Recommendations for virtual care in primary care practices: a survey of patients across Ontario, Canada.

Context: The onset of COVID-19 has required the rapid adoption of virtual services in primary care (PC) practices, and virtual care delivery is likely to continue to some extent post-pandemic. Objective: To understand patient experience with synchronous virtual (telephone (Tel)/Video) appointments and elicit recommendations for its future use. Design: Mixed method, including patient survey co-developed with stakeholders and implemented online Feb-Mar 2021 with large promotional efforts through social media, patient and caregiver organizations, and other networks. We report on the survey results. Eligibility: 1+ virtual encounter in PC. Outcome measures: A) Patient experience scale (12/17 questions for Tel/Video) covering 4 sub-dimensions; B) Access related questions. Questions had 5-point Likert scale items (strongly disagree (-2) to strongly agree (+2)) and were converted into percentage (potential range -100%, +100%) Setting : Ontario, Canada which offers universal coverage for PC visits with no co-payment. Results: 534 eligible respondents (402/18/114 had Tel/Video/both): Females (78%), < 55 years (61%), white (75%), employed (61%), bachelor's degree (74%), family income > 100k (52%). Encounters evaluated were with family physicians (vs other health professionals) for 75%/46% of Tel/Video encounters. A) Patient Experience (Tel/Video) overall score: 75%/78%; Sub-dimensions: technology: 92%/84%, patient-provider relationship: 83%/86%, quality of care: 66%/66%, whole-person care: 43%/53%. Factors associated with a statistically significant(*) > 10% higher overall score in tel and/or video were: non-females: (8%*/14%*), French speaking (13%*/16%*), patient-provider relationship >1 year (16%*/7%), provider age < 50 (5%/15%*), having the choice of appointment time (15%*/21%*). Wanting to show problem to the provider was associated with a lower scores (-23%*/NA). B) Access Respondents overwhelmingly reported that Tel/Video visits reduced time (97%/97%), costs (81%/85%), and was more convenient (91%/91%). The majority wanted Tel (69%) and Video (71%) visits at least as often as in person visits post-covid. Only 5% did not want any future virtual care. Conclusions: Patient experience was largely positive and is influenced by patient/provider factors. Patients and providers may benefit from support/training to optimize care experience. We are now evaluating whether the reasons for visits influences care experience.

Is equity considered in systematic reviews of interventions for mitigating social isolation and loneliness in older adults?

BACKGROUND: Social isolation and loneliness affect one in four older adults in many regions around the world. Social isolation and loneliness are shown to be associated with declines in physical and mental health. Intersecting social determinants of health influence both the risk of being socially isolated and lonely as well as the access and uptake of interventions. Our objective is to evaluate what evidence is available within systematic reviews on how to mitigate inequities in access to and effectiveness of interventions. METHODS: We performed an overview of reviews following methods of the Cochrane Handbook for Overviews of Reviews. We selected systematic reviews of effectiveness of interventions aimed at mitigating social isolation and loneliness in older adults (aged 60 or above) published in the last 10 years. In addition, we assessed all primary studies from the most recent systematic review with a broad intervention focus. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus in collaboration with a librarian scientist. We used a structured framework called PROGRESS-Plus to assess the reporting and consideration of equity. PROGRESS-Plus stands for place of residence, race/ethnicity/culture/language, occupation, gender or sex, religion, education, socioeconomic status (SES), social capital, while "plus" stands for additional factors associated with discrimination and exclusion such as age, disability, and sexual orientation. We assessed whether PROGRESS-Plus factors were reported in description of the population, examination of differential effects, or discussion of applicability or limitations. RESULTS: We identified and assessed 17 eligible systematic reviews. We assessed all 23 primary studies from the most recent systematic review with a broad intervention focus. All systematic reviews and primary studies described the population by one or more PROGRESS-Plus factor, most commonly across place of residence and age, respectively. None of the reviews and five primary studies examined differential effects across one or more PROGRESS-Plus dimension. Nine reviews and four primary studies discussed applicability or limitations of their findings by at least one PROGRESS-Plus factor. CONCLUSIONS: Although we know that social isolation and loneliness are worse for the poorest and most socially disadvantaged older adults, the existing evidence base lacks details on how to tailor interventions for these socially disadvantaged older people.

