Patient Experience With Resident Versus Staff Physicians: Results From a Cross-Sectional Patient Survey From Canadian Family Medicine Residencies.

BACKGROUND AND OBJECTIVES: We compared experiences of patients who reported usually being seen by a resident with those usually seen by a staff physician. METHODS: We analyzed responses to a patient experience survey distributed at 13 family medicine teaching practices affiliated with the University of Toronto between May and June 2020. We analyzed responses to seven questions pertaining to timely access, continuity, and patient-centeredness. We compared responses between two types of usual primary care clinicians and calculated odds ratios before and after adjustment for patient characteristics. RESULTS: We analyzed data from 6,545 unique surveys; 18.6% reported their usual clinician was a resident physician. Resident patients were more likely to be older, born outside of Canada, report a high school education or less, and report having difficulty making ends meet. Compared to patients of staff physicians, patients of resident physicians had lower odds of being able to see their preferred primary care clinician and lower odds of getting nonurgent care in a reasonable time. They also had lower odds of reporting patient-centered care, but we found no significant differences in whether the time for an urgent appointment was about right or whether accessing care after hours was easy. CONCLUSIONS: In our setting, patients who reported usually seeing resident physicians had worse continuity of care and timeliness for nonurgent care than patients who reported usually seeing staff physicians despite resident patients being older, sicker, and having a lower socioeconomic position. Postgraduate training programs need to test models to support access and continuity for resident patient panels.

The Development and Characterization of a Next-Generation Oncolytic Virus Armed with an Anti-PD-1 sdAb for Osteosarcoma Treatment In Vitro.

Osteosarcoma (OS) is a primary bone malignancy characterized by an aggressive nature, limited treatment options, low survival rate, and poor patient prognosis. Conditionally replicative adenoviruses (CRAds) armed with immune checkpoint inhibitors hold great potential for enhanced therapeutic efficacy. The present study aims to investigate the anti-tumor efficacy of CAV2-AU-M2, a CAV2-based CRAd armed with an anti-PD-1 single-domain antibody (sdAb), against OS cell lines in vitro. The infection, conditional replication, cytopathic effects, and cytotoxicity of CAV2-AU-M2 were tested in four different OS cell lines in two-dimensional (2D) and three-dimensional (3D) cell cultures. CAV2-AU-M2 showed selective replication in the OS cells and induced efficient tumor cell lysis and death. Moreover, CAV2-AU-M2 produced an anti-PD-1 sdAb that demonstrated effective binding to the PD-1 receptors. This study demonstrated the first CRAd armed with an anti-PD-1 sdAb. This combined approach of two distinct immunotherapies is intended to enhance the anti-tumor immune response in the tumor microenvironment.

Developing an Audit and Feedback Dashboard for Family Physicians: User-Centered Design Process.

BACKGROUND: Audit and feedback (A&F), the summary and provision of clinical performance data, is a common quality improvement strategy. Successful design and implementation of A&F-or any quality improvement strategy-should incorporate evidence-informed best practices as well as context-specific end user input. OBJECTIVE: We used A&F theory and user-centered design to inform the development of a web-based primary care A&F dashboard. We describe the design process and how it influenced the design of the dashboard. METHODS: Our design process included 3 phases: prototype development based on A&F theory and input from clinical improvement leaders; workshop with family physician quality improvement leaders to develop personas (ie, fictional users that represent an archetype character representative of our key users) and application of those personas to design decisions; and user-centered interviews with family physicians to learn about the physician's reactions to the revised dashboard. RESULTS: The team applied A&F best practices to the dashboard prototype. Personas were used to identify target groups with challenges and behaviors as a tool for informed design decision-making. Our workshop produced 3 user personas, Dr Skeptic, Frazzled Physician, and Eager Implementer, representing common users based on the team's experience of A&F. Interviews were conducted to further validate findings from the persona workshop and found that (1) physicians were interested in how they compare with peers; however, if performance was above average, they were not motivated to improve even if gaps compared to other standards in their care remained; (2) burnout levels were high as physicians are trying to catch up on missed care during the pandemic and are therefore less motivated to act on the data; and (3) additional desired features included integration within the electronic medical record, and more up-to-date and accurate data. CONCLUSIONS: We found that carefully incorporating data from user interviews helped operationalize generic best practices for A&F to achieve an acceptable dashboard that could meet the needs and goals of physicians. We demonstrate such a design process in this paper. A&F dashboards should address physicians' data skepticism, present data in a way that spurs action, and support physicians to have the time and capacity to engage in quality improvement work; the steps we followed may help those responsible for quality improvement strategy implementation achieve these aims.

