How Timid or Bold Are Ministries of Health and Provincial Health Authorities in Canada in Planning for Healthcare Quality?

Introduction: World Health Organization (WHO) guidelines recommend countries set quality plans for their health systems with clear priorities, indicators and targets. This paper examines whether Canada's federal, provincial and territorial governments are applying these principles. Methods: We evaluated plans from 2010 to 2019 for 14 ministries of health and four health authorities in provinces with a single authority against a rubric that considered the existence of indicators, baselines, targets, time frames and progress reports. Results: Ratings ranged from A+ to F with a median B/B-. Most jurisdictions had indicators, but only five of 18 jurisdictions had clear baselines, numeric targets and time frames. Irregularities were observed, such as vague indicators; setting goals to "improve" without targets; announcing targets only after plans had ended; setting minimal targets; removing targets after missing them previously; or inappropriate characterization of progress. Discussion: Most Canadian governments are reluctant to set quality targets. We speculate there may be fear of criticism if targets are missed. However, several jurisdictions had clear, ambitious plans that may serve as examples for others.

Diabetes prevalence and complication rates: In individual First Nations communities in the Sioux Lookout region of Ontario.

OBJECTIVE: To test the feasibility of reporting diabetes indicators at a regional and community level in order to provide feedback to local leaders on health system performance. DESIGN: Analysis of administrative data from hospital discharges and physician billings. SETTING: Sioux Lookout region of Ontario. PARTICIPANTS: Residents from 30 remote communities served by the Sioux Lookout First Nations Health Authority. MAIN OUTCOME MEASURES: Incidence and prevalence of diabetes and incidence of diabetes complications, including heart attack, stroke, retinopathy, amputations, end-stage kidney disease, diabetes-related hospitalizations, and death. RESULTS: Data were available for 18 542 residents from the 30 remote communities. Residents were almost entirely of First Nations descent. The prevalence of diabetes was 12.9%, the annual incidence was 1.0%, and the annual rate of complications was 5.4% in 2015-2016. Prevalence increased slightly over time. We had sufficient data to report prevalence in 25 of 30 communities (average population 738; range 234 to 2626). We reported statistically significant differences in prevalence by community; 8 were above average and 2 were below average. For diabetes complications, data were pooled over 5 years, and while community-level results could be reported, the variance was too high to allow detection of significant differences. Using 2-tailed t tests for difference of proportions, we determined that grouping communities into subregions of approximately 2000 persons would permit the detection of differences of 30% from the average 5-year complication rate. CONCLUSION: This study demonstrates the possibility of reporting diabetes prevalence by individual First Nations reserve communities. Complication rates can be reported by individual community, but estimates are more useful for comparison if the smallest communities are grouped together. Such studies could be replicated across Canada to promote local use of these data for resource planning and monitoring long-term progress of diabetes programs and services.

Graduates of northern Ontario family medicine residency programs practise where they train.

OBJECTIVE: To examine where graduates of the Northeastern Ontario Family Medicine (NOFM) residency program in Sudbury and the Family Medicine North (FMN) program in Thunder Bay practise after graduation, using cross-sectional and longitudinal analyses. METHODS: Data from the Scott's Medical Database were examined. All physicians who graduated from NOFM and FMN between 1993 and 2002 were included in this analysis. Differences in the location of first practice between NOFM and FMN graduates were tested using chi-squared tests. Logistic regression analyses were used to examine the impact of the training program on a physician's first, as well as continuing, practice location. RESULTS: Between 1993 and 2002, FMN graduates were 4.56 times more likely (95% confidence interval [CI] 2.34-8.90) to practise in rural areas, compared with NOFM graduates, but NOFM graduates were 2.50 times more likely than FMN graduates (95% CI 1.35-4.76) to practise in northern Ontario. There was no statistically significant difference between the graduates of the 2 programs in the likelihood of working in either northern Ontario or a rural area. About two-thirds (67.5%) of all person-years of medical practice provided by NOFM and FMN graduates took place in northern Ontario or rural areas outside the north. CONCLUSION: NOFM and FMN have been successful in producing family physicians to work in northern Ontario and rural areas. Results from this study add to the growing evidence from Canada and abroad that rural or northern medical education and training increases the likelihood that the graduates will practise in rural or northern communities.

