidence there is a pressing need to provide accessible mental health services in flexible yet cost-effective ways. To further expand capacity and access to mental health care in the province, Nova Scotia Health has launched a novel mental health initiative for people in need of mental health care without requiring emergency department visits or hospitalization. This new service is referred to as the Rapid Access and Stabilization Program (RASP). This study evaluates the effectiveness and impact of the RASP on high-cost health services utilization (e.g. ED visits, mobile crisis visits, and inpatient treatments) and related costs. It also assesses healthcare partners' (e.g. healthcare providers, policymakers, community leaders) perceptions and patient experiences and satisfaction with the program and identifies sociodemographic characteristics, psychological conditions, recovery, well-being, and risk measures in the assisted population. METHOD: This is a hypothesis-driven program evaluation study that employs a mixed methods approach. A within-subject comparison (pre- and post-evaluation study) will examine health services utilization data from patients attending RASP, one year before and one year after their psychiatry assessment at the program. A controlled between-subject comparison (cohort study) will use historical data from a control population will examine whether possible changes in high-cost health services utilization are associated with the intervention (RASP). The primary analysis involves extracting secondary data from provincial information systems, electronic medical records, and regular self-reported clinical assessments. Additionally, a qualitative sub-study will examine patient experience and satisfaction, and health care partners' impressions. DISCUSSION: We expect that RASP evaluation findings will demonstrate a minimum 10% reduction in high-cost health services utilization and corresponding 10% cost savings, and also a reduction in the wait times for patient consultations with psychiatrists to less than 30 calendar days, in both within-subject and between-subject comparisons. In addition, we anticipate that patients, healthcare providers and healthcare partners would express high levels of satisfaction with the new service. CONCLUSION: This study will demonstrate the results of the Mental Health and Addictions Program (MHAP) efforts to provide stepped-care, particularly community-based support, to individuals with mental illnesses. Results will provide new insights into a novel community-based approach to mental health service delivery and contribute to knowledge on how to implement mental health programs across varying contexts.

Understanding the uptake of virtual care for first and return outpatient appointments in child and adolescent mental health services: a mixed-methods study.

OBJECTIVE: To describe patterns of virtual and in-person outpatient mental health service use and factors that may influence the choice of modality in a child and adolescent service. DESIGN: A pragmatic mixed-methods approach using routinely collected administrative data between 1 April 2020 and 31 March 2022 and semi-structured interviews with clients, caregivers, clinicians and staff. Interview data were coded according to the Consolidated Framework for Implementation Research (CFIR) and examined for patterns of similarity or divergence across data sources, respondents or other relevant characteristics. SETTING: Child and adolescent outpatient mental health service, Nova Scotia, Canada. PARTICIPANTS: IWK Health clinicians and staff who had participated in virtual mental healthcare following its implementation in March 2020 and clients (aged 12-18 years) and caregivers of clients (aged 3-18 years) who had received treatment from an IWK outpatient clinic between 1 April 2020 and 31 March 2022 (n=1300). Participants (n=48) in semi-structured interviews included nine clients aged 13-18 years (mean 15.7 years), 10 caregivers of clients aged 5-17 years (mean 12.7 years), eight Community Mental Health and Addictions booking and registration or administrative staff and 21 clinicians. RESULTS: During peak pandemic activity, upwards of 90% of visits (first or return) were conducted virtually. Between waves, return appointments were more likely to be virtual than first appointments. Interview participants (n=48) reported facilitators and barriers to virtual care within the CFIR domains of 'outer setting' (eg, external policies, client needs and resources), 'inner setting' (eg, communications within the service), 'individual characteristics' (eg, personal attributes, knowledge and beliefs about virtual care) and 'intervention characteristics' (eg, relative advantage of virtual or in-person care). CONCLUSIONS: Shared decision-making regarding treatment modality (virtual vs in-person) requires consideration of client, caregiver, clinician, appointment, health system and public health factors across episodes of care to ensure accessible, safe and high-quality mental healthcare.

What are effective vaccine distribution approaches for equity-deserving and high-risk populations during COVID-19? Exploring best practices and recommendations in Canada: protocol for a mixed-methods multiple case codesign study.

