Adapting care provision in family practice during the COVID-19 pandemic: a qualitative study exploring the impact of primary care reforms in four Canadian regions.

BACKGROUND: Over the past two decades, Canadian provinces and territories have introduced a series of primary care reforms in an attempt to improve access to and quality of primary care services, resulting in diverse organizational structures and practice models. We examine the impact of these reforms on family physicians' (FPs) ability to adapt their roles during the COVID-19 pandemic, including the provision of routine primary care. METHODS: As part of a larger case study, we conducted semi-structured qualitative interviews with FPs in four Canadian regions: British Columbia, Newfoundland and Labrador, Nova Scotia, and Ontario. During the interviews, participants were asked about their personal and practice characteristics, the pandemic-related roles they performed over different stages of the pandemic, the facilitators and barriers they experienced in performing these roles, and potential roles FPs could have filled. Interviews were transcribed and a thematic analysis approach was applied to identify recurring themes in the data. RESULTS: Sixty-eight FPs completed an interview across the four regions. Participants described five areas of primary care reform that impacted their ability to operate and provide care during the pandemic: funding models, electronic medical records (EMRs), integration with regional entities, interdisciplinary teams, and practice size. FPs in alternate funding models experienced fewer financial constraints than those in fee-for-service practices. EMR access enhanced FPs' ability to deliver virtual care, integration with regional entities improved access to personal protective equipment and technological support, and team-based models facilitated the implementation of infection prevention and control protocols. Lastly, larger group practices had capacity to ensure adequate staffing and cover additional costs, allowing FPs more time to devote to patient care. CONCLUSIONS: Recent primary care system reforms implemented in Canada enhanced FPs' ability to adapt to the uncertain and evolving environment of providing primary care during the pandemic. Our study highlights the importance of ongoing primary care reforms to enhance pandemic preparedness and advocates for further expansion of these reforms.

Practice- and System-Based Interventions to Reduce COVID-19 Transmission in Primary Care Settings: A Qualitative Study.

Using qualitative interviews with 68 family physicians (FPs) in Canada, we describe practice- and system-based approaches that were used to mitigate COVID-19 exposure in primary care settings across Canada to ensure the continuation of primary care delivery. Participants described how they applied infection prevention and control procedures (risk assessment, hand hygiene, control of environment, administrative control, personal protective equipment) and relied on centralized services that directed patients with COVID-19 to settings outside of primary care, such as testing centres. The multi-layered approach mitigated the risk of COVID-19 exposure while also conserving resources, preserving capacity and supporting supply chains.

Strengthening the integration of primary care in pandemic response plans: a qualitative interview study of Canadian family physicians.

BACKGROUND: As the first point of contact in health care, primary care providers play an integral role in pandemic response. Despite this, primary care has been overlooked in previous pandemic plans, with a lack of emphasis on ways in which the unique characteristics of family practice could be leveraged to create a more effective response. AIM: To explore family physicians' perceptions of the integration of primary care in the COVID-19 pandemic response. DESIGN AND SETTING: Descriptive qualitative approach examining family physician roles during the COVID-19 pandemic across four regions in Canada. METHOD: Semi-structured qualitative interviews were conducted with family physicians and participants were asked about their roles during each pandemic stage, as well as facilitators and barriers they experienced in performing these roles. Interviews were transcribed and a thematic analysis approach was employed to develop a unified coding template across the four regions and identify recurring themes. RESULTS: In total, 68 family physicians completed interviews. Four priorities for integrating primary care in future pandemic planning were identified: 1) improve communication with family physicians; 2) prioritise community-based primary care; 3) leverage the longitudinal relationship between patients and family physicians; and 4) preserve primary care workforce capacity. Across all regions, family physicians felt that primary care was not well incorporated into the COVID-19 pandemic response. CONCLUSION: Future pandemic plans require greater integration of primary care to ensure the delivery of an effective and coordinated pandemic response. Strengthening pandemic preparedness requires a broader reconsideration and better understanding of the central role of primary care in health system functioning.

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

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

Family physicians' responses to personal protective equipment shortages in four regions in Canada: a qualitative study.