Drug Dissolution in Oral Drug Absorption: Workshop Report.

The in-person workshop "Drug Dissolution in Oral Drug Absorption" was held on May 23-24, 2023, in Baltimore, MD, USA. The workshop was organized into lectures and breakout sessions. Three common topics that were re-visited by various lecturers were amorphous solid dispersions (ASDs), dissolution/permeation interplay, and in vitro methods to predict in vivo biopharmaceutics performance and risk. Topics that repeatedly surfaced across breakout sessions were the following: (1) meaning and assessment of "dissolved drug," particularly of poorly water soluble drug in colloidal environments (e.g., fed conditions, ASDs); (2) potential limitations of a test that employs sink conditions for a poorly water soluble drug; (3) non-compendial methods (e.g., two-stage or multi-stage method, dissolution/permeation methods); (4) non-compendial conditions (e.g., apex vessels, non-sink conditions); and (5) potential benefit of having both a quality control method for batch release and a biopredictive/biorelevant method for biowaiver or bridging scenarios. An identified obstacle to non-compendial methods is the uncertainty of global regulatory acceptance of such methods.

The STOP COVID 2 Study: Fluvoxamine vs Placebo for Outpatients With Symptomatic COVID-19, a Fully Remote Randomized Controlled Trial.

Background: Prior randomized clinical trials have reported benefit of fluvoxamine ≥200 mg/d vs placebo for patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Methods: This randomized, double-blind, placebo-controlled, fully remote multisite clinical trial evaluated whether fluvoxamine prevents clinical deterioration in higher-risk outpatients with acute coronavirus disease 2019 (COVID-19). Between December 2020 and May 2021, nonhospitalized US and Canadian participants with confirmed symptomatic infection received fluvoxamine (50 mg on day 1, 100 mg twice daily thereafter) or placebo for 15 days. The primary modified intent-to-treat (mITT) population included participants who started the intervention within 7 days of symptom onset with a baseline oxygen saturation ≥92%. The primary outcome was clinical deterioration within 15 days of randomization, defined as having both (1) shortness of breath (severity ≥4 on a 0-10 scale or requiring hospitalization) and (2) oxygen saturation <92% on room air or need for supplemental oxygen. Results: A total of 547 participants were randomized and met mITT criteria (n = 272 fluvoxamine, n = 275 placebo). The Data Safety Monitoring Board recommended stopping early for futility related to lower-than-predicted event rates and declining accrual concurrent with vaccine availability in the United States and Canada. Clinical deterioration occurred in 13 (4.8%) participants in the fluvoxamine group and 15 (5.5%) participants in the placebo group (absolute difference at day 15, 0.68%; 95% CI, -3.0% to 4.4%; log-rank P = .91). Conclusions: This trial did not find fluvoxamine efficacious in preventing clinical deterioration in unvaccinated outpatients with symptomatic COVID-19. It was stopped early and underpowered due to low primary outcome rates. Clinical Trials Registration: ClinicalTrials.gov Identifier: NCT04668950.

miRNAs: Potential as Biomarkers and Therapeutic Targets for Cancer.