INTRODUCTION: The WHO has stated that vaccine hesitancy is a serious threat to overcoming COVID-19. Vaccine hesitancy among underserved and at-risk communities is an ongoing challenge in Canada. Public confidence in vaccine safety and effectiveness and the principles of equity need to be considered in vaccine distribution. In Canada, governments of each province or territory manage their own healthcare system, providing an opportunity to compare and contrast distribution strategies. The overarching objective of this study is to identify effective vaccine distribution approaches and advance knowledge on how to design and implement various strategies to meet the different needs of underserved communities. METHODS AND ANALYSIS: Multiple case studies in seven Canadian provinces will be conducted using a mixed-methods design. The study will be informed by Experience-Based CoDesign techniques and theoretically guided by the Socio-Ecological Model and the Vaccine Hesitancy Matrix frameworks. Phase 1 will involve a policy document review to systematically explore the vaccine distribution strategy over time in each jurisdiction. This will inform the second phase, which will involve (2a) semistructured, in-depth interviews with policymakers, public health officials, researchers, providers, groups representing patients, researchers and stakeholders and (2b) an analysis of population-based administrative health data of vaccine administration. Integration of qualitative and quantitative data will inform the identification of effective vaccine distribution approaches for various populations. Informed by this evidence, phase 3 of the study will involve conducting focus groups with multiple stakeholders to codesign recommendations for the design and implementation of effective vaccine delivery strategies for equity-deserving and at-risk populations. ETHICS AND DISSEMINATION: This study is approved by the University of Toronto's Health Sciences Research Ethics Board (#42643), University of British Columbia Behavioural Research Ethics Board (#H22-01750-A002), Research Ethics Board of the Nova Scotia Health Authority (#48272), Newfoundland and Labrador Health Research Ethics Board (#2022.126), Conjoint Health Research Ethics Board, University of Calgary (REB22-0207), and University of Manitoba Health Research Board (H2022-239). The outcome of this study will be to produce a series of recommendations for implementing future vaccine distribution approaches from the perspective of various stakeholders, including equity-deserving and at-risk populations.

Protocol for a longitudinal cohort study of Lyme disease with physical, mental and immunological assessment.

INTRODUCTION: There are limited data on the longitudinal impact of Lyme disease. Predictors of recovery have not been fully established using validated data collection instruments. There are sparse data on the immunological response to infection over time. METHODS AND ANALYSIS: This study is a longitudinal cohort study that will recruit 120 participants with Lyme disease in Ontario and Nova Scotia, Canada, with follow-up for up to 24 months. Data will be collected using the Short-Form 36 physical and mental component summaries, Depression and Anxiety Severity Scale Questionnaire, Fatigue Severity Scale and a battery of neuropsychological tests. Mononuclear cells, gene expression and cytokine profiling from blood samples will be used to assess immunological response. Analyses will include the use of non-linear mixed-effects modelling and proportional hazards models. ETHICS AND DISSEMINATION: Ethics approval has been obtained from ethics boards at McMaster University (Hamilton Integrated Research Ethics Board) (7564), Queens University (EMD 315-20) and Nova Scotia Health Research Ethics Board (1027173), and the study is enrolling participants. Written informed consent is obtained from all participants. The results will be disseminated by publication in a peer-reviewed journal and presented at a relevant conference. A brief report will be provided to decision-makers and patient groups.

Environmental and economic impacts of retrieved abandoned, lost, and discarded fishing gear in Southwest Nova Scotia, Canada.

Abandoned, lost, and discarded fishing gear (ALDFG), negatively impacts marine environments. Managing ALDFG in Atlantic Canada is challenging due to knowledge gaps on loss rates, locations, data availability/accuracy, impacts, and regulatory barriers for retrieval. This study removed ALDFG in Southwest Nova Scotia in collaboration with local fishers (with local knowledge and practical ALDFG removal expertise), government, non-profit organizations, and academia. A total of 29,298 kg of ALDFG was retrieved, including 24,630 kg using towed grapples covering ~3986 km of seafloor and 4668 kg from shorelines (comprising, 68 % lobster traps and 12 % dragger cable by weight). Traps ranged from <1 to 37 years old (median, 10 years). Traps continued to catch target and non-target species with 25 species released, including 652 individual lobsters (82 % were market-sized) and 57 fish (42 were species-at-risk). Based on estimated 2 % trap losses, annual commercial losses from ALDFG were $155,836 CAD in Lobster Fishing Area 34.