BACKGROUND: Despite well-documented increased demands and shortages of personal protective equipment (PPE) during previous disease outbreaks, health systems in Canada were poorly prepared to meet the need for PPE during the COVID-19 pandemic. In the primary care sector, PPE shortages impacted the delivery of health services and contributed to increased workload, fear, and anxiety among primary care providers. This study examines family physicians' (FPs) response to PPE shortages during the first year of the COVID-19 pandemic to inform future pandemic planning. METHODS: As part of a multiple case study, we conducted semi-structured qualitative interviews with FPs across four regions in Canada. During the interviews, FPs were asked to describe the pandemic-related roles they performed over different stages of the pandemic, facilitators and barriers they experienced in performing these roles, and potential roles they could have filled. Interviews were transcribed and a thematic analysis approach was employed to identify recurring themes. For the current study, we examined themes related to PPE. RESULTS: A total of 68 FPs were interviewed across the four regions. Four overarching themes were identified: 1) factors associated with good PPE access, 2) managing PPE shortages, 3) impact of PPE shortages on practice and providers, and 4) symbolism of PPE in primary care. There was a wide discrepancy in access to PPE both within and across regions, and integration with hospital or regional health authorities often resulted in better access than community-based practices. When PPE was limited, FPs described rationing and reusing these resources in an effort to conserve, which often resulted in anxiety and personal safety concerns. Many FPs expressed that PPE shortages had come to symbolize neglect and a lack of concern for the primary care sector in the pandemic response. CONCLUSIONS: During the COVID-19 pandemic response, hospital-centric plans and a lack of prioritization for primary care led to shortages of PPE for family physicians. This study highlights the need to consider primary care in PPE conservation and allocation strategies and to examine the influence of the underlying organization of primary care on PPE distribution during the pandemic.

The roles of family physicians during a pandemic.

Family physicians play important roles throughout all stages of a pandemic response; however, actionable descriptions outlining these roles are absent from current pandemic plans. Using a multiple case study design, we conducted a document analysis and interviewed 68 family physicians in four Canadian regions. We identified roles performed by family physicians in five distinct stages of pandemic response: pre-pandemic, phased closure and re-opening, acute care crisis, vaccination, and pandemic recovery. In addition to adopting public health guidance to ensure continued access to primary care services, family physicians were often expected to operationalize public health roles (eg, staffing assessment centres), modulate access to secondary/tertiary services, help provide surge capacity in acute care facilities, and enhance supports and outreach to vulnerable populations. Future pandemic plans should include family physicians in planning, explicitly incorporate family physician roles, and ensure needed resources are available to allow for an effective primary care response.

Designs, facilitators, barriers, and lessons learned during the implementation of emergency department led virtual urgent care programs in Ontario, Canada.

Introduction: Virtual patient care has seen incredible growth since the beginning of the COVID-19 pandemic. To provide greater access to safe and timely urgent care, in the fall of 2020, the Ministry of Health introduced a pilot program of 14 virtual urgent care (VUC) initiatives across the province of Ontario. The objective of this paper was to describe the overall design, facilitators, barriers, and lessons learned during the implementation of seven emergency department (ED) led VUC pilot programs in Ontario, Canada. Methods: We assembled an expert panel of 13 emergency medicine physicians and researchers with experience leading and implementing local VUC programs. Each VUC program lead was asked to describe their local pilot program, share common facilitators and barriers to adoption of VUC services, and summarize lessons learned for future VUC design and development. Results: Models of care interventions varied across VUC pilot programs related to triage, staffing, technology, and physician remuneration. Common facilitators included local champions to guide program delivery, provincial funding support, and multi-modal marketing and promotions. Common barriers included behaviour change strategies to support adoption of a new service, access to high-quality information technology to support new workflow models that consider privacy, risk, and legal perspectives, and standardized data collection which underpin overall objective impact assessments. Conclusions: These pilot programs were rapidly implemented to support safe access to care and ED diversion of patients with low acuity issues during the COVID-19 pandemic. The heterogeneity of program implementation respects local autonomy yet may present challenges for sustainability efforts and future funding considerations.

Family physician leadership during the COVID-19 pandemic: roles, functions and key supports.