Inequities in the delivery of mental health care: a grounded theory study of the policy context of primary care.

BACKGROUND: Strengthening capacity for mental health in primary care improves health outcomes by providing timely access to coordinated and integrated mental health care. The successful integration of mental health in primary care is highly dependent on the foundation of the surrounding policy context. In Ontario, Canada, policy reforms in the early 2000's led to the implementation of a new interprofessional team-model of primary care called Family Health Teams. It is unclear the extent to which the policy context in Ontario influenced the integration of mental health care in Family Health Teams emerging from this period of policy reform. The research question guiding this study was: what were key features of Ontario's policy context that influenced FHTs capacity to provide mental health services for mood and anxiety disorders? METHODS: A qualitative study informed by constructivist grounded theory. Individual interviews were conducted with executive directors, family physicians, nurse practitioners, nurses, and the range of professionals who provide mental health services in interprofessional primary care teams; community mental health providers; and provincial policy and decision makers. We used an inductive approach to data analysis. The electronic data management programme NVivo11 helped organise the data analysis process. RESULTS: We conducted 96 interviews with 82 participants. With respect to the contextual factors considered to be important features of Ontario's policy context that influenced primary care teams' capacity to provide mental health services, we identified four key themes: i) lack of strategic direction for mental health, ii) inadequate resourcing for mental health care, iii) rivalry and envy, and, iv) variations across primary care models. CONCLUSIONS: As the first point of contact for individuals experiencing mental health difficulties, primary care plays an important role in addressing population mental health care needs. In Ontario, the successful integration of mental health in primary care has been hindered by the lack of strategic direction, and inconsistent resourcing for mental health care. Achieving health equity may be stunted by the structural variations for mental health care across Family Health Teams and across primary care models in Ontario.

Improving access to primary health care: a cross-case comparison based on an a priori program theory.

BACKGROUND: Inequitable access to primary health care (PHC) remains a problem for most western countries. Failure to scale up effective interventions has been due, in part, to a failure to share the logic and essential elements of successful programs. The aim of this paper is to describe what we learned about improving access to PHC for vulnerable groups across multiple sites through use of a common theory-based program logic model and a common evaluation approach. This was the IMPACT initiative. METHODS: IMPACT's evaluation used a mixed methods design with longitudinal (pre and post) analysis of six interventions. The analysis for this paper included four of the six sites that met study criteria. These sites were located in Canada (Alberta, Quebec and Ontario) and Australia (New South Wales). Using the overarching logic model, unexpected findings were reviewed, and alternative explanations were considered to understand how the mechanisms of each intervention may have contributed to results. RESULTS: Each site addressed their local access problem with different strategies and from different starting points. All sites observed changes in patient abilities to access PHC and provider access capabilities. The combination of intended and observed consequences for consumers and providers was different at each site, but all sites achieved change in both consumer ability and provider capability, even in interventions where there was no activity targeting provider behaviors. DISCUSSION: The model helped to identify, explore and synthesize intended and unintended consequences of four interventions that appeared to have more differences than similarities. Similar outcomes for different interventions and multiple impacts of each intervention on abilities were observed, implying complex causal pathways. CONCLUSIONS: All the interventions were a low-cost incremental attempt to address unmet health care needs of vulnerable populations. Change is possible; sustaining change may be more challenging. Access to PHC requires attention to both patient abilities and provider characteristics. The logic model proved to be a valuable heuristic tool for defining the objectives of the interventions, evaluating their impacts, and learning from the comparison of 'cases'.

Patient perspectives on quality of care for depression and anxiety in primary health care teams: A qualitative study.

BACKGROUND: Widespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team-based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care. OBJECTIVE: The main study objective was to understand patients' perspectives on the quality of care that they received for anxiety and depression in primary care teams. METHODS: This was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data. RESULTS: Forty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs. CONCLUSION: Greater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process.

Does healthcare inequity reflect variations in peoples' abilities to access healthcare? Results from a multi-jurisdictional interventional study in two high-income countries.