Views of leaders in under-represented and equity-denied communities on organ and tissue donation in Nova Scotia, Canada, in light of the Human Organ and Tissue Donation Act: a qualitative descriptive study.

OBJECTIVE: To explore the views of underserved and equity-denied communities in Nova Scotia, Canada, regarding organ and tissue donation and deemed consent legislation. DESIGN: A qualitative descriptive study was undertaken, employing both interviews and focus groups. SETTING: The province of Nova Scotia, Canada-the first jurisdiction in North America to implement deemed consent legislation for organ and tissue donation. PARTICIPANTS: Leaders of African Nova Scotian, Lesbian, Gay, Bisexual, Trans, Queer, Two Spirit (LGBTQ2S+) and Faith-based communities (Islam and Judaism) were invited to participate (n=11). Leaders were defined as persons responsible for community organisations or in other leadership roles, and were purposively recruited by the research team. RESULTS: Through thematic analysis, four main themes were identified: (1) alignment with personal values as well as religious beliefs and perspectives; (2) trust and relationships, which need to be acknowledged and addressed in the context of deemed consent legislation; (3) cultural competence, which is essential to the roll-out of the new legislation and (4) communication and information to combat misconceptions and misinformation, facilitate informed decision-making, and mitigate conflict within families. CONCLUSIONS: Leaders of African Nova Scotian, LGBTQ2S+ and Faith-based communities in Nova Scotia are highly supportive of deemed consent legislation. Despite this, many issues exemplify the need for cultural competence at all levels. These findings should inform ongoing implementation of the legislation and other jurisdictions considering a deemed consent approach to organ and tissue donation.

The Cost of a Nutritious Diet for Households Including People Living with HIV/AIDS in Nova Scotia: Findings and Lessons Learned by FoodNOW 2020 to 2022.

Purpose: FoodNOW (Food to eNhance Our Wellness) engaged in assessment of simulated households that include a person living with HIV/AIDS (PLWHA) in Nova Scotia to determine if a basic nutritious diet is affordable.Methods: We used supermarket websites to cost food and beverage items listed in the National Nutritious Food Basket (NNFB) for simulated households, each with a PLWHA. Food costing methodologies were co-developed and adapted with community members in response to barriers presented by the COVID-19 pandemic.Results: We found that simulated households, each with one PLWHA, that had a potential deficit after monthly expenses were a household of four on Income Assistance (-$1,058.70), a lone mother with two children on Income Assistance (-$973.65), a lone man on Income Assistance (-$677.40), and a household of four with one minimum-wage earner (-$383.45).Conclusions: Nova Scotia households with a PLWHA living on Income Assistance or with a minimum-wage earner cannot reasonably afford a nutritious diet in addition to basic household expenses. Using these food costing data can allow dietitians to efficiently inform government action and policy change to improve the health and wellness of individuals and families.

Effect of socioeconomic status on patients undergoing elective abdominal aortic aneurysm repair in a publicly funded health care system.

