Practice Facilitation to Support Family Physicians in Encouraging COVID-19 Vaccine Uptake: A Multimethod Process Evaluation.

PURPOSE: We offered a practice facilitation intervention to family physicians in Ontario, Canada, known to have large numbers of patients not yet vaccinated against coronavirus disease 2019 (COVID-19). METHODS: We conducted a multimethod process evaluation embedded within a randomized controlled trial (clinical trial #NCT05099497). We collected descriptive statistics regarding engagement and qualitative interview data from family physicians and practice facilitators, as well as data from facilitator field notes. We analyzed and triangulated the data using thematic analysis and mapped barriers to and enablers for implementation to structural, organizational, physician, and patient factors. RESULTS: Of the 300 approached, 90 family physicians (30%) accepted facilitation. Of these, 57% received technical support to identify unvaccinated patients, 29% used trained medical student volunteers to contact patients on their behalf, and 30% used automated calling to reach patients. Key factors affecting engagement with the intervention were staff shortages owing to COVID-19 (structural), clinic characteristics such as technical issues and gatekeeping by staff, which prevented facilitators from talking with physicians (organizational), burnout (physician), and specialized populations that required targeted resources (patient). The facilitator's ability to address technical issues and connect family physicians with medical students helped with engagement. CONCLUSIONS: Strategies to help underresourced family physicians serving high-needs populations for issues of public health importance, such as vaccine promotion, must acknowledge the scarcity of physicians' time and provide new resources. To successfully engage family physicians, practice facilitators should seek to build trust and relationships over time, including with front-office staff.

Social workers' formal and informal leadership in interprofessional primary care teams in Ontario, Canada.

The development of interprofessional teams in primary care presents opportunities for social workers to take on new leadership positions. This study seeks to describe how social workers engaged in leadership roles in primary care during the COVID-19 pandemic. A cross-sectional on-line survey was disseminated to primary care social workers across Ontario, Canada, with a total of 159 respondents. Most respondents engaged in informal leadership roles and showcased a range of leadership skills promoting team collaboration and consultations, along with adapting to virtual care transitions. Findings suggest there needs to be intentional cultivation of social work leaders through supportive environments and training. Social workers in primary care have leadership capacity and are providing leadership to their primary care teams through formal and informal means. The leadership potential of social workers in primary care teams, however, is being underutilized and can be further developed.

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.

Interprofessional primary care: indispensable for family physicians yet invisible to older patients.

There is growing consensus that interprofessional primary care is key to delivering timely, coordinated, and comprehensive care, especially in the older patient population who often live with complex and chronic needs. Despite significant investments in reforming health systems toward interprofessional primary care, there is a paucity of evidence describing the importance of interprofessional primary care for older patients and physicians. This qualitative descriptive study aimed to understand the use and utility of interprofessional primary care for older patients and family physicians from the perspective of different stakeholders within primary care in Ontario, Canada. Twenty-five semi-structured interviews (including 16 older patients, six family physicians, three primary care managers) and a focus group with 13 patient representatives were conducted. Our study found that while the benefits of interprofessional primary care teams for family physicians were clearly emphasized, stakeholders consistently reported that older patients often appeared to be unaware of the presence of, or roles played by, non-physician healthcare professionals in their clinic. Better transparency and education regarding available services and roles of different care providers may allow for more optimal use of interprofessional family medicine clinics by patients.

An emerging and variant viral promoter of HIV-1 subtype C exhibits low-level gene expression noise.