BACKGROUND: Primary healthcare services must respond to the healthcare-seeking needs of persons with a wide range of personal and social characteristics. In this study, examined whether socially vulnerable persons exhibit lower abilities to access healthcare. First, we examined how personal and social characteristics are associated with the abilities to access healthcare described in the patient-centered accessibility framework and with the likelihood of reporting problematic access. We then examined whether higher abilities to access healthcare are protective against problematic access. Finally, we explored whether social vulnerabilities predict problematic access after accounting for abilities to access healthcare. METHODS: This is an exploratory analysis of pooled data collected in the Innovative Models Promoting Access-To-Care Transformation (IMPACT) study, a Canadian-Australian research program that aimed to improve access to primary healthcare for vulnerable populations. This specific analysis is based on 284 participants in four study regions who completed a baseline access survey. Hierarchical linear regression models were used to explore the effects of personal or social characteristics on the abilities to access care; logistic regression models, to determine the increased or decreased likelihood of problematic access. RESULTS: The likelihood of problematic access varies by personal and social characteristics. Those reporting at least two social vulnerabilities are more likely to experience all indicators of problematic access except hospitalizations. Perceived financial status and accumulated vulnerabilities were also associated with lower abilities to access care. Higher scores on abilities to access healthcare are protective against most indicators of problematic access except hospitalizations. Logistic regression models showed that ability to access is more predictive of problematic access than social vulnerability. CONCLUSIONS: We showed that those at higher risk of social vulnerability are more likely to report problematic access and also have low scores on ability to seek, reach, pay, and engage with healthcare. Equity-oriented healthcare interventions should pay particular attention to enhancing people's abilities to access care in addition to modifying organizational processes and structures that reinforce social systems of discrimination or exclusion.

High-performing physicians are more likely to participate in a research study: findings from a quality improvement study.

BACKGROUND: Participants in voluntary research present a different demographic profile than those who choose not to participate, affecting the generalizability of many studies. Efforts to evaluate these differences have faced challenges, as little information is available from non-participants. Leveraging data from a recent randomized controlled trial that used health administrative databases in a jurisdiction with universal medical coverage, we sought to compare the quality of care provided by participating and non-participating physicians prior to the program's implementation in order to assess whether participating physicians provided a higher baseline quality of care. METHODS: We conducted clustered regression analyses of baseline data from provincial health administrative databases. Participants included all family physicians who were eligible to participate in the Improved Delivery of Cardiovascular Care (IDOCC) project, a quality improvement project rolled out in a geographically defined region in Ontario (Canada) between 2008 and 2011. We assessed 14 performance indicators representing measures of access, continuity, and recommended care for cancer screening and chronic disease management. RESULTS: In unadjusted and patient-adjusted models, patients of IDOCC-participating physicians had higher continuity scores at the provider (Odds Ratio (OR) [95% confidence interval]: 1.06 [1.03-1.09]) and practice (1.06 [1.04-1.08]) level, lower risk of emergency room visits (Rate Ratio (RR): 0.93 [0.88-0.97]) and hospitalizations (RR:0.87 [0.77-0.99]), and were more likely to have received recommended diabetes tests (OR: 1.25 [1.06-1.49]) and cancer screening for cervical cancer (OR: 1.32 [1.08-1.61] and breast cancer (OR: 1.32 [1.19-1.46]) than patients of non-participating physicians. Some indicators remained statistically significant in the model after adjusting for provider factors. CONCLUSIONS: Our study demonstrated a participation bias for several quality indicators. Physician characteristics can explain some of these differences. Other underlying physician or practice attributes also influence interest in participating in quality improvement initiatives and existing quality levels. The standard for addressing participation bias by controlling for basic physician and practice level variables is inadequate for ensuring that results are generalizable to primary care providers and practices.

Impact of health care reform on enrolment of immigrants in primary care in Ontario, Canada.