BACKGROUND: The association between socioeconomic status (SES) and outcomes after abdominal aortic aneurysm (AAA) repair in publicly funded health care systems is poorly described. The purpose of this study was to determine the effect of SES on postoperative outcomes in patients who underwent AAA repair in Nova Scotia, Canada. METHODS: We performed a retrospective analysis of all elective AAA repairs in Nova Scotia between November 2005 and March 2015 using administrative data sources. We compared postoperative 30-day outcomes and long-term survival across socio-economic quintiles, defined as the Pampalon Material Deprivation Index (MDI) and Social Deprivation Index (SDI). We also compared the relation between baseline characteristics, MDI quintile, SDI quintile and 30-day mortality. We used multivariable logistic regression and survival analysis to calculate adjusted 30-day mortality and long-term survival, respectively. RESULTS: A total of 1913 patients underwent AAA repair during the study period. The overall 30-day mortality rate was 2.6% (50 patients). Thirty-day outcomes including death (p = 0.8), stroke (p = 0.7), myocardial infarction (p = 0.06), length of stay (p = 0.3) and discharge disposition other than home (p = 0.8) were similar across MDI quintiles. Similarly, there was no statistically significant association between SDI quintile and postoperative outcomes. Multivariable analysis showed that age greater than 70 years (odds ratio [OR] 3.06, 95% confidence interval [CI] 1.55-6.06) and open repair (OR 3.22, 95% CI 1.59-6.52) but not MDI quintile (p = NS) or SDI quintile (p = NS) were associated with increased 30-day mortality. There was no effect of MDI or SDI quintile on long-term survival on univariable or multivariable analysis. CONCLUSION: Socioeconomic status does not appear to affect short- or long-term mortality after AAA repair in a publicly funded health care system. Further research is needed to address any existing gaps in screening and referral before repair.

"Oh, you're my health care provider?" Recounting the experiences of people of African descent in Nova Scotia pursuing or working in health professions.

BACKGROUND: Increasing, supporting and cultivating diversity in health programs is key to addressing health inequities. We sought to investigate barriers and facilitators that could affect enrolment and success in health professions among people of African descent in Nova Scotia, Canada. METHODS: We conducted semistructured interviews with people who self-identified as being of African descent who resided or grew up in Nova Scotia, who were working in or pursuing a career in a health profession, and who had participated in culturally specific mentorship programs. Semistructured interviews explored participant experiences that shaped their pursuit of a health profession, as a person of African descent. We thematically analyzed transcribed interviews using constructivist grounded theory. RESULTS: We interviewed 23 participants. Thematic coding showed 4 major themes. The theme of "stand on my shoulders" spoke to the importance of mentorship within the Black community. "Growing through pain" spoke to resilience amidst race-related challenges. "Never the student; ever the teacher" showed the repeated need to educate on issues of race or diversity. The final theme, "change," highlighted next steps, including the need for improvement in curricula, for development of Black faculty and for initiatives that offer support. INTERPRETATION: We found that mentorship, particularly within the community, was instrumental to promoting feelings of belonging. However, participants described the need for resilience in the face of discrimination during training and in practice in health care professions. Rather than focusing on their education, many had to educate those around them. Increased representation, support programs and updated curricula are needed to promote change.

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.

Operationalizing integrated needs-based workforce planning at Nova Scotia Health in response to the COVID-19 pandemic.

This paper documents Nova Scotia Health's progress in operationalizing integrated needs-based workforce planning as part of its ongoing response to the pandemic. A multidisciplinary workforce planning team with representation spanning key portfolios was created to facilitate the organization's response to the pandemic. Analyses applied early in Wave 3 of the pandemic showed large projected shortages in several professions and identified which services would likely be scarcest among the available workforce relative to patient need. Based on these results, the workforce planning team recommended and supported operational teams in implementing a multi-faceted set of interventions aimed at increasing the availability of individuals with these competencies. These interventions collectively yielded an adequate supply of additional competent personnel to meet the needs of COVID-19 inpatients across the province through the third wave of the pandemic. Lessons learned are proving critical to maintaining core operations during Wave 4 of the pandemic.

A rapid assessment technique for coastal plastic debris sampling: Applications for remote regions and community science.

Marine debris is an environmental issue of increasing importance worldwide, with 80% of marine plastics estimated to originate from land-based sources. While much work has been conducted to quantify plastics in coastal environments, many of these approaches are site-specific and not amenable to rapid surveys. We surveyed beaches around Nova Scotia, Canada for plastic and other anthropogenic debris to: 1) quantify debris density on the high tide line; and 2) test a rapid survey technique using digital photos, with applications for community science and remote regions. Most (72%) beaches in Nova Scotia contained debris, but plastic densities along the daily high tide line were relatively low (mean 0.2 debris/m2) with little interannual variation. Despite small differences in plastic densities between observers, this rapid assessment technique appears viable for relative quantification and monitoring of plastic debris on beaches across large geographic scales to assess trends and sources.

Identifying children with medical complexity in administrative datasets in a Canadian context: study protocol.