Big cities and bright lights: rural- and northern-trained physicians in urban practice.

INTRODUCTION: Rural medical education is increasing in popularity in Canada. This study examines why some family physicians who completed their residency training in northern Ontario decided to practise in urban centres. METHODS: We used a qualitative research method. We interviewed 14 graduates of the Family Medicine North program and the Northeastern Ontario Family Medicine program. The interview transcripts were content-analyzed. RESULTS: There were different pathways leading to urban practice. While some pathways were straightforward, others were more complicated. Most participants offered multiple reasons for choosing to work in urban areas, suggesting that the decision-making processes could be quite complex. Family and personal factors were most frequently mentioned as reasons for choosing the urban option. The needs of the spouse and the children were especially important. Most of the participants had no plans to return to rural medical practice, but even these physicians retained some vestiges of rural practice. CONCLUSION: Most Canadian medical schools now offer some rural medical training opportunities. The findings of this study provide some useful insights that could help medical educators and decision-makers know what to expect and understand how practice location decisions are made by doctors.

A rural CT scanner: evaluating the effect on local health care.

OBJECTIVE: The first small rural hospital in Ontario to propose a computed tomography (CT) scanner was in Walkerton, a town 160 km north of London. The Ontario Ministry of Health approved the proposal as a pilot project to evaluate the effect on local health care of a rural scanner. This evaluation study had 3 parts: a survey of physicians, a survey of patients, and an analysis of population CT scanning rates. METHOD: The physicians in the area served by the scanner were asked about its impact on their care of their patients in a mailed questionnaire and in semistructured interviews. Scanner outpatients were given a questionnaire in which they rated the importance of its advantages. The analysis of scanning rates--the ratio of number of scans to estimated population--compared rates in the area with other Ontario rates before and after the scanner was introduced. RESULTS: The physicians reported that local CT allowed them to diagnose and treat patients sooner, closer to home, and with greater confidence. On average, 75% of the patients ranked faster and closer access as very important. Scanning rates in the area rose, although they did not match urban rates. CONCLUSIONS: The study confirms that the rural scanner changed the area's health care in significant ways and that it helped to narrow the gap between rural and urban service levels. We recommend that CT be expanded to other rural regions.

Duration of rural training during residency: rural family physicians prefer 6 months.

OBJECTIVE: To determine whether rural family physicians thought they had received enough months of rural exposure during family medicine residency, how many months of rural exposure those who were satisfied with their training had had, and how many months of rural exposure those who were not satisfied with their training wanted. DESIGN: Mailed survey. SETTING: Rural Canada. PARTICIPANTS: Rural family physicians who had graduated between 1991 and 2000 from a Canadian medical school. MAIN OUTCOME MEASURES: Respondents' opinions about whether their exposure to rural medicine during training had been adequate. RESULTS: Response rate was 59% (382/651). After excluding physicians who had not had Canadian family medicine residency training, 348 physicians remained, and of those, 58% thought they had had adequate rural exposure during residency. Median duration of rural training among those who thought they had had enough rural exposure was 6 months; median duration of rural exposure among those who thought they had not had enough was 2 months. Median duration of rural exposure desired by those who thought they had not had enough rural training was 6 months. Some physicians wanted much more than 6 months of rural training; for example, one quarter of those satisfied with their rural training had had 10 or more months of rural rotations. Fewer than 1% of respondents thought they had received too much rural training. There was no significant difference in number of months of rural training preferred by men and women (P = .94). One third of respondents had graduated from rural-focused family practice residency programs. Rural program graduates were more likely than non-rural program graduates to report that the duration of their rural training was adequate (84% vs 46%, P < .0001) and to report more mean months of rural exposure (8.9 vs 3.4; P < .0001). CONCLUSION: Typical rural family physicians prefer to have 6 months of rural exposure during residency. This finding is consistent with the recommendation of a College of Family Physicians of Canada committee that rural family medicine training programs offer at least 6 months of rural rotations. Almost half of rural family physicians wished they had had more rural training. Both rural-focused and non-rural-focused programs should consider providing opportunities for pursuing elective rotations in rural areas in addition to mandatory rotations if they want to respond to these preferences for training.