OBJECTIVES: In 2003, Ontario introduced a patient enrolment system as part of health care reforms, aimed at enhancing primary health care services, but it is unclear whether immigrants have benefited from this health care reform. Therefore, we studied whether this reform changed the extent of immigrants' enrolment in primary care services in Ontario between 2003 and 2012. METHODS: This is a population-based retrospective cohort study, in which a closed cohort of 9231840 Ontario residents between 1985 and 2003 was created, using linked health administrative and immigration databases. Levels of enrolment for traditional and more comprehensive capitation-based practice between 2003 and 2012 were compared by immigrant status. Logistic regression modelling was used to assess the odds of enrolment on primary care practices. RESULTS: Overall enrolment in primary care practices increased gradually after 2004, until 2012, when two-thirds of the cohort (67%) were enrolled. The immigrants' enrolment level remained consistently lower than that of long-term residents over the study period. By 2012, enrolment of immigrants in capitation-based models was significantly lower (17.3% versus 25.4%). In particular, enrolment in Family Health Teams, considered the most comprehensive care model, was considerably lower in immigrants compared with long-term residents (5.6% versus 18.0%; OR = 0.40, 95% CI: 0.40 to 0.41). CONCLUSIONS: Immigrant enrolment rates in new comprehensive primary care models were consistently lower than among long-term residents. This has implication on equitable primary care access for immigrant populations.

The impact of the adoption of a patient rostering model on primary care access and continuity of care in urban family practices in Ontario, Canada.

BACKGROUND: Greater continuity and access to primary care results in improved patient health, satisfaction, and reduced healthcare costs. Although patient rostering is considered to be a cornerstone of a high performing primary care system and is believed to improve continuity and access, few studies have examined these relationships. This study examined the impact of the adoption of a patient rostering enhanced fee-for-service model (eFFS) on continuity, coordination of specialized care, and access. METHOD: A population-based longitudinal study was conducted using health administrative data from urban family practices in Ontario, Canada. Family physicians that transitioned from traditional FFS (tFFS) to eFFS between 2004 and 2013 were followed overtime. Physicians providing comprehensive primary care that had at least 4 years of pre-transition and 2 years of post-transition data were eligible. Patients were attributed to physicians on an annual basis by determining the provider that billed the largest dollar amount over a 2 year period. Outcomes of interest were the usual provider of care index (UPC), a referral index (RI) (% of total primary care referrals for a physician's roster made by the main provider), and emergency department (ED) visits for family practice sensitive conditions (FPSCs). Mixed-effects segmented linear and logistic regressions were used to examine changes in outcomes while controlling for patient and provider contextual factors. RESULTS: Prior to transitioning, UPC was decreasing at a rate of 0.27%/year (95% CI: -0.34 to - 0.21, p < 0.0001). Following the transition, UPC began decreasing by an additional 0.59%/year (95% CI: -0.69 to - 0.49, p < 0.0001) relative to the pre-transition rate. RI decreased by an additional 0.34%/year (95% CI: -0.43 to - 0.24, p < 0.0001) relative to the pre-transition period, where it had been stable. The transition had minimal impact on FPSC ED visits. CONCLUSION: Continuity and coordination of specialized care slightly decreased upon transition from tFFS to eFFS. This is likely due to physicians working in groups and sharing patients following the transition to the eFFS model. Adoption of an enrolment model with after-hours care did not decrease non-urgent ED use, which may reflect the small impact that primary care access has on these types of ED visits.

End-of-career practice patterns of primary care physicians in Ontario.

OBJECTIVE: To characterize the process of end-of-career attrition among primary care physicians. DESIGN: Longitudinal, open cohort, population-based study of primary care physicians using health administrative data from ICES.Setting Ontario. PARTICIPANTS: All family physicians providing comprehensive care between 1992 and 2013. MAIN OUTCOME MEASURES: Changes in workload and scopes of practice over time. RESULTS: The cohort included 15 552 family physicians who provided comprehensive care at some point during the study period. Physicians reduced workloads and narrowed scopes of practice in advance of full retirement at an average age of 70.5 (95% CI 70.1 to 70.8) years. Female physicians provided fewer clinical services than male physicians did and retired 5 years earlier. Canadian medical graduates provided fewer clinical services and retired 2 years earlier than international medical graduates did. Up to 60% of physicians stopped providing comprehensive primary care before retirement, continuing with other clinical activities, at reduced workloads, for an average of 3 years before retiring fully. CONCLUSION: End-of-career practice patterns are characterized by gradual, modest changes in the provision of services rather than abrupt declines, and the retirement process unfolds differently for different physicians. This study highlights the importance of considering physician workload, scope of practice, and demographic factors for more accurate prediction of physician retirement trends and effective work force planning.

Equity of primary care service delivery for low income "sicker" adults across 10 OECD countries.