INTRODUCTION: Children with medical complexity and their families are an important population of interest within the Canadian healthcare system. Despite representing less than 1% of the paediatric population, children with medical complexity require extensive care and account for one third of paediatric healthcare expenditures. Opportunities to conduct research to assess disparities in care and appropriate allocation of health resources relies on the ability to accurately identify this heterogeneous group of children. This study aims to better understand the population of children with medical complexity in the Canadian Maritimes, including Nova Scotia (NS), New Brunswick (NB) and Prince Edward Island (PEI). This will be achieved through three objectives: (1) Evaluate the performance of three algorithms to identify children with medical complexity in the Canadian Maritimes in administrative data; then using the 'best fit' algorithm (2) Estimate the prevalence of children with medical complexity in the Canadian Maritimes from 2003 to 2017 and (3) Describe patterns of healthcare utilisation for this cohort of children across the Canadian Maritimes. METHODS AND ANALYSIS: The research will be conducted in three phases. In Phase 1, an expert panel will codevelop a gold-standard definition of paediatric medical complexity relevant to the Canadian Maritime population. A two-gate validation process will then be conducted using NS data and the gold-standard definition to determine the 'best fit' algorithm. During phase 2 the 'best fit' algorithm will be applied to estimate the prevalence of children with medical complexity in NS, NB and PEI. Finally, in phase 3 will describe patterns of healthcare utilisation across the Canadian Maritimes. ETHICS AND DISSEMINATION: Ethics approval for this protocol was granted by the institutional research ethics board at the IWK Health Centre (REB # 1026245). A waiver of consent was approved. This study will use an integrated knowledge translation approach, where end users are involved in each stage of the project, which could increase uptake of the research into policy and practice. The findings of this research study will be submitted for publication and dissemination through conference presentations and with our end users.

"My Cancer Is Worth Only Fifteen Weeks"? A Critical Analysis of the Lived Experiences of Financial Toxicity and Cancer in Canada.

BACKGROUND: Cancer patients experience financial hardship due to rising expenses related to cancer treatment and declining income levels associated with reduced employability. Employment Insurance Sick Benefits (EI-SB) is a social income support program which provides temporary income replacement to Canadians when they fall ill. Although EI-SB is designed to maintain continuity of income during an illness, little is known about the perspectives of cancer patients who receive EI-SB. This knowledge can inform the development of public policies which are responsive to the needs and priorities of cancer patients. METHODS: We conducted a theory-informed thematic analysis of data collected from twenty semi-structured interviews with participants who were receiving care in a cancer centre in Cape Breton, Nova Scotia and had received EI-SB. A coding framework was developed using Taplin and colleagues' intermediate outcomes of patient care across the cancer care continuum. Interpretation of findings was guided by the synergies of oppression theoretical lens. RESULTS: Three overarching themes describe the experiences of cancer patients receiving social income support: Economic exclusion, in which the structure of the labour market and social welfare system determine access to workplace benefits and continuity of reasonable income; financial toxicity, a vicious cycle of financial burden and increasing financial distress; and constrained choices, where cancer influences employability and lowered income influences the need to be employed. CONCLUSION: Cancer patients need income support programs that are tailored to match their healthcare priorities. In addition, policies which strengthen working conditions and facilitate a reintegration to work when possible will be important in addressing the structural drivers of income insecurity experienced by cancer patients.

Surviving Long Enough to Die? An Analysis of Incomplete Assessments for Medical Assistance in Dying.

Background: Medical assistance in dying (MAiD) was legalized in Canada on June 17, 2016, yet many who request MAiD do not complete the assessment process and instead experience a natural death. This analysis of patients who made a formal request for MAiD aims to clarify timelines and factors associated with completion of the MAiD assessment process, and factors associated with completion or noncompletion of MAiD once eligible. Materials and Methods: This retrospective cohort study included all patients in Nova Scotia who requested MAiD between January 1, 2018 and December 31, 2018, were deceased at the time of analysis, did not withdraw their request, and were not formally deemed ineligible for the procedure (n = 218). Descriptive statistics, Kaplan-Meier curves, and logistic regression were used in data analysis. Results: Of 218 patients, 48 did not complete the MAiD assessment process. Of the 170 patients who completed the assessment process and were deemed eligible for MAiD, 79.4% (n = 135) completed the procedure. Those with an incomplete assessment had a median survival from request to death of 8.0 days (interquartile range [IQR] = 11.5), whereas for those deemed eligible, median survival from request to determination of MAiD eligibility was also 8.0 days (IQR = 16.0). Interpretation: Proximity to natural death and poor performance status at the time of MAiD request may drive incomplete MAiD assessments. The majority of patients deemed eligible for MAiD complete the procedure, and as such, patients who did not complete the MAiD assessment process may not have experienced their preferred mode of death.