Quality councils as catalysts and leaders in quality improvement: the experience of the health quality council in Saskatchewan.

Quality councils are an increasingly common phenomenon in Canada. The Health Quality Council in Saskatchewan, the largest such council in Canada, is similar to other councils in that it reports publicly on quality of care, but it differs in that it has an explicit, central role to support quality improvement activities. The HQC strives to gain buy-in and cooperation from provider groups, even those identified as having suboptimal care, by offering them quality improvement training, measurement tools, information about best practices and advice from experts in change management, group psychology, process redesign and operations research. Developing relationships with stakeholders is a very labour- intensive process, but it is essential to fostering a blame-free culture of quality improvement. The HQC works with senior leaders to help coordinate province-wide priorities for quality improvement and with middle managers and frontline staff to establish local quality improvement teams. It does not alter the structure of existing accountability relationships; rather, it tries to make the dialogue more quality-focused. Its largest-scale activity is a Learning Collaborative involving 20% of all family physicians in the province in an effort to improve chronic disease management. The HQC believes that these targeted, coordinated activities in quality improvement will ultimately be far more effective than simply releasing reports or making recommendations.

Finding the right balance between evidence for judgment and evidence for quality improvement.

"Evidence for judgment" asks whether healthcare practitioners did what they were supposed to do. "Evidence for improvement" asks whether quality is improving due to the deliberate efforts of managers and care providers. The former describes the gap between optimal and actual care, examines peer-to-peer comparisons, is retrospective and often measured only at a single point in time, and identifies problems but not necessarily solutions. Knowledge tends to flow from researchers to practitioners, and knowledge transfer mechanisms are unclear. Evidence for improvement is prospective, focuses on comparisons to self over time, uses longitudinal data, and includes evidence on "how" to improve. Knowledge transfer mechanisms are built into quality improvement projects. Both types of evidence have their role; evidence for judgment helps system leaders identify priorities for improvement, whereas evidence for improvement helps leaders assess whether their implementation strategies have been successful. Currently, however, evidence for judgment predominates. Funding mechanisms, data systems, measurement tools, publication guidelines, and health professional training programs will need to be modified if we want more evidence for improvement.

Time trends and geographic disparities in acute complications of diabetes in Ontario, Canada.

OBJECTIVE: This study examines whether acute diabetes complication rates have fallen in recent years and whether geographic factors influence these trends. RESEARCH DESIGN AND METHODS: A population-based time-trend analysis of acute complications of diabetes was conducted using linked administrative and census data from Ontario, Canada. The study population included all adults identified through a province-wide electronic diabetes registry between 1994 and 1999 (n = 577,659). The primary outcome was hospitalizations for hyper- and hypoglycemia and emergency department visits for diabetes. RESULTS: Between 1994 and 1999, rates of hospitalization for hyper- and hypoglycemic emergencies decreased by 32.5 and 76.9%, respectively; emergency department visits for diabetes fell by 23.9%. On multivariate analysis, fiscal year was an independent predictor of acute diabetes complications, with individuals in our cohort experiencing a decline in risk of approximately 6% per year for either being hospitalized with hyper- or hypoglycemia or requiring an emergency department visit for diabetes. After accounting for variation in physician service use, diabetic individuals living in rural areas or Aboriginal communities were nearly twice as likely to have an acute complication, whereas those residing in remote areas of the province were nearly three times as likely to experience an event. CONCLUSIONS: Although our findings suggest an overall improvement in diabetes care in Ontario, certain subgroups of the population continue to experience higher rates of complications that are potentially preventable through good ambulatory care. Measures to improve access to timely and effective outpatient care may further reduce rates of acute complications among the diabetic population.

Quality of care of international and Canadian medical graduates in acute myocardial infarction.