BACKGROUND: Despite significant investments to support primary care internationally, income-based inequities in access to quality health care are present in many high-income countries. This study aims to determine whether low- and middle-income groups are more likely to report poor quality of primary care (PC) than high-income groups cross-nationally. METHODS: The 2011 Commonwealth Fund Telephone Survey of Sicker Adults is a cross-sectional study across eleven countries. Respondents were recruited from randomly selected households. We used data from surveys conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. We identified all questions relating to primary care performance, and categorized these into five dimensions: 1) access to care, 2) coordination 3) patient-centered care, and 4) technical quality of care. We used logistic regression with low and middle-income as the comparison groups and high-income as the referent. RESULTS: Fourteen thousand two hundred sixty-two respondents provided income data. Countries varied considerably in their extent of income disparity. Overall, 24.7% were categorized as low- and 13.9% as high-income. The odds of reporting poor access to care were higher for low- and middle-income than high-income respondents in Canada, New Zealand and the US. Similar results were found for Sweden and Norway on coordination; the opposite trend favoring the low- and middle-income groups was found in New Zealand, United Kingdom, and the United States. The odds of reporting poor patient-centered care were higher for low-income than high-income respondents in the Netherlands, Norway, and the US; in Australia, this was true for low- and middle-income respondents. On technical quality of care, the odds of reporting poor care were higher for the low- and middle-income comparisons in Canada and Norway; in Germany, the odds were higher for low-income respondents only. The odds of reporting poor technical quality of care were higher for high-income than low-income respondents in the Netherlands. CONCLUSION: Inequities in quality PC for low and middle income groups exist on at least one dimension in all countries, including some that in theory provide universal access. More research is needed to fully understand equity in the PC sector.

Cancer screening inequities in a time of primary care reform: a population-based longitudinal study in Ontario, Canada.

BACKGROUND: Primary care has been reformed in recent years in Ontario, Canada, with a move away from traditional fee-for-service to enhanced fee-for-service and capitation-based models. It is unclear how new models have affected disparities in cancer screening. We evaluated whether Ontario's enhanced fee-for-service model was associated with a change in the gaps in cancer screening for people living with low income and people who are foreign-born. METHODS: We conducted a population-based longitudinal analysis from 2002 to 2013 of Ontario family physicians who transitioned from traditional fee-for-service to enhanced fee-for-service. The binary outcomes of interest were adherence to cervical, breast and colorectal cancer screening recommendations. Outcomes were analyzed using mixed-effects logistic regression. Analyses produced annual odds ratios comparing the odds of being up-to-date for screening among patients in enhanced fee-for-service versus patients in traditional fee-for-service for each social stratum separately. We calculated the ratios of stratum-specific odds ratios to assess whether the transition from traditional to enhanced fee-for-service was associated with a change in screening gaps between immigrants and long-term residents, and between people in the lowest and highest neighbourhood income quintiles. RESULTS: Throughout the study period, cancer screening was consistently lower among immigrants and among people in the lowest income quintile. Transition to enhanced fee-for-service was generally associated with increased screening uptake for all, however for most years, ratios of ratios were significantly less than 1 for all three cancer screening types, indicating that there was a widening of the screening gap between immigrants and long-term residents and between people living in the lowest vs. highest income quintile associated with transitions. CONCLUSION: The transition to enhanced fee-for-service in Ontario was generally associated with a widening of screening inequities for foreign-born and low-income patients.

Characteristics of Nurse Practitioner Practice in Family Health Teams in Ontario, Canada.

Nurse practitioners (NPs) in Ontario work in a number of settings, including physician-led, interprofessional Family Health Teams (FHTs). However, many aspects of NP practice within the FHTs are unknown. Our study aimed to describe the characteristics of NP practice in FHTs and the relationships between NPs and physicians within this model. This cross-sectional descriptive study analyzed NP service and diagnostic code data collected for every NP patient encounter from 2012 to 2015. Encounter data were linked to health administrative data housed at the Institute for Clinical Evaluative Sciences to allow for comparison with physician service and diagnostic codes. Findings demonstrated that NPs saw patients across all age groups for one to more than five problems per encounter and that NPs handled both acute and episodic care and chronic disease management issues. Patients with chronic conditions had more encounters with physicians than with NPs. In addition, compared to physicians, NPs saw more female than male patients. Our findings provide a snapshot of NP practice in FHTs and may be useful in informing other practice models in Ontario, elsewhere in Canada, and internationally. More evidence is needed, however, to clarify the responsibilities of the NPs in collaborative relationships with physicians and to embed policies that will ensure that NPs work to their full potential. In addition, applying service coding to all health care providers in FHTs could enhance data on interprofessional teams and the individual clinicians that comprise them.