MicroRNAs (miRNAs) are single-stranded, non-coding RNA molecules that regulate gene expression post-transcriptionally by binding to messenger RNAs. miRNAs are important regulators of gene expression, and their dysregulation is implicated in many human and canine diseases. Most cancers tested to date have been shown to express altered miRNA levels, which indicates their potential importance in the oncogenic process. Based on this evidence, numerous miRNAs have been suggested as potential cancer biomarkers for both diagnosis and prognosis. miRNA-based therapies have also been tested in different cancers and have provided measurable clinical benefits to patients. In addition, understanding miRNA biogenesis and regulatory mechanisms in cancer can provide important knowledge about resistance to chemotherapies, leading to more personalized cancer treatment. In this review, we comprehensively summarized the importance of miRNA in human and canine cancer research. We discussed the current state of development and potential for the miRNA as both a diagnostic marker and a therapeutic target.

Impact of virtual visits on primary care physician work flows.

OBJECTIVE: To understand the impact of virtual visits on primary care physician (PCP) work flows. DESIGN: Qualitative semistructured interviews. SETTING: Primary care practices within 5 regions in southern Ontario. PARTICIPANTS: Physicians representing primary care practices of various sizes and remuneration models (eg, capitation and fee-for-service models). METHODS: Interviews were conducted with PCPs involved in a large-scale pilot project implementing virtual visits (via a Web-based application) into clinical practices. Convenience and purposive sampling were used to recruit PCPs between January 2018 and March 2019. To obtain a representative sample, participants were sought from a variety of practice types and geographic regions. High and low users of virtual visits were included. Interviews were audiorecorded and transcribed. An inductive thematic analysis was used to identify prominent themes and subthemes. MAIN FINDINGS: Twenty-six physicians were interviewed (n=15 using convenience sampling and n=11 through purposive sampling). Four themes were identified: PCPs employ diverse approaches to integrate virtual care into their work flow; PCPs recognize that implementing virtual visits requires upfront time and effort but have variable perceptions regarding long-term impact of virtual care on processes; asynchronous messaging is preferable to synchronous audio or video visits; and strategies were identified to improve the integration of virtual visits. CONCLUSION: The potential of virtual care to improve work flow is dependent on the way these visits are implemented and used. Dedicated time for implementation, emphasis on using asynchronous secure messaging, and access to clinical champions and structured change management support were associated with more seamless integration of virtual visits.

Redesigning primary care: Provider perspectives on the clinical utility of virtual visits.

OBJECTIVE: To explore primary care physician (PCP) perspectives on the clinical utility of virtual visits. DESIGN: Qualitative design involving semistructured interviews. SETTING: Primary care practices within 5 regions in southern Ontario. PARTICIPANTS: Primary care physicians representing different practice sizes and remuneration models. METHODS: Interviews were conducted with PCPs who were involved in a large-scale pilot implementation of virtual visits (patient-provider asynchronous messaging, or synchronous audio or video communication). The first phase involved a convenience sample of users in the first 2 regions where the pilot was initiated; after implementation in all 5 regions, purposive sampling was used to ensure diversity within the sample (eg, physicians representing different use frequencies of virtual visits, regions, and remuneration models). Interviews were audiorecorded and transcribed. An inductive thematic analysis was used to identify prominent themes and subthemes. MAIN FINDINGS: Twenty-six physicians were interviewed. Fifteen were recruited using convenience sampling and 11 through purposive sampling. Four themes regarding the clinical utility of virtual visits were identified: virtual visits can effectively resolve many patient concerns, with some variation in PCP comfort using virtual visits for specific conditions; virtual visits are beneficial for a range of patients but some patients might overuse or inappropriately use them; PCPs prefer to use asynchronous messaging (eg, text or online messaging) because of its convenience and flexibility; and virtual visits can provide value at the patient, provider, and health system levels. CONCLUSION: While participants believed that virtual visits can be appropriately used to resolve a variety of clinical concerns, they found in practice that virtual visits are fundamentally different from face-to-face encounters. Professional guidelines on appropriate use cases should be established to develop a standard framework for virtual care.

Improving diagnosis and treatment of knee osteoarthritis in persons with type 2 diabetes: development of a complex intervention.

