Characteristics of primary care practices by proportion of patients unvaccinated against SARS-CoV-2: a cross-sectional cohort study.

BACKGROUND: Variations in primary care practices may explain some differences in health outcomes during the COVID-19 pandemic. We sought to evaluate the characteristics of primary care practices by the proportion of patients unvaccinated against SARS-CoV-2. METHODS: We conducted a population-based, cross-sectional cohort study using linked administrative data sets in Ontario, Canada. We calculated the percentage of patients unvaccinated against SARS-CoV-2 enrolled with each comprehensive-care family physician, ranked physicians according to the proportion of patients unvaccinated, and identified physicians in the top 10% (v. the other 90%). We compared characteristics of family physicians and their patients in these 2 groups using standardized differences. RESULTS: We analyzed 9060 family physicians with 10 837 909 enrolled patients. Family physicians with the largest proportion (top 10%) of unvaccinated patients (n = 906) were more likely to be male, to have trained outside of Canada, to be older, and to work in an enhanced fee-for-service model than those in the remaining 90%. Vaccine coverage (≥ 2 doses of SARS-CoV-2 vaccine) was 74% among patients of physicians with the largest proportion of unvaccinated patients, compared with 87% in the remaining patient population. Patients in the top 10% group tended to be younger and live in areas with higher levels of ethnic diversity and immigration and lower incomes. INTERPRETATION: Primary care practices with the largest proportion of patients unvaccinated against SARS-CoV-2 served marginalized communities and were less likely to use team-based care models. These findings can guide resource planning and help tailor interventions to integrate public health priorities within primary care practices.

Characteristics of patients attached to near-retirement family physicians: a population-based serial cross-sectional study in Ontario, Canada.

OBJECTIVES: Population ageing is a global phenomenon. Resultant healthcare workforce shortages are anticipated. To ensure access to comprehensive primary care, which correlates with improved health outcomes, equity and costs, data to inform workforce planning are urgently needed. We examined the medical and social characteristics of patients attached to near-retirement comprehensive primary care physicians over time and explored the early-career and mid-career workforce's capacity to absorb these patients. DESIGN: A serial cross-sectional population-based analysis using health administrative data. SETTING: Ontario, Canada, where most comprehensive primary care is delivered by family physicians (FPs) under universal insurance. PARTICIPANTS: All insured Ontario residents at three time points: 2008 (12 936 360), 2013 (13 447 365) and 2019 (14 388 566) and all Ontario physicians who billed primary care services (2008: 11 566; 2013: 12 693; 2019: 15 054). OUTCOME MEASURES: The number, proportion and health and social characteristics of patients attached to near-retirement age comprehensive FPs over time; the number, proportion and characteristics of near-retirement age comprehensive FPs over time. SECONDARY OUTCOME MEASURES: The characteristics of patients and their early-career and mid-career comprehensive FPs. RESULTS: Patient attachment to comprehensive FPs increased over time. The overall FP workforce grew, but the proportion practicing comprehensiveness declined (2008: 77.2%, 2019: 70.7%). Over time, an increasing proportion of the comprehensive FP workforce was near retirement age. Correspondingly, an increasing proportion of patients were attached to near-retirement physicians. By 2019, 13.9% of comprehensive FPs were 65 years or older, corresponding to 1 695 126 (14.8%) patients. Mean patient age increased, and all physicians served markedly increasing numbers of medically and socially complex patients. CONCLUSIONS: The primary care sector faces capacity challenges as both patients and physicians age and fewer physicians practice comprehensiveness. Nearly 15% (1.7 million) of Ontarians may lose their comprehensive FP to retirement between 2019 and 2025. To serve a growing, increasingly complex population, innovative solutions are needed.

Trends in attachment to a primary care provider in Ontario, 2008-2018: an interrupted time-series analysis.

BACKGROUND: Attachment to a regular primary care provider is associated with better health outcomes, but 15% of people in Canada lack a consistent source of ongoing primary care. We sought to evaluate trends in attachment to a primary care provider in Ontario in 2008-2018, through an equity lens and in relation to policy changes in implementation of payment reforms and team-based care. METHODS: Using linked, population-level administrative data, we conducted a retrospective observational study to calculate rates of patients attached to a regular primary care provider from Apr. 1, 2008, to Mar. 31, 2019. We evaluated the association of patient characteristics and attachment in 2018 using sex-stratified, adjusted, multivariable logistic regression models and used segmented piecewise regression to evaluate changing trends before and after implementation of a policy that restricted physician entry to alternate models. RESULTS: Attachment increased from 80.5% (n = 10 352 385) in 2008 to 88.9% of the population (n = 12 537 172) in 2018, but was lower among people with low comorbidity, high residential instability, material deprivation, rural residence and recent immigrants. Inequities narrowed for recent immigrants, males and people with lower incomes over the study period, but disparities persisted for these groups. Attachment grew by 1.47% annually until 2014 (p < 0.0001), but was stagnant thereafter (annual percent change of 0.13, p = 0.16). INTERPRETATION: Lack of sustained progress in attachment followed reduced levels of physician entry to alternate funding models. Although disparities narrowed for many groups over the study period, persistent gaps remained for immigrants and people with lower incomes; targeted interventions and policy changes are needed to address these persistent gaps.

A fresh perspective on metal ammonia molecular complexes and expanded metals: opportunities in catalysis and quantum information.