PURPOSE: Strong leadership in primary care is necessary to coordinate an effective pandemic response; however, descriptions of leadership roles for family physicians are absent from previous pandemic plans. This study aims to describe the leadership roles and functions family physicians played during the COVID-19 pandemic in Canada and identify supports and barriers to formalizing these roles in future pandemic plans. DESIGN/METHODOLOGY/APPROACH: This study conducted semi-structured qualitative interviews with family physicians across four regions in Canada as part of a multiple case study. During the interviews, participants were asked about their roles during each pandemic stage and the facilitators and barriers they experienced. Interviews were transcribed and a thematic analysis approach was used to identify recurring themes. FINDINGS: Sixty-eight family physicians completed interviews. Three key functions of family physician leadership during the pandemic were identified: conveying knowledge, developing and adapting protocols for primary care practices and advocacy. Each function involved curating and synthesizing information, tailoring communications based on individual needs and building upon established relationships. PRACTICAL IMPLICATIONS: Findings demonstrate the need for future pandemic plans to incorporate formal family physician leadership appointments, as well as supports such as training, communication aides and compensation to allow family physicians to enact these key roles. ORIGINALITY/VALUE: The COVID-19 pandemic presents a unique opportunity to examine the leadership roles of family physicians, which have been largely overlooked in past pandemic plans. This study's findings highlight the importance of these roles toward delivering an effective and coordinated pandemic response with uninterrupted and safe access to primary care.

Development of a primary care pandemic plan informed by in-depth policy analysis and interviews with family physicians across Canada during COVID-19: a qualitative case study protocol.

INTRODUCTION: Given the recurrent risk of respiratory illness-based pandemics, and the important roles family physicians play during public health emergencies, the development of pandemic plans for primary care is imperative. Existing pandemic plans in Canada, however, do not adequately incorporate family physicians' roles and perspectives. This policy and planning oversight has become increasingly evident with the emergence of the novel coronavirus disease, COVID-19, pandemic. This study is designed to inform the development of pandemic plans for primary care through evidence from four provinces in Canada: British Columbia, Newfoundland and Labrador, Nova Scotia, and Ontario. METHODS AND ANALYSIS: We will employ a multiple-case study of regions in four provinces. Each case consists of a mixed methods design which comprises: (1) a chronology of family physician roles in the COVID-19 pandemic response; (2) a provincial policy analysis; and (3) qualitative interviews with family physicians. Relevant policy and guidance documents will be identified through targeted, snowball and general search strategies. Additionally, these policy documents will be analysed to identify gaps and/or emphases in existing policies and policy responses. Interviews will explore family physicians' proposed, actual and potential roles during the pandemic, the facilitators and barriers they have encountered throughout and the influence of gender on their professional roles. Data will be thematically analysed using a content analysis framework, first at the regional level and then through cross-case analyses. ETHICS AND DISSEMINATION: Approval for this study has been granted by the Research Ethics of British Columbia, the Health Research Ethics Board of Newfoundland and Labrador, the Nova Scotia Health Authority Research Ethics Board and the Western University Research Ethics Board. Findings will be disseminated via conferences and peer-reviewed publications. Evidence and lessons learnt will be used to develop tools for government ministries, public health units and family physicians for improved pandemic response plans for primary care.

Suppressor of fused controls mid-hindbrain patterning and cerebellar morphogenesis via GLI3 repressor.

Sonic Hedgehog and its GLI transcriptional effectors control foliation complexity during cerebellar morphogenesis by promoting granule cell precursor proliferation. Here, we reveal a novel contribution of Sonic Hedgehog-GLI signaling to cerebellar patterning and cell differentiation by generating mice with targeted deletion of Suppressor of Fused (SuFu), a regulator of Sonic Hedgehog signaling, in the mid-hindbrain. Postnatal SuFu-deficient mice exhibit impaired motor coordination and severe cerebellar mispatterning. SuFu conditional knock-out embryos display abnormal mid-hindbrain morphology associated with misexpression of Fgf8, and delayed differentiation and abnormal migration of major cerebellar cell types. Sonic Hedgehog is ectopically expressed in the external granule layer and Hedgehog signaling is upregulated. While expression of full-length GLI transcriptional activators downstream of Hedgehogs is markedly reduced, a processed form of GLI3, a transcriptional repressor, is essentially lost. Genetic expression of a Gli3 allele encoding GLI3 repressor in SuFu-deficient mice largely rescues abnormal cerebellar patterning and cell differentiation observed in mice with SuFu deficiency alone. Together, our data demonstrate that SuFu controls cerebellar patterning and cell differentiation in a GLI3 repressor-dependent manner.