BACKGROUND: We observe the emergence of several promoter-variant viral strains in India during recent years. The variant viral promoters contain additional copies of transcription factor binding sites present in the viral modulatory region or enhancer, including RBEIII, LEF-1, Ap-1 and/or NF-κB. These sites are crucial for governing viral gene expression and latency. Here, we infer that one variant viral promoter R2N3-LTR containing two copies of RBF-2 binding sites (an RBEIII site duplication) and three copies of NF-κB motifs may demonstrate low levels of gene expression noise as compared to the canonical RN3-LTR or a different variant R2N4-LTR (a duplication of an RBEIII site and an NF-κB motif). To demonstrate this, we constructed a panel of sub-genomic viral vectors of promoter-variant LTRs co-expressing two reporter proteins (mScarlet and Gaussia luciferase) under the dual-control of Tat and Rev. We established stable pools of CEM.NKR-CCR5 cells (CEM-CCR5RL reporter cells) and evaluated reporter gene expression under different conditions of cell activation. RESULTS: The R2N3-LTR established stringent latency that was highly resistant to reversal by potent cell activators such as TNF-α or PMA, or even to a cocktail of activators, compared to the canonical RN3- or the variant R2N4-LTR. The R2N3-LTR exhibited low-level basal gene expression in the absence of cell activation that enhanced marginally but significantly when activated. In the presence of Tat and Rev, trans-complemented in the form of an infectious virus, the R2N3-LTR demonstrated gene expression at levels comparable to the wild-type viral promoter. The R2N3-LTR is responsive to Tat and Rev factors derived from viral strains representing diverse genetic subtypes. CONCLUSION: With extremely low-level transcriptional noise, the R2N3-LTR can serve as an excellent model to examine the establishment, maintenance, and reversal of HIV-1 latency. The R2N3-LTR would also be an ideal viral promoter to develop high-throughput screening assays to identify potent latency-reversing agents since the LTR is not affected by the usual background noise of the cell.

Primary care teams' experiences of delivering mental health care during the COVID-19 pandemic: a qualitative study.

BACKGROUND: Integrated primary care teams are ideally positioned to support the mental health care needs arising during the COVID-19 pandemic. Understanding how COVID-19 has affected mental health care delivery within primary care settings will be critical to inform future policy and practice decisions during the later phases of the pandemic and beyond. The objective of our study was to describe the impact of the COVID-19 pandemic on primary care teams' delivery of mental health care. METHODS: A qualitative study using focus groups conducted with primary care teams in Ontario, Canada. Focus group data was analysed using thematic analysis. RESULTS: We conducted 11 focus groups with 10 primary care teams and a total of 48 participants. With respect to the impact of the COVID-19 pandemic on mental health care in primary care teams, we identified three key themes: i) the high demand for mental health care, ii) the rapid transformation to virtual care, and iii) the impact on providers. CONCLUSIONS: From the outset of the COVID-19 pandemic, primary care quickly responded to the rising mental health care demands of their patients. Despite the numerous challenges they faced with the rapid transition to virtual care, primary care teams have persevered. It is essential that policy and decision-makers take note of the toll that these demands have placed on providers. There is an immediate need to enhance primary care's capacity for mental health care for the duration of the pandemic and beyond.

Offering Patients a Medical Home - Not a Hallway - and a Stronger Health System.

This article examines three family health teams (FHTs) in different Ontario communities that exemplify the features of a Patient's Medical Home (PMH), a vision developed by the College of Family Physicians of Canada. With PMH supports and foundations in place, these FHTs deliver high-quality care enabled by strong PMH functions: accessible, comprehensive, patient- and family-centred continuous care that is responsive to a community's unique needs. Adhering to PMH principles not only improves patient experience, health outcomes and provider satisfaction but also leads to fewer unnecessary hospital admissions and emergency room visits - system savings and better use of public resources.

Innovation in Ontario's Family Health Teams: How Palliative and Coordinated Care Programs Are Filling Service Gaps and Keeping Patients at Home.

Collaborative interprofessional primary care (PC) teams are widely seen as an essential attribute of high-performing PC systems (Aggarwal and Hutchinson 2012). Effective PC teams play a key role in the mobilization of healthcare resources and navigation of the health and social care system for their patients. In Ontario, the establishment of Family Health Teams has resulted in the implementation of unique programs that deliver services to palliative and elderly patients with a focus on keeping them at home and out of hospital. Case studies cited in this article highlight two innovative programs in Family Health Teams and provide perspectives on lessons for successful implementation.

Pharmacists' role and experiences with delivering mental health care within team-based primary care settings during the COVID-19 pandemic.

OBJECTIVES: Pharmacists have been increasingly integrated into primary care teams, leading to improved health outcomes for patients. The two objectives of this study were (i) to describe how the COVID-19 pandemic impacted pharmacists' role in mental health care within Canadian primary care teams and (ii) to describe Canadian pharmacists' experiences collaborating with other healthcare providers in the delivery of mental health services during the COVID-19 pandemic. METHODS: Cross-sectional observational study utilizing an online survey consisting of closed-ended and open-ended questions. Primary care pharmacists in Ontario were eligible to participate. Descriptive statistics were collated, and qualitative data underwent thematic analysis. A total of 51 pharmacists participated in the study. KEY FINDINGS: The COVID-19 pandemic has led to the expanding role of pharmacists in attending to the mental health care of patients. Working within a collaborative, interprofessional healthcare environment, pharmacists support patients' mental health in a variety of ways, including medication education and management, non-pharmacologic approaches and supportive conversations, and identification of resources, including referrals, wellness checks, and consulting with physicians. Increasing demand for mental health services has led to higher referrals to pharmacists, which will likely persist and require further education of pharmacists in mental health along with better access to deliver virtual care. CONCLUSION: In response to the increasing mental health care needs of patients since the COVID-19 pandemic, primary care pharmacists reported increased attention spent on mental health care. Building capacity and ensuring support for pharmacists to continue to address the increasing mental health care demands is essential.