BACKGROUND: International medical graduates (IMGs) make up a substantial proportion of the physician workforce and play an important role in the care of patients with acute myocardial infarction (AMI). There are concerns that IMGs may provide inferior medical care compared with locally trained medical graduates, but that has not been established. METHODS: We performed a retrospective cohort study of linked administrative databases containing health care claims of physicians' service payments, hospital discharge abstracts, and patients' vital status. We included 127,275 AMI patients admitted between April 1, 1992, and March 31, 2000, to acute care hospitals in Ontario. We then compared the risk-adjusted mortality rates and adjusted use of secondary prevention medications and cardiac invasive procedures in patients treated by IMGs vs Canadian medical graduates. RESULTS: Of the 127,275 admitted AMI patients, 28,061 (22.0%) were treated by IMGs and 99,214 (78.0%) by Canadian medical graduates. The risk-adjusted mortality rates of IMG- and Canadian medical graduate-treated patients were not significantly different at 30 days (13.3% vs 13.4%, P = .57) and at 1 year (21.8% vs 21.9%, P = .63). Furthermore, AMI patients treated by both groups had similar adjusted likelihood of receiving secondary prevention medications at 90 days and cardiac invasive procedures at 1 year. CONCLUSIONS: The use of secondary prevention medications and cardiac procedures and the mortality of AMI patients were similar, regardless of the origin of medical education of the admitting physician. This information places the care provided by IMGs into perspective and supports the ability of well-selected IMGs in caring for AMI patients.

Factors influencing family physicians to enter rural practice: does rural or urban background make a difference?

OBJECTIVE: To examine where rural physicians grew up, when during their training they became interested in rural medicine, factors influencing their decision to practise rural medicine, and differences in these measures according to rural or urban upbringing. DESIGN: Mailed survey. SETTING: Rural Canada. PARTICIPANTS: Rural family physicians who graduated between 1991 and 2000 from a Canadian medical school. MAIN OUTCOME MEASURES: Backgrounds of recently graduated rural physicians, when physicians first became interested in rural practice during training, and most influential factors in decisions to practise rural medicine. RESULTS: Response rate was 59% (382/651). About 33% of rural physicians grew up in communities of less than 10 000 people, 44% in cities of 10 000 to 499 999 people, and 23% in cities of more than 500 000 people. Physicians raised in rural areas were more likely than those raised in urban areas to have some interest in rural family practice at the start and end of medical school (90% vs 67% at the start, 98% vs 91% at the end, respectively, P < .0001). Physicians raised in urban areas were more likely to state that rural medical training was the most influential factor in their choice of rural practice (19% vs 9%, P = .015). Other factors cited as influential were the challenge of rural practice (24% for both urban and rural upbringing), rural lifestyle (14% for urban and 18% for rural upbringing) and, for physicians raised in rural areas, having grown up or spent time in a rural area (27% for rural and 4.1% for urban upbringing, P < .001). Financial incentives were least frequently cited as the most influential factor (7.5% for urban and 4.9% for rural upbringing, P = .35). CONCLUSION: Although other studies have suggested that physicians with a rural upbringing are more likely to practise rural medicine and policy makers might still wish to target students raised in rural areas as candidates for rural medicine, this study shows that physicians raised in urban areas remain the main source of human resources for rural communities. They account for two thirds of new physicians in rural areas. Education in rural medicine during medical training has a stronger influence on physicians raised in urban areas than on physicians raised in rural areas. Undergraduate and postgraduate training periods, therefore, offer an important opportunity for recruiting physicians raised in urban areas to rural practice.

Canadian rural family medicine training programs: growth and variation in recruitment.