BACKGROUND: Symptomatic knee osteoarthritis (OA) commonly co-occurs in people with type 2 diabetes (T2DM) and increases the risk for diabetes complications, yet uptake of evidence-based treatment is low. We combined theory, stakeholder involvement and existing evidence to develop a multifaceted intervention to improve OA care in persons with T2DM. This was done in partnership with Arthritis Society Canada to leverage the existing infrastructure and provincial funding for community arthritis care. METHODS: Each step was informed by a User Advisory Panel of stakeholder representatives, including persons with lived experience. First, we identified the target groups and behaviours through consulting stakeholders and current literature. Second, we interviewed persons living with T2DM and knee OA (n = 18), health professionals (HPs) who treat people with T2DM (n = 18) and arthritis therapists (ATs, n = 18) to identify the determinants of seeking and engaging in OA care (patients), assessing and treating OA (HPs) and considering T2DM in OA treatment (ATs), using the Theoretical Domains Framework (TDF). We mapped the content to behavioural change techniques (BCTs) to identify the potential intervention components. Third, we conducted stakeholder meetings to ascertain the acceptability and feasibility of intervention components, including content and modes of delivery. Fourth, we selected intervention components informed by prior steps and constructed a programme theory to inform the implementation of the intervention and its evaluation. RESULTS: We identified the barriers and enablers to target behaviours across a number of TDF domains. All stakeholders identified insufficient access to resources to support OA care in people with T2DM. Core intervention components, incorporating a range of BCTs at the patient, HP and AT level, sought to identify persons with knee OA within T2DM care and refer to Arthritis Society Canada for delivery of evidence-based longitudinal OA management. Diverse stakeholder input throughout development allowed the co-creation of an intervention that appears feasible and acceptable to target users. CONCLUSIONS: We integrated theory, evidence and stakeholder involvement to develop a multifaceted intervention to increase the identification of knee OA in persons with T2DM within diabetes care and improve the uptake and engagement in evidence-based OA management. Our partnership with Arthritis Society Canada supports future spread, scalability and sustainability. We will formally assess the intervention feasibility in a randomized pilot trial.

Development of OX40 agonists for canine cancer immunotherapy.

Recent breakthroughs in cancer immunotherapy have provided unprecedented clinical benefits to human cancer patients. Cancer is also one of the most common causes of death in pet dogs. Thus, canine-specific immune therapies targeting similar signaling pathways can provide better treatment options for canine cancer patients. Here, we describe the development and characterization of two canine-specific anti-OX40 agonists to activate OX40 signaling. We show that canine OX40, like human OX40, is not expressed on resting T cells, and its expression is markedly increased on canine CD4 T cells and Tregs after stimulation with concanavalin A (Con-A). cOX40 is also expressed on tumor-infiltrating lymphocytes (TILs) in canine osteosarcoma patients. The canine-specific OX40 agonists strongly activates cPBMCs by increasing IFN-γ expression and do not require Fc receptor-mediated cross-linking for OX40 agonism. Together, these results suggest that cFcOX40L proteins are potent OX40 agonists and have the potential to enhance antitumor immunity in canine cancer patients.

Patient and Provider Experiences With Virtual Care in a Large, Ambulatory Care Hospital in Ontario, Canada During the COVID-19 Pandemic: Observational Study.

BACKGROUND: Virtual care use increased during the COVID-19 pandemic. The impact of that shift on patient and provider experiences is unclear. OBJECTIVE: We evaluated patient and provider experiences with virtual visits across an academic, ambulatory hospital in Toronto, Canada and assessed predictors of positive experience with virtual care. METHODS: Survey data were analyzed from consenting patients who attended at least one virtual visit (video or telephone) and from consenting providers who delivered at least one virtual visit. Distributions for demographic variables and responses to survey questions are reported, with statistical significance assessed using chi-square tests and t tests. Ordinal logistic regression analysis was used to identify any patient predictors of responses. RESULTS: During the study period, 253 patients (mean age 45.1, SD 15.6 years) completed 517 video visit surveys, and 147 patients (mean age 41.6, SD 16.4 years) completed 209 telephone visit surveys. A total of 75 and 94 providers completed the survey in June 2020 and June 2021, respectively. On a scale from 1 to 10 regarding likelihood to recommend virtual care to others, fewer providers rated a score of 8 or above compared with patients (providers: 62/94, 66% for video and 49/94, 52% for telephone; patients: 415/517, 80% for video and 150/209, 72% for telephone). Patients of non-White ethnicity had lower odds of rating a high score of 9 or 10 compared with White patients (odds ratio 0.52, 95% CI 0.28-0.99). CONCLUSIONS: Patient experiences with virtual care were generally positive, but provider experiences were less so. Findings suggest potential differences in patient experience by ethnicity, warranting further investigation into equity concerns with virtual care.