Building capacity for medical education research in family medicine: the Program for Innovation in Medical Education (PIME).

BACKGROUND: Despite the apparent benefits to teaching, many faculty members are reluctant to participate in medical education research (MER) for a variety of reasons. In addition to the further demand on their time, physicians often lack the confidence to initiate MER projects and require more support in the form of funding, structure and guidance. These obstacles have contributed to a decline in physician participation in MER as well as to a perceived decay in its quality. As a countermeasure to encourage physicians to undertake research, the Department of Family Medicine at the University of Ottawa implemented a programme in which physicians receive the funding, coaching and support staff necessary to complete a 2-year research project. The programme is intended primarily for first-time researchers and is meant to serve as a gateway to a research career funded by external grants. Since its inception in 2010, the Program for Innovation in Medical Education (PIME) has supported 16 new clinician investigators across 14 projects. METHODS: We performed a programme evaluation 3 years after the programme launched to assess its utility to participants. This evaluation employed semi-structured interviews with physicians who performed a research project within the programme. RESULTS: Programme participants stated that their confidence in conducting research had improved and that they felt well supported throughout their project. They appreciated the collaborative nature of the programme and remarked that it had improved their willingness to solicit the expertise of others. Finally, the programme allowed participants to develop in the scholarly role expected by family physicians in Canada. CONCLUSION: The PIME may serve as a helpful model for institutions seeking to engage faculty physicians in Medical Education Research and to thereby enhance the teaching received by their medical learners.

Activities performed by pharmacists integrated in family health teams: Results from a web-based survey.

OBJECTIVES: Family health teams (FHTs), an interprofessional primary care practice model, were established in Ontario in 2005. As of October 2014, 191 FHT organizations were in operation, and 111 (58%) included one or several pharmacists. The objective of this study was to document the focus of pharmacist activities in FHTs. APPROACH: We invited all 155 known FHT pharmacists to a web-based survey. The survey was constructed using information obtained from previously done semi-structured telephone interviews with pharmacists working in FHTs. The survey consisted of a list of activities, grouped into 5 main categories, and participants were asked to estimate time spent on each category. Free-text response questions allowed participants to identify activities not listed. Survey results were analyzed using descriptive statistics and content analysis for open-ended responses. RESULTS: Seventy (45%) pharmacists completed the survey. The mean respondent age was 43 years, and the average length of time working in an FHT was 4 years. All pharmacists reported being engaged in some form of direct patient care, including managing single therapeutic issues (96%), conducting general medication reviews (70%) and medication reconciliation after hospitalization (63%). Most reported providing education and drug information (83%). Pharmacists felt their work would increase patient medication adherence (94%) and physician adherence to recommended guidelines (86%), as well as reduce inappropriate prescribing (93%), polypharmacy (90%), emergency room and hospital utilization (70%-81%). CONCLUSION: Pharmacists in FHTs are strongly focused on direct patient care activities, managing specific medication issues and unstructured drug information to physicians. The majority of pharmacists reported that their activities had a substantial impact on patient medication use and health. The findings from this survey can assist pharmacists new to FHT practice, health policy planning and health research to assess associations between pharmacist activities and measures of health and health care system performance.

A Comprehensive Assessment of Family Physician Gender and Quality of Care: A Cross-Sectional Analysis in Ontario, Canada.