Canonical WNT/beta-catenin signaling is required for ureteric branching.

WNT/beta-catenin signaling has an established role in nephron formation during kidney development. Yet, the role of beta-catenin during ureteric morphogenesis in vivo is undefined. We generated a murine genetic model of beta-catenin deficiency targeted to the ureteric bud cell lineage. Newborn mutant mice demonstrated bilateral renal aplasia or renal dysplasia. Analysis of the embryologic events leading to this phenotype revealed that abnormal ureteric branching at E12.5 precedes histologic abnormalities at E13.5. Microarray analysis of E12.5 kidney tissue identified decreased Emx2 and Lim1 expression among a small subset of renal patterning genes disrupted at the stage of abnormal branching. These alterations are followed by decreased expression of genes downstream of Emx2, including Lim1, Pax2, and the ureteric tip markers, c-ret and Wnt 11. Together, these data demonstrate that beta-catenin performs essential functions during renal branching morphogenesis via control of a hierarchy of genes that control ureteric branching.

At the crossroads between tension-type headache and fibromyalgia.

Fibromyalgia syndrome and tension-type headache have multiple clinical features in common, and pathogenic mechanisms partly overlap. Significant differences need to be recognized as well. Studying the correlations of these often comorbid conditions represents a unique opportunity to gain insight into their pathophysiology and that of other chronic pain syndromes, to increase the accuracy of their diagnosis, and to improve the therapeutic armamentarium.

Control of murine kidney development by sonic hedgehog and its GLI effectors.

Sonic hedgehog (SHH) controls cell differentiation and morphogenesis in many tissues and species. The mammalian kidney is a paradigm for studying epithelial-mesenchymal interactions and growth factor signaling during embryogenesis. Here, we review our recent findings demonstrating that SHH is required for normal murine kidney development. During renal morphogenesis, SHH controls a hierarchy of genes including renal patterning genes, cell cycle modulators, and GLI family members. Our investigation of GLI protein processing and binding of GLI activators and repressor to SHH target genes provide insight into the molecular mechanisms by which SHH and its GLI family of effectors control renal embryogenesis. Further, we highlight the roles of BMP, WNT and FGF signaling during renal development and discuss possible interactions of these pathways with SHH signaling.

A 10-year retrospective review of 758 DIEP flaps for breast reconstruction.

This study examined 758 deep inferior epigastric perforator flaps for breast reconstruction, with respect to risk factors and associated complications. Risk factors that demonstrated significant association with any breast or abdominal complication included smoking (p = 0.0000), postreconstruction radiotherapy (p = 0.0000), and hypertension (p = 0.0370). Ninety-eight flaps (12.9 percent) developed fat necrosis. Associated risk factors were smoking (p = 0.0226) and postreconstruction radiotherapy (p = 0.0000). Interestingly, as the number of perforators increased, so did the incidence of fat necrosis. There were only 19 cases (2.5 percent) of partial flap loss and four cases (0.5 percent) of total flap loss. Patients with 45 flaps (5.9 percent) were returned to the operating room before the second-stage procedure. Patients with 29 flaps (3.8 percent) were returned to the operating room because of venous congestion. Venous congestion and any complication were observed to be statistically unrelated to the number of venous anastomoses. Overall, postoperative abdominal hernia or bulge occurred after only five reconstructions (0.7 percent). Complication rates in this large series were comparable to those in retrospective reviews of pedicle and free transverse rectus abdominis musculocutaneous flaps. Previous studies of the free transverse rectus abdominis musculocutaneous flap described breast complication rates ranging from 8 to 13 percent and abdominal complication rates ranging from 0 to 82 percent. It was noted that, with experience in microsurgical techniques and perforator selection, the deep inferior epigastric perforator flap offers distinct advantages to patients, in terms of decreased donor-site morbidity and shorter recovery periods. Mastery of this flap provides reconstructive surgeons with more extensive options for the treatment of postmastectomy patients.