Toxicity Mitigation of Textile Dye Reactive Blue 4 by Hairy Roots of Helianthus annuus and Testing Its Effect in In Vivo Model Systems.

An anthraquinone textile dye, Reactive Blue 4 (RB4), poses environmental health hazards. In this study, remediation of RB4 (30-110 ppm) was carried out by hairy roots (HRs). UV-visible spectroscopy and FTIR analysis showed that the dye undergoes decolourization followed by degradation. In addition, toxicity and safety analyses of the bioremediated dye were performed on Allium cepa and zebrafish embryos, which revealed lesser toxicity of the bioremediated dye as compared to untreated dye. For Allium cepa, the highest concentration, i.e., 110 ppm of the treated dye, showed less chromosomal aberrations with a mitotic index of 8.5 ± 0.5, closer to control. Two-fold decrease in mortality of zebrafish embryos was observed at the highest treated dye concentration indicating toxicity mitigation. A higher level of lipid peroxidation (LPO) was recorded in the zebrafish embryo when exposed to untreated dye, suggesting a possible role of oxidative stress-inducing mortality of embryos. Further, the level of LPO was significantly normalized along with the other antioxidant enzymes in embryos after dye bioremediation. At lower concentrations, mitigated samples displayed similar antioxidant activity comparable to control underlining the fact that the dye at lesser concentration can be more easily degraded than the dye at higher concentration.

Quality of virtual care for ambulatory care sensitive conditions: Patient and provider experiences.

BACKGROUND: The COVID-19 pandemic and the need for physical distancing has led to rapid uptake of virtual visits to deliver ambulatory health care. Despite widespread adoption, there has been limited evaluation of the quality of care being delivered through virtual modalities for ambulatory care sensitive conditions (ACSCs). OBJECTIVE: To characterize patients' and providers' experiences with the quality and sustainability of virtual care for ACSCs. DESIGN: This was a multi-method study utilizing quantitative and qualitative data from patient surveys, provider surveys, and provider focus groups at a large academic ambulatory care hospital between May 2020 and June 2021. We included patients and providers utilizing telephone or video visits for the following ACSCs: hypertension, angina, heart failure, atrial fibrillation, diabetes, chronic obstructive pulmonary disease, or asthma. MAIN MEASURES: Quantitative and qualitative patient and provider survey responses were mapped to the Six Domains of Healthcare Quality framework. Provider focus groups were coded to identify themes within each quality domain. KEY RESULTS: Surveys were completed by 110/352 (31%) consenting patients and 20/61 (33%) providers. 5 provider focus groups were held with 14 participants. Patients found virtual visits to be generally more convenient than in-person visits for ACSCs. The perceived effectiveness of virtual visits was dependent on the clinical and social complexity of individual encounters. Respondents reported difficulty forming effective patient-provider relationships in the virtual environment. Patients and providers felt that virtual care has potential to both alleviate and exacerbate structural barriers to equitable access to care. CONCLUSIONS: In a large academic ambulatory care hospital, patients and providers experienced the quality of virtual visits for the management of ACSCs to be variable depending on the biopsychosocial complexity of the individual encounter. Our findings in each quality domain highlight key considerations for patients, providers and institutions to uphold the quality of virtual care for ACSCs.

Implementation and Evaluation of COVIDCare@Home, a Family Medicine-Led Remote Monitoring Program for Patients With COVID-19: Multimethod Cross-sectional Study.