BACKGROUND: Studies evaluating primary care quality across physician gender are limited to primary and secondary prevention. OBJECTIVES: Investigate the relationship between family physician gender and quality of primary care using indicators that cover 5 key dimensions of primary care. RESEARCH DESIGN: Cross-sectional analysis using linked health administrative datasets (April 1, 2008 to March 31, 2010). SUBJECTS: All family physicians working in the 3 main primary care models in the province of Ontario (Canada), providing general care and having a panel size >1200. MEASURES: Indicators of cancer screening (3), chronic disease management (9), continuity (2), comprehensiveness (2), and access (5). RESULTS: A total of 4195 physicians (31% female) were eligible. Adjusting for provider and patient factors, patients of female physicians were more likely to have received recommended cancer screening (odds ratios [95% confidence interval (CI)] (OR) range: 1.24 [1.18-1.30], 1.85 [1.78-1.92]) and diabetes management (OR: 1.04 [1.01-1.08], 1.28 [1.05-1.57]). They had fewer emergency room visits (rate ratio [95% CI] (RR) range: 0.83 [0.79-0.87]) and hospitalizations (RR: 0.89 [0.86-0.93]), and higher referrals (RR: 1.12 [1.09-1.14]). There was evidence of effect modification by patient gender (female vs. male) for hospitalization (RR: 0.74 [0.70-0.79] vs. 0.96 [0.90-1.02]) and emergency room visits (RR: 0.84 [0.81-0.88] vs. 0.98 [0.94-1.01]). Lower emergency room visits were also more evident in more complex patients of female physicians. There were no significant differences in the continuity or comprehensiveness measures. CONCLUSIONS: The indicators assessed in this study point to a benefit for patients under the care of female physicians. Potential explanations are discussed.

Primary Care Physician Panel Size and Quality of Care: A Population-Based Study in Ontario, Canada.

PURPOSE: The purpose of this study was to determine the relationship between the number of patients under a primary care physician's care (panel size) and primary care quality indicators. METHODS: We conducted a cross-sectional, population-based study of fee-for-service and capitated interprofessional and non-interprofessional primary health care practices in Ontario, Canada between April 2008 and March 2010, encompassing 4,195 physicians with panel sizes ≥1,200 serving 8.3 million patients. Data was extracted from multiple linked, health-related administrative databases and covered 16 quality indicators spanning 5 dimensions of care: access, continuity, comprehensiveness, and evidence-based indicators of cancer screening and chronic disease management. RESULTS: The likelihood of being up-to-date on cervical, colorectal, and breast cancer screening showed relative decreases of 7.9% (P <.001), 5.9% (P = .01), and 4.6% (P <.001), respectively, with increasing panel size (from 1,200 to 3,900). Eight chronic care indicators (4 medication-based and 4 screening-based) showed no significant association with panel size. The likelihood of individuals with a new diagnosis of congestive heart failure having an echocardiogram, however, increased by a relative 8.1% (P <.001) with higher panel size. Increasing panel size was also associated with a 10.8% relative increase in hospitalization rates for ambulatory-care-sensitive conditions (P = .04) and a 10.8% decrease in non-urgent emergency department visits (P = .004). Continuity was highest with medium panel sizes (P <.001), and comprehensiveness had a small decrease (P = .03) with increasing panel size. CONCLUSIONS: Increasing panel size was associated with small decreases in cancer screening, continuity, and comprehensiveness, but showed no consistent relationships with chronic disease management or access indicators. We found no panel size threshold above which quality of care suffered.

What is the impact of primary care model type on specialist referral rates? A cross-sectional study.

BACKGROUND: Several new primary care models have been implemented in Ontario, Canada over the past two decades. These practice models differ in team structure, physician remuneration, and group size. Few studies have examined the impact of these models on specialist referrals. We compared specialist referral rates amongst three primary care models: 1) Enhanced Fee-for-service, 2) Capitation- Non-Interdisciplinary (CAP-NI), 3) Capitation - Interdisciplinary (CAP-I). METHODS: We conducted a cross-sectional study using health administrative data from primary care practices in Ontario from April 1st, 2008 to March 31st, 2010. The analysis included all family physicians providing comprehensive care in one of the three models, had at least 100 patients, and did not have a prolonged absence (eight consecutive weeks). The primary outcome was referral rate (# of referrals to all medical specialties/1000 patients/year). A multivariable clustered Poisson regression analysis was used to compare referral rates between models while adjusting for provider (sex, years since graduation, foreign trained, time in current model) and patient (age, sex, income, rurality, health status) characteristics. RESULTS: Fee-for-service had a significantly lower adjusted referral rate (676, 95% CI: 666-687) than the CAP-NI (719, 95% confidence interval (CI): 705-734) and CAP-I (694, 95% CI: 681-707) models and the interdisciplinary CAP-I group had a 3.5% lower referral rate than the CAP-NI group (RR = 0.965, 95% CI: 0.943-0.987, p = 0.002). Female and Canadian-trained physicians referred more often, while female, older, sicker and urban patients were more likely to be referred. CONCLUSIONS: Primary care model is significantly associated with referral rate. On a study population level, these differences equate to 111,059 and 37,391 fewer referrals by fee-for-service versus CAP-NI and CAP-I, respectively - a difference of $22.3 million in initial referral appointment costs. Whether a lower rate of referral is more appropriate or not is not known and requires further investigation. Physician remuneration and team structure likely account for the differences; however, further investigation is also required to better understand whether other organizational factors associated with primary care model also impact referral.