OBJECTIVE: To document the proliferation of rural family medicine residency programs and to note differences in design as they affect rural recruitment. DESIGN: Descriptive study using semistructured telephone interviews. SETTING: All family medicine residency programs in Canada in 2002. PARTICIPANTS: Directors of Canadian family medicine residency programs. MAIN OUTCOME MEASURES: Number of rural training programs and positions; months of rural exposure, degree of remoteness, and specialist support of rural communities within rural training programs. RESULTS: The number of rural training programs rose from one in 1973 to 12 in 2002. Most medical schools now offer dedicated rural training streams. From 1989 to 2002, the number of rural residency positions quadrupled from 36 to 144; large jumps in capacity occurred from 1989 to 1991 and then from 1999 to 2001. Rural positions now represent 20% of all family medicine residency positions. Among rural programs, minimum rural exposure ranged from 4 to 12 months, and the median distance between rural training communities and referral sites ranged from 50 to 440 km (median 187 km). Rotations in communities with no hospital were mandatory in five of 12 rural programs, optional in five, and unavailable in two. The proportion of training communities used by rural programs that had family physicians only (ie, no immediate specialty backup) ranged from 0 to 78% (mean 44%). Most training communities (78%) used by rural programs had fewer than 10 000 residents. Four of 12 rural programs offered various specialty medicine rotations in small communities. CONCLUSION: Rural residency programs have proliferated in Canada. The percentage of residency positions that are rural now equals the proportion of the general population in Canada living in rural areas. National guidelines for rural programs recommend at least 6 months of rural rotations and at least some training in communities without hospitals. Major variations among programs exist, and most program designs differ from designs recommended in national guidelines in at least one aspect.

Canadian Cardiovascular Society Consensus Conference 2002: Management of heart disease in the elderly patient.

Cardiovascular disease is a major health issue for the elderly patient. Many diagnostic, therapeutic and ethical issues are specific for the the older adult with heart disease. The Canadian Cardiovascular Society 2002 Consensus Conference provides recommendations for the most frequently encountered cardiac problems in the elderly patient. A common theme of the recommendations is the need to apply the best evidence based medicine together with an assessment of frailty, comorbidity and quality of life. A major goal of the conference was to identify treatments that are not optimally used in the older patient.

Factors influencing participation in obstetrics by obstetrician-gynecologists.

OBJECTIVE: To examine factors affecting participation in obstetrics among obstetrician-gynecologists and changes in participation over time. METHODS: Using physician billings from Ontario, Canada, from 1992/1993 to 2001/2002, we examined the impact of physician age, gender, practice location, and years of practice on participation in obstetrics with multiple logistic regression and repeated measures analyses. We also examined differences in practice patterns between obstetrics providers and nonproviders using linear and log-linear regressions. RESULTS: Obstetrics participation declined with age, from 96% among physicians under age 35, to 34% among those aged 65 and over (2001/2002 figures). Regressions demonstrated a lower likelihood of performing obstetrics in successive years (odds ratio [OR] 0.95 per year; 95% confidence interval [CI] 0.93, 0.98) and among physicians who were older (OR 0.91 per year of age; 95% CI 0.90, 0.93), female (OR 0.57; 95% CI 0.36, 0.91), and practicing in cities with medical schools (OR 0.58; 95% CI 0.44, 0.78). The crude obstetrics participation rate dropped from 82% to 77%, from 1992/1993 to 2001/2002. The physician age-sex-adjusted participation rate dropped from 80% in 1992/1993 to 77% in 2001/2002. Obstetrics providers had almost double the annual billings of nonproviders ($364,000 verus $187,000; P <.001), but more on-call days worked (105 versus 13; P <.001). Nonproviders of obstetrics derived more of their billings from outpatient visits, psychotherapy, and diagnostic tests. The likelihood of an obstetrics nonprovider resuming obstetrics was 1.1% per year. CONCLUSION: The proportion of obstetrician-gynecologists practicing obstetrics declined modestly in the last decade, partly because of more female physicians in the workforce who were less likely to practice obstetrics. Planners should consider these trends when estimating how many obstetrician-gynecologists to train to meet future societal needs. LEVEL OF EVIDENCE: II-2

Chronic migraineurs: an important subgroup of patients who visit emergency departments frequently.