BACKGROUND: COVIDCare@Home (CC@H) is a multifaceted, interprofessional team-based remote monitoring program led by family medicine for patients diagnosed with COVID-19, based at Women's College Hospital (WCH), an ambulatory academic center in Toronto, Canada. CC@H offers virtual visits (phone and video) to address the clinical needs and broader social determinants of the health of patients during the acute phase of COVID-19 infection, including finding a primary care provider (PCP) and support for food insecurity. OBJECTIVE: The objective of this evaluation is to understand the implementation and quality outcomes of CC@H within the Quadruple Aim framework of patient experience, provider experience, cost, and population health. METHODS: This multimethod cross-sectional evaluation follows the Quadruple Aim framework to focus on implementation and service quality outcomes, including feasibility, adoption, safety, effectiveness, equity, and patient centeredness. These measures were explored using clinical and service utilization data, patient experience data (an online survey and a postdischarge questionnaire), provider experience data (surveys, interviews, and focus groups), and stakeholder interviews. Descriptive analysis was conducted for surveys and utilization data. Deductive analysis was conducted for interviews and focus groups, mapping to implementation and quality domains. The Ontario Marginalization Index (ON-Marg) measured the proportion of underserved patients accessing CC@H. RESULTS: In total, 3412 visits were conducted in the first 8 months of the program (April 8-December 8, 2020) for 616 discrete patients, including 2114 (62.0%) visits with family physician staff/residents and 149 (4.4%) visits with social workers/mental health professionals. There was a median of 5 (IQR 4) visits per patient, with a median follow-up of 7 days (IQR 27). The net promoter score was 77. In addition, 144 (23.3%) of the patients were in the most marginalized populations based on the residential postal code (as per ON-Marg). Interviews with providers and stakeholders indicated that the program continued to adapt to meet the needs of patients and the health care system. CONCLUSIONS: Future remote monitoring should integrate support for addressing the social determinants of health and ensure patient-centered care through comprehensive care teams.

Sociodemographic differences in patient experience with primary care during COVID-19: results from a cross-sectional survey in Ontario, Canada.

PURPOSE: We sought to understand patients' care-seeking behaviours early in the pandemic, their use and views of different virtual care modalities, and whether these differed by sociodemographic factors. METHODS: We conducted a multisite cross-sectional patient experience survey at 13 academic primary care teaching practices between May and June 2020. An anonymised link to an electronic survey was sent to a subset of patients with a valid email address on file; sampling was based on birth month. For each question, the proportion of respondents who selected each response was calculated, followed by a comparison by sociodemographic characteristics using χ2 tests. RESULTS: In total, 7532 participants responded to the survey. Most received care from their primary care clinic during the pandemic (67.7%, 5068/7482), the majority via phone (82.5%, 4195/5086). Among those who received care, 30.53% (1509/4943) stated that they delayed seeking care because of the pandemic. Most participants reported a high degree of comfort with phone (92.4%, 3824/4139), video (95.2%, 238/250) and email or messaging (91.3%, 794/870). However, those reporting difficulty making ends meet, poor or fair health and arriving in Canada in the last 10 years reported lower levels of comfort with virtual care and fewer wanted their practice to continue offering virtual options after the pandemic. CONCLUSIONS: Our study suggests that newcomers, people living with a lower income and those reporting poor or fair health have a stronger preference and comfort for in-person primary care. Further research should explore potential barriers to virtual care and how these could be addressed.

Operationalizing and Evaluating Synchronous Virtual Group Health Interventions: Wide-Scale Implementation at a Tertiary Care Academic Hospital.

Group-based health interventions are an important component of health promotion and management. To provide continuity of care throughout the COVID-19 pandemic, our institution undertook a rapid pivot to delivering group-based health interventions via a videoconferencing service which was securely embedded into both the electronic medical record and the patient portal to sustainably address immediate health service delivery needs during the pandemic and beyond. In this paper, we (1) describe the institutionally driven operationalization of a system to provide integrated synchronous video group visits across our hospital and (2) present a proposed strategy to comprehensively evaluate outcomes regarding their implementation, quality, and impact. Lessons for other institutions and the potential future role of synchronous video group visits to enhance how care can be scaled for delivery are discussed.