Roles of nurse practitioners and family physicians in community health centres.

OBJECTIVE: To describe the models of practice used by nurse practitioners (NPs) and FPs in community health centres (CHCs), and to examine the roles of NPs and FPs in these models. DESIGN: Cross-sectional study using an organizational survey completed by managers of the CHC sites, as well as administrative data on patient sociodemographic characteristics and encounter activities. SETTING: A total of 21 CHCs (13 main sites and 8 satellite sites) operating in eastern Ontario during the period from December 1, 2006, to November 30, 2008. PARTICIPANTS: A total of 44 849 patients, 53 full-time equivalent FPs, and 41 full-time equivalent NPs. MAIN OUTCOME MEASURES: Family physicians' and NPs' models of practice, the sociodemographic characteristics and medical profiles of patients who were treated in each model of practice, and FPs' and NPs' use of time. RESULTS: Patients were attributed to 1 of 3 models of practice in CHCs based on the proportion of visits to FPs and NPs: FP care (53% of patients), NP care (29%), and shared care (18%). Patients who received care in the NP model of practice were younger and more likely to be female, be homeless, and not have postsecondary education.Patients who received care in the FP model of practice had more complex medical conditions (cardiovascular disease, mental illness, lung disease, and diabetes) and more annual visits. Patients who received care in the shared care model had intermediate profiles. Nurse practitioners performed more off-site care and walk-in visits. Family physicians and NPs spent a similar proportion of time performing various duties such as direct clinical care and administration tasks. CONCLUSION: Although NPs mainly cared for their own patient panels (in the NP care model), they did share some patients with FPs and provide some care to patients under the FP model of practice. Patients who were cared for by FPs and NPs had quite different characteristics.

Patient-reported access to primary care in Ontario: effect of organizational characteristics.

OBJECTIVE: To describe patient-reported access to primary health care across 4 organizational models of primary care in Ontario, and to explore how access is associated with patient, provider, and practice characteristics. DESIGN: Cross-sectional survey. SETTING: One hundred thirty-seven randomly selected primary care practices in Ontario using 1 of 4 delivery models (fee for service, established capitation, reformed capitation, and community health centres). PARTICIPANTS: Patients included were at least 18 years of age, were not severely ill or cognitively impaired, were not known to the survey administrator, had consenting providers at 1 of the participating primary care practices, and were able to communicate in English or French either directly or through a translator. MAIN OUTCOME MEASURES: Patient-reported access was measured by a 4-item scale derived from the previously validated adult version of the Primary Care Assessment Tool. Questions were asked about physician availability during and outside of regular office hours and access to health information via telephone. Responses to the scale were normalized, with higher scores reflecting greater patient-reported access. Linear regressions were used to identify characteristics independently associated with access to care. RESULTS: Established capitation model practices had the highest patient-reported access, although the difference in scores between models was small. Our multilevel regression model identified several patient factors that were significantly (P = .05) associated with higher patient-reported access, including older age, female sex, good-to-excellent self-reported health, less mental health disability, and not working. Provider experience (measured as years since graduation) was the only provider or practice characteristic independently associated with improved patient-reported access. CONCLUSION: This study adds to what is known about access to primary care. The study found that established capitation models outperformed all the other organizational models, including reformed capitation models, independent of provider and practice variables save provider experience. This suggests that the capitation models might provide better access to care and that it might take time to realize the benefits of organizational reforms.