STUDY OBJECTIVE: We examine whether patients with frequent migraines represent a distinct subgroup of patients who visit emergency departments (EDs) frequently. METHODS: This population-based, cross-sectional study used fiscal year 1998 physician billing data from Ontario, Canada. "Frequent ED visitors" were individuals with at least 12 ED visits per year and were classified as either "frequent migraineurs" (> or =50% of ED visits for migraine) and "other frequent ED visitors." RESULTS: There were 2,158,291 ED visitors, of whom 6,839 were frequent ED visitors. These individuals accounted for 3.5% of all ED visits. Among frequent ED visitors, 478 were frequent migraineurs. The proportion of patients who were female was 79% among frequent migraineurs, 53% among other frequent ED visitors, and 50% among patients who were not frequent ED visitors. The proportions between ages 30 and 54 years for these 3 groups were 79%, 43%, and 31%, respectively. Average annual visits to EDs were 26, 18, and 1.7, respectively, and average visits to family physicians were 40, 20, and 5.9, respectively. Despite heavy health care use, frequent migraineurs sought 83% of their ED care from their most frequently visited ED and 71% of their primary care from their main family physician. CONCLUSION: Frequent migraineurs are predominantly women aged 30 to 54 years and with a particularly intense use of health care services. Management strategies may require targeted interventions for these individuals. Because these patients seek most of their care from 1 main ED and 1 principal primary care physician, coordination of care may be easier than expected.

Patient, physician, and community factors affecting referrals to specialists in Ontario, Canada: a population-based, multi-level modelling approach.

QUESTION ADDRESSED: This population-based study examines the factors affecting referrals by primary care physicians (PCPs) to specialists. MATERIALS AND METHODS: Multilevel Poisson models were used to test the impact of patient, physician and community-level variables on the referral rate (the number of office-based specialist referrals per patient by the patient's customary PCP in fiscal year 1997/98). Patients from each of 6972 PCPs with sufficient data in Ontario were examined. RESULTS: The average patient had 0.56 referrals per year (range 0-61). Referrals were higher at ages 1 and 77 to 78, and among women of childbearing age. Chronic disease variables were strongly correlated with referral rates. Patients in poor neighborhoods had more referrals, because they had more chronic diseases. After controlling for disease, individuals in the top 9% wealthiest neighborhoods had 4% more referrals. Female physicians made 8% more referrals than men. Older physicians referred more because they saw older patients; after controlling for patient age, physician age had no effect. Referrals were 14% higher in cities with medical schools compared with other cities and 12% lower in small towns. However, local specialist supply was unrelated to referral rates. CONCLUSION: This study improves our understanding of the impact of physician gender and age on referrals. It suggests that community type, not specialist supply, predicts variations in referrals. Lastly, it identifies preferential access to specialists among high-income earners, even within Canada's universal health insurance system. However, this effect is modest, suggesting that the system does provide reasonably equitable access to referrals.

Geography and service supply do not explain socioeconomic gradients in angiography use after acute myocardial infarction.

BACKGROUND: Socioeconomic status appears to be an important predictor of coronary angiography use after acute myocardial infarction. One potential explanation for this is that patients with lower socioeconomic status live in neighbourhoods near nonteaching hospitals that have no catheterization capacity, few specialists and lower volumes of patients with acute myocardial infarction. This study was conducted to determine whether the impact of socioeconomic status on angiography use would be lessened by considering variations in the supply of services. METHODS: We examined payment claims for physician services, hospital discharge abstracts and vital status data for 47 036 patients with acute myocardial infarction admitted to hospitals in Ontario between April 1994 and March 1997. Neighbourhood income of each patient was obtained from Canada's 1996 census. Using multivariate hierarchical logistic regression and adjusting for baseline patient and physician factors, we examined the interaction among hospital and regional characteristics, socioeconomic status and angiography use in the first 90 days after admission to hospital for acute myocardial infarction. RESULTS: Within each hospital and geographic subgroup, crude rates of angiography rose progressively with increases in neighbourhood income. After adjusting for sociodemographic, clinical and physician characteristics, hospitals with on-site angiography capacity (adjusted odds ratio [OR] 1.88, 95% confidence interval [CI] 1.52-2.33), those with university affiliations (adjusted OR 1.60, 95% CI 1.27-2.01) and those closest to tertiary institutions (adjusted OR 1.57, 95% CI 1.32-1.87) were all associated with higher 90-day angiography use after acute myocardial infarction. However, the relative impact of socioeconomic status on 90-day angiography use was similar whether or not hospitals had on-site procedural capacity (interaction term p = 0.68), had university affiliations (interaction term p = 0.99), were near tertiary facilities (interaction term p = 0.67) or were in rural or urban regions (interaction term p = 0.90). INTERPRETATION: Socioeconomic status was as important a predictor of angiography use in hospitals with ready access to cardiac catheterization facilities as it was in those without. The socioeconomic gradient in the use of angiography after acute myocardial infarction cannot be explained by the distribution of specialists or tertiary hospitals.