Transcriptomic Analysis of Canine Osteosarcoma from a Precision Medicine Perspective Reveals Limitations of Differential Gene Expression Studies.

Despite significant advances in cancer diagnosis and treatment, osteosarcoma (OSA), an aggressive primary bone tumor, has eluded attempts at improving patient survival for many decades. The difficulty in managing OSA lies in its extreme genetic complexity, drug resistance, and heterogeneity, making it improbable that a single-target treatment would be beneficial for the majority of affected individuals. Precision medicine seeks to fill this gap by addressing the intra- and inter-tumoral heterogeneity to improve patient outcome and survival. The characterization of differentially expressed genes (DEGs) unique to the tumor provides insight into the phenotype and can be useful for informing appropriate therapies as well as the development of novel treatments. Traditional DEG analysis combines patient data to derive statistically inferred genes that are dysregulated in the group; however, the results from this approach are not necessarily consistent across individual patients, thus contradicting the basis of precision medicine. Spontaneously occurring OSA in the dog shares remarkably similar clinical, histological, and molecular characteristics to the human disease and therefore serves as an excellent model. In this study, we use transcriptomic sequencing of RNA isolated from primary OSA tumor and patient-matched normal bone from seven dogs prior to chemotherapy to identify DEGs in the group. We then evaluate the universality of these changes in transcript levels across patients to identify DEGs at the individual level. These results can be useful for reframing our perspective of transcriptomic analysis from a precision medicine perspective by identifying variations in DEGs among individuals.

Aligning Virtual Care in Canada with the Needs of Older Adults.

Public health measures associated with coronavirus disease (COVID-19) have accelerated the adoption of virtual health care across Canada. We explore the opportunities that virtual care presents in achieving the Quadruple Aim and challenges to navigate, through the lens of care for older adults. In particular, we recommend virtual care-related policies related to older adults that address (a) limited uptake among the socio-economically disadvantaged, (b) user-centered design of virtual care technologies, and (c) integration of iterative evaluations to ensure equitable and efficient achievement of desired outcomes. As virtual care accelerates forward, we must not leave older Canadians behind.

Outpatient visit trends for internal medicine ambulatory care sensitive conditions after the COVID-19 pandemic: a time-series analysis.

BACKGROUND: The COVID-19 pandemic led to a dramatic shift in the delivery of outpatient medicine with reduced in-person visits and a transition to predominantly virtual visits. We sought to understand trends in visit patterns for ambulatory care sensitive conditions (ACSCs) commonly seen in internal medicine clinics. METHODS: We included adult outpatients seen for an ACSC between March 15th, 2017 and March 14th, 2021 at a single-centre in Ontario, Canada. Monthly visits were assessed by visit type (new consultation, follow-up), diagnosis, and clinic. Time series analyses compared visit volumes pre- and post-pandemic. Proportion of virtual visits were compared before and during the pandemic. Patient and visit factors were compared between in-person and virtual visits. RESULTS: 8274 patients with 34,021 visits were included. Monthly visits increased by 15% during the pandemic (p <  0.0001). New consultations decreased by 10% (p = 0.0053) but follow-up visits increased by 21% (p <  0.0001). Monthly heart failure visits increased by 43% (p <  0.0001) whereas atrial fibrillation visits decreased. Pre- pandemic, < 1% of visits were virtual compared to 82% during the pandemic (p <  0.0001). Less than half of heart failure visits were virtual whereas > 95% of diabetes visits were virtual. CONCLUSIONS: We found a significant increase in overall visits to internal medicine clinics driven by increased volumes of follow-up visits, which more than offset decreased new consultations. There was variability in visit trends and uptake of virtual care by visit diagnosis, which may indicate challenges with delivery of virtual care for certain conditions.