"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 expenditures after first hospital admission for heart failure in Nova Scotia, Canada: a retrospective cohort study.

BACKGROUND: Although the frequency of heart failure makes it among the costliest of illnesses, there are scant Canadian data on annual costs of treatment or the costs as the condition advances. Our objective was to estimate mean prevalence- and incidence-based direct medical costs among older adults discharged alive after a first hospital admission for heart failure. METHODS: We conducted a retrospective cohort study using population-based administrative health databases for Nova Scotia. The cohort comprised persons 50 years of age or older with an incident hospital admission for heart failure between 2009 and 2012. We considered the costs (expressed as 2020 Canadian dollars) of hospital admissions, physician visits and, for patients 65 years of age or older, outpatient cardiac medications. We estimated costs for calendar years, longitudinally and in the last 2 years of life. We analyzed costs from the perspective of a third-party public payer. RESULTS: The cohort consisted of 3327 patients (mean age 77.6 yr; 1605 [48.2%] women). Median survival was 2.5 and 2.2 years among men and women, respectively. Annual prevalence-based costs were about $7100. Mean incidence-based costs ranged between $65 000 and $164 000 in the year after diagnosis and decreased by 90% subsequently. Costs were 4 to 7 times higher in the year before death than in the period from 1 to 2 years before death. INTERPRETATION: The direct medical costs of treating patients with heart failure in Nova Scotia displayed a reverse J shape, with costs highest after diagnosis, declining subsequently and then increasing during the final year of life. Strategies designed to improve the quality of care immediately after diagnosis and during more advanced stages of disease might reduce these costs.

How is the medical assistance in dying (MAID) process carried out in Nova Scotia, Canada? A qualitative process model flowchart study.

OBJECTIVES: The aims of this study are: (1) to create a flowchart process model of how medical assistance in dying (MAID) occurs in Nova Scotia (NS), Canada and (2) to detail how NS healthcare professionals are involved in each stage of MAID. The research questions are: how is the MAID process carried out and which professionals are involved at which points? and which roles and activities do professionals carry out during MAID? DESIGN: Qualitative process model flowchart study with semistructured interviews. SETTING: Primary and secondary care in NS, Canada. PARTICIPANTS: Thirty-two interviewees self-selected to participate (12 physicians, 3 nurse practitioners (NP), 6 nurses, 6 pharmacists and 5 healthcare administrators and advocates). Participants were included if they conduct assessments, provide MAID, fill prescriptions, insert the intravenous lines, organise care and so on. RESULTS: The flowchart process model details five stages of how MAID occurs in NS: (1) starting the MAID process, (2) MAID assessments, (3) MAID preparation (hospital in-patient, hospital outpatient, non-hospital), (4) day of MAID and (5) post-MAID (hospital in-patient and outpatient, non-hospital, after leaving setting). Nineteen points where the process could stop or be delayed were identified. MAID differs slightly by location and multiple professionals from different organisations are involved at different points. Some physicians and NP provide MAID for free as they cannot be reimbursed or find it too difficult to be reimbursed. CONCLUSIONS: Our study adds knowledge about the MAID activities and roles of NS professionals, which are not documented in the international literature. Clinicians and pharmacists spend significant additional time to participate, raising questions about MAID's sustainability and uncompensated costs. The process model flowchart identifies where MAID can stop or be delayed, signalling where resources, training and relationship-building may need to occur. Knowing where potential delays can occur can help clinicians, administrators and policymakers in other jurisdictions improve MAID.