Frequent users of emergency departments. Do they also use family physicians' services?

OBJECTIVE: To determine whether frequent users of emergency department (ED) services use more or fewer primary care services than other ED patients. DESIGN: Population-based, observational, cross-sectional study. SETTING: Province of Ontario in 1997-1998. PARTICIPANTS: Frequent users of EDs, defined as people with at least 12 ED physician assessments yearly, were compared with those with one to 11 assessments yearly. MAIN OUTCOME MEASURES: Number of general practitioner and family physician (GP/FP) office visits and number of GP/FPs visited; diagnoses made during office visits; referrals by GP/FPs to specialists. RESULTS: Three quarters of frequent users of EDs visited GP/FPs at least six times yearly, and more than half visited at least 12 times yearly. Although frequent users of EDs saw many GP/FPs (4.2 vs 1.6 in the control group, P < .001), they received, on average, 73% of their primary care from the GP/FPs whom they saw most frequently. Frequent users of EDs also had more referrals to specialists (4.0 vs 1.0). Frequent users of EDs were more likely to live in low socioeconomic neighbourhoods and to be diagnosed with psychosocial conditions (24.1% vs 11.1%). CONCLUSION: Most frequent users of EDs have periodic contact with primary care physicians. Communication and coordination of care between EDs and primary care settings could be easier than anticipated, because in most cases, frequent users of EDs seek most of their care from one main ED and one primary care physician.

The declining comprehensiveness of primary care.

BACKGROUND: Recent studies suggest that comprehensiveness of primary care has declined steadily over the past decade. This study tracks the participation rates of general practitioners and family physicians in 6 nonoffice settings across Ontario and examines among which types of physicians this decline in comprehensiveness has occurred. METHODS: Billing (claims) records were used to determine the proportions of fee-for-service general practitioners and family physicians who provided emergency, inpatient, nursing home, house call, anesthesia or obstetrical services from 1989/90 to 1999/2000. "Office-only" physicians were those who worked in none of these nonoffice settings. The relation of various physician characteristics to comprehensiveness of care was tested with multivariate analysis for 1999/2000. RESULTS: The proportion of "office-only" general practitioners and family physicians rose from 14% in 1989/90 to 24% in 1999/2000 (p < 0.001). Significant increases in this proportion were noted among general practitioners and family physicians of all ages, both sexes and all practice locations. In 1999/2000, recent graduates (who had completed medical school within the past 7 years) had higher participation rates for emergency medicine (40% v. 5% for physicians aged 65 years and older); female physicians had higher participation rates for obstetrics (16% v. 11% for males); and older physicians had higher participation rates for nursing home visits and house calls (20% and 57% respectively v. 11% and 37% for recent graduates). However, "office-only" physicians were more likely to be female (odds ratio [OR] 2.65, 95% confidence interval [CI] 2.37-2.96), recent graduates (OR 1.35, 95% CI 1.15-1.60), aged 65 years and older (OR 1.45, 95% CI 1.20-1.75) or practising in a city with a medical school (OR 2.30, 95% CI 2.06-2.56) and were less likely to be rural physicians (OR 0.31, 95% CI 0.24-0.41) or certified in family medicine (OR 0.58, 95% CI 0.52-0.66). INTERPRETATION: There has been a decline in the provision of comprehensive care by general practitioners and family physicians in Ontario. The decline is evident across all age groups and for both male and female physicians. It is also evident in rural areas and in cities with and without medical schools.