Impact of remuneration, extrinsic and intrinsic incentives on interprofessional primary care teams: protocol for a rapid scoping review.

INTRODUCTION: Interprofessional teams and funding and payment provider arrangements are key attributes of high-performing primary care. Several Canadian jurisdictions have introduced team-based models with different payment models. Despite these investments, the evidence of impact is mixed. This has raised questions about whether team-based primary care models are being implemented to facilitate team collaboration and effectiveness. Thus, we present a protocol for a rapid scoping review to systematically map, synthesise and summarise the existing literature on the impact of provider remuneration mechanisms and extrinsic and intrinsic incentives in team-based primary care. This review will answer three research questions: (1) What is the impact of provider remuneration models on team, patient, provider and system outcomes in primary care?; (2) What extrinsic and intrinsic incentives have been used in interprofessional primary care teams?; and (3) What is the impact of extrinsic and intrinsic team-based incentives on team, patient, provider and system outcomes? METHODS AND ANALYSIS: We will conduct a rapid scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. We will search electronic databases (Medline, Embase, CINAHL, PsycINFO, EconLit) and grey literature sources (Google Scholar, Google). This review will consider all empirical studies and full-text English-language articles published between 2000 and 2022. Reviewers will independently perform the literature search, data extraction and synthesis of included studies. The Mixed Methods Appraisal Tool will be used to appraise the quality of evidence. The literature will be synthesised, summarised and mapped to themes that answer the research question of this review. ETHICS AND DISSEMINATION: Ethics approval is not required. Findings from this study will be written for publication in an open-access peer-review journal and presented at national and international conferences. Knowledge users are part of the research team and will assist with disseminating findings to the public, clinicians, funders and professional associations.

Qualitative examination of collaboration in team-based primary care during the COVID-19 pandemic.

OBJECTIVE: The objective of this study was to describe Ontario primary care teams' experiences with collaboration during the COVID-19 pandemic. Descriptive qualitative methods using focus groups conducted virtually for data collection. SETTING: Primary care teams located in Ontario, Canada. PARTICIPANTS: Our study conducted 11 focus groups with 10 primary care teams, with a total of 48 participants reflecting a diverse range of interprofessional healthcare providers and administrators working in primary care. RESULTS: Three themes were identified using thematic analysis: (1) prepandemic team functioning facilitated adaptation, (2) new processes of team interactions and collaboration, and (3) team as a foundation of support. CONCLUSIONS: Results revealed the importance of collaboration for provider well-being, and the challenges of providing collaborative team-based primary care in the pandemic context. Caution against converting primary care collaboration to predominantly virtual modalities postpandemic is recommended. Further research on team functioning during the COVID-19 pandemic in other healthcare organisations will offer additional insight regarding how primary care teams can work collaboratively in a postpandemic environment.

The Benefits and Challenges of Precepting Pharmacy Students Virtually in Interprofessional Primary Care Teams.

OBJECTIVE: The objective of this study was to identify pharmacists' perspectives on the benefits and challenges of precepting pharmacy students during circumstances that require using virtual care in team-based primary care practices. METHODS: A cross-sectional online survey was disseminated through Qualtrics software from July 5, 2021, to October 13, 2021. We used a convenience sampling technique to recruit a sample of pharmacists working in primary care teams across Ontario, Canada, who were able to complete a web-based survey in English. RESULTS: A total of 51 pharmacists participated in the survey and provided complete responses (response rate of 41%). Participants noted benefits at 3 levels of precepting pharmacy students in primary care during the COVID-19 pandemic: (1) benefits to pharmacists, (2) benefits to patients, and (3) benefits to students. Challenges of precepting pharmacy students were: (1) difficulty training students virtually, (2) students not being ideally prepared to begin a practicum training during a pandemic, and (3) reduced availability and new workload demands. CONCLUSION: Pharmacists in team-based primary care highlighted substantial benefits and challenges for precepting students during a pandemic. Alternative mechanisms of experiential education delivery can provide new opportunities for pharmacy care yet can also restrict immersion into interprofessional team-based primary care and diminish pharmacist capacity. Additional support and resources to facilitate capacity are critical for pharmacy students to succeed in future practice in team-based primary care.

Identify and classify interprofessional primary care performance indicators: a scoping review protocol.

INTRODUCTION: Measuring the performance of interprofessional primary care is needed to examine whether this model of care is achieving its desired outcomes on patient care and health system effectiveness as well as to guide quality improvement initiatives. The aim of this scoping review is to map the literature on primary care performance measurement indicators to determine the extent to which current indicators capture or could be adapted to capture processes, outputs and outcomes that reflect interprofessional primary care. METHODS AND ANALYSIS: The review will be guided by the six-stage framework by Arksey and O'Malley (2005). MEDLINE, Embase, CINAHL, grey literature and the reference list of key studies will be searched to identify any study, published in English or French between 2000 and 2022, related to the concepts of performance indicators, frameworks, interprofessional teams and primary care. Two reviewers will independently screen all abstracts and full-text studies for inclusion. Eligible indicators will be classified according to process, output and outcome domains proposed by two validated frameworks. This study started in November 2022 and is expected to be completed by July 2023. ETHICS AND DISSEMINATION: This review does not require ethical approval. The results will be disseminated through a peer-reviewed publication, conference presentations and presentations to stakeholders.

The experience of primary care teams during the early phase of COVID-19: A qualitative study of primary care practice leaders in Ontario, Canada.

BACKGROUND: The COVID-19 pandemic has caused a rapid shift to virtual care in primary care practices around the globe. There has been little focus on the experiences of interprofessional teams through the lens of primary care practice leaders. The objective of this study was to examine the experience of primary care teams during the first wave of the COVID-19 pandemic from the perspective of primary care leadership. METHODS: Qualitative study using qualitative description methods. Executive Directors of interprofessional primary care teams belonging to the Association of Family Health Teams of Ontario (AFHTO) were invited to participate. Executive Directors were interviewed and the interview transcripts were analyzed using thematic analysis. RESULTS: Seventy-one Executive Directors from across all regions of Ontario were interviewed for the study, representing 37% of the AFHTO member clinics. Four themes were identified in the data: i) Complexities of Virtual Care, ii) Continuation of In-person Care, iii) Supporting Patients at Risk, and iv) Stepping up and into New Roles. CONCLUSIONS: Primary care teams rapidly mobilized to deliver the majority of their care virtually, while continuing to provide in-person and home care as required. Major challenges to virtual care included technological infrastructure and unfamiliarity with virtual platforms. Advantages to virtual care included convenience and time savings. Virtual care will likely continue to be an important mode of primary care delivery moving forward.

An Optimized Tat/Rev Induced Limiting Dilution Assay for the Characterization of HIV-1 Latent Reservoirs.

The administration of antiretroviral therapy (ART) leads to a rapid reduction in plasma viral load in HIV-1 seropositive subjects. However, when ART is suspended, the virus rebounds due to the presence of a latent viral reservoir. Several techniques have been developed to characterize this latent viral reservoir. Of the various assay formats available presently, the Tat/Rev induced limiting dilution assay (TILDA) offers the most robust and technically simple assay strategy. The TILDA formats reported thus far are limited by being selective to one or a few HIV-1 genetic subtypes, thus, restricting them from a broader level application. The novel TILDA, labelled as U-TILDA ('U' for universal), can detect all the major genetic subtypes of HIV-1 unbiasedly, and with comparable sensitivity of detection. U-TILDA is well suited to characterize the latent reservoirs of HIV-1 and aid in the formulation of cure strategies. Graphical abstract.

Erratum: Correction Notice: An Optimized Tat/Rev Induced Limiting Dilution Assay for the Characterization of HIV-1 Latent Reservoirs.

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The Delivery of Patient Care in Ontario's Family Health Teams during the First Wave of the COVID-19 Pandemic.

OBJECTIVE: The objective of this paper was to identify continuations and changes in care delivery methods in primary care teams during the COVID-19 pandemic. DESIGN: The study used a cross-sectional, web-based survey comprising close-ended and open-ended questions. SETTING: The setting comprised family health teams (FHTs) across Ontario, Canada. PARTICIPANTS: The participants included executive directors of FHTs or designates of their choosing. SURVEY: Descriptive statistics were derived from responses to close-ended questions, and responses to open-ended questions were coded using thematic analysis. RESULTS: With 93 participants, the response rate was 48%. Participants reported the continuation of in-person care, the implementation of virtual care across FHTs and collaboration within these teams and their communities.

An Improved Tat/Rev Induced Limiting Dilution Assay With Enhanced Sensitivity and Breadth of Detection.

Tat/Rev Induced Limiting Dilution Assay (TILDA) is instrumental in estimating the size of latent reservoirs of HIV-1. Here, we report an optimized TILDA containing a broader detection range compared to the reported methods and high sensitivity. Giving priority to sequence conservation, we positioned the two forward primers and the probe in exon-1 of HIV-1. The reverse primers are positioned in highly conserved regions of exon-7. The optimized TILDA detected eight molecular clones belonging to five major genetic subtypes of HIV-1 with a comparable detection sensitivity. Using the optimized assay, we show that only a minor proportion of CD4+ T cells of primary clinical samples can spontaneously generate multiply spliced viral transcripts. A significantly larger proportion of the cells produced viral transcripts following activation. The optimized TILDA is suitable to characterize HIV-1 latent reservoirs and the therapeutic strategies intended to target the reservoir size.

The Evolution of Regulatory Elements in the Emerging Promoter-Variant Strains of HIV-1 Subtype C.

In a multicentric, observational, investigator-blinded, and longitudinal clinical study of 764 ART-naïve subjects, we identified nine different promoter variant strains of HIV-1 subtype C (HIV-1C) emerging in the Indian population, with some of these variants being reported for the first time. Unlike several previous studies, our work here focuses on the evolving viral regulatory elements, not the coding sequences. The emerging viral strains contain additional copies of the existing transcription factor binding sites (TFBS), including TCF-1α/LEF-1, RBEIII, AP-1, and NF-κB, created by sequence duplication. The additional TFBS are genetically diverse and may blur the distinction between the modulatory region of the promoter and the viral enhancer. In a follow-up analysis, we found trends, but no significant associations between any specific variant promoter and prognostic markers, probably because the emerging viral strains might not have established mono infections yet. Illumina sequencing of four clinical samples containing a coinfection indicated the domination of one strain over the other and establishing a stable ratio with the second strain at the follow-up time points. Since a single promoter regulates viral gene expression and constitutes the master regulatory circuit with Tat, the acquisition of additional and variant copies of the TFBS may significantly impact viral latency and latent reservoir characteristics. Further studies are urgently warranted to understand how the diverse TFBS profiles of the viral promoter may modulate the characteristics of the latent reservoir, especially following the initiation of antiretroviral therapy.

The prevalence of malocclusion and orthodontic treatment needs in school going children of Nalagarh, Himachal Pradesh, India.

OBJECTIVE: The aim of this study was to determine the prevalence of malocclusion and orthodontic treatment need in 13-18-year-old schoolchildren of Nalagarh, Himachal Pradesh, India using the Index of Orthodontic Treatment need (IOTN) and to analyze the treatment needs between males and females and correlation between the esthetic component (AC) and dental health component (DHC) of IOTN. SUBJECTS AND METHODS: The sample comprised 2000 school children (1125 females and 875 males) who had not undergone orthodontic treatment. No radiographs, study casts, were used; IOTN was calculated from clinical examination. RESULTS: DHC results showed that little need for orthodontic treatment was found in 31.6% and moderate need in 30.85%. A great need was estimated at 37.55%. Severe contact point displacement of more than 4 mm was the most common occlusal feature in the definite treatment need group, followed by increased overjet, impeded eruption of teeth, and anterior or posterior cross bite. AC results showed that little need for orthodontic treatment was in 86.15%, moderate need in 8.90%, and great need in 4.95%. LIMITATIONS: Index does not consider midline discrepancy, soft tissue abnormalities, and AC does not include Class III and Class II div 2 malocclusion photographs. CONCLUSIONS: There seems a discrepancy in the proportion of children needing orthodontic treatment on esthetic and dental health grounds. This study provides baseline data on the need and demand for orthodontic treatment among the sample which is important for planning public orthodontic and dental services.