Recent advances in our comprehension of the electronic structure of metal ammonia complexes have opened avenues for novel materials with diffuse electrons. These complexes in their ground state can host peripheral "Rydberg" electrons which populate a hydrogenic-type shell model imitating atoms. Aggregates of such complexes form the so-called expanded or liquid metals. Expanded metals composed of d- and f-block metal ammonia complexes offer properties, such as magnetic moments and larger numbers of diffuse electrons, not present for alkali and alkaline earth (s-block) metals. In addition, tethering metal ammonia complexes via hydrocarbon chains (replacement of ammonia ligands with diamines) yields materials that can be used for redox catalysis and quantum computing, sensing, and optics. This perspective summarizes the recent findings for gas-phase isolated metal ammonia complexes and projects the obtained knowledge to the condensed phase regime. Possible applications for the newly introduced expanded metals and linked solvated electrons precursors are discussed and future directions are proposed.

Transition metal oxide complexes as molecular catalysts for selective methane to methanol transformation: any prospects or time to retire?

Transition metal oxides have been extensively used in the literature for the conversion of methane to methanol. Despite the progress made over the past decades, no method with satisfactory performance or economic viability has been detected. The main bottleneck is that the produced methanol oxidizes further due to its weaker C-H bond than that of methane. Every improvement in the efficiency of a catalyst to activate methane leads to reduction of the selectivity towards methanol. Is it therefore prudent to keep studying (both theoretically and experimentally) metal oxides as catalysts for the quantitative conversion of methane to methanol? This perspective focuses on molecular metal oxide complexes and suggests strategies to bypass the current bottlenecks with higher weight on the computational chemistry side. We first discuss the electronic structure of metal oxides, followed by assessing the role of the ligands in the reactivity of the catalysts. For better selectivity, we propose that metal oxide anionic complexes should be explored further, while hydrophylic cavities in the vicinity of the metal oxide can perturb the transition-state structure for methanol increasing appreciably the activation barrier for methanol. We also emphasize that computational studies should target the activation reaction of methanol (and not only methane), the study of complete catalytic cycles (including the recombination and oxidation steps), and the use of molecular oxygen as an oxidant. The titled chemical conversion is an excellent challenge for theory and we believe that computational studies should lead the field in the future. It is finally shown that bottom-up approaches offer a systematic way for exploration of the chemical space and should still be applied in parallel with the recently popular machine learning techniques. To answer the question of the title, we believe that metal oxides should still be considered provided that we change our focus and perform more systematic investigations on the activation of methanol.

Gßγ subunits colocalize with RNA polymerase II and regulate transcription in cardiac fibroblasts.

Gßγ subunits mediate many different signaling processes in various compartments of the cell, including the nucleus. To gain insight into the functions of nuclear Gßγ signaling, we investigated the functional role of Gßγ signaling in the regulation of GPCR-mediated gene expression in primary rat neonatal cardiac fibroblasts. We identified a novel, negative, regulatory role for the Gß1γ dimer in the fibrotic response. Depletion of Gß1 led to derepression of the fibrotic response at the mRNA and protein levels under basal conditions and an enhanced fibrotic response after sustained stimulation of the angiotensin II type I receptor. Our genome-wide chromatin immunoprecipitation experiments revealed that Gß1 colocalized and interacted with RNA polymerase II on fibrotic genes in an angiotensin II-dependent manner. Additionally, blocking transcription with inhibitors of Cdk9 prevented association of Gßγ with transcription complexes. Together, our findings suggest that Gß1γ is a novel transcriptional regulator of the fibrotic response that may act to restrict fibrosis to conditions of sustained fibrotic signaling. Our work expands the role for Gßγ signaling in cardiac fibrosis and may have broad implications for the role of nuclear Gßγ signaling in other cell types.

Relational Continuity, Physician Payment, and Team-Based Primary Care in the Canadian Health Care System.

PURPOSE: Continuity is a core component of primary care and known to differ by patient characteristics. It is unclear how primary care physician payment and organization are associated with continuity. METHODS: We analyzed administrative data from 7,110,036 individuals aged 16+ in Ontario, Canada who were enrolled to a physician and made at least 2 visits between October 1, 2017 and September 30, 2019. Continuity with physician and practice group was quantified using the usual provider of care index. We used log-binomial regression to assess the relationship between enrollment model and continuity adjusting for patient characteristics. RESULTS: Mean physician and group continuity were 67.3% and 73.8%, respectively, for patients enrolled in enhanced fee-for-service, 70.7% and 76.2% for nonteam capitation, and 70.6% and 78.7% for team-based capitation. These differences were attenuated in regression models for physician-level continuity and group-level continuity. Older age was the most notable factor associated with continuity. Compared with those 16 to 34, those 80 and older had 1.45 times higher continuity with their physician. CONCLUSION: Our results suggest that continuity does not differ substantially by physician payment or organizational model among primary care patients who are formally enrolled with a physician in a setting with universal health insurance.

Impact of Zinc, Vitamins C and D on Disease Prognosis among Patients with COVID-19 in Bangladesh: A Cross-Sectional Study.

Vitamin C, (ascorbic acid), vitamin D (cholecalciferol) and zinc (zinc sulfate monohydrate) supplements are important in immunity against coronavirus disease-2019 (COVID-19). However, a limited number of studies have been conducted on the association of vitamins and supplements with the reduced risks of COVID-19 infection. This study aims to evaluate the association of vitamins and supplements as treatment options to reduce the severity of COVID-19. Data were collected from 962 participants from 13 December 2020 to 4 February 2021. The presence of COVID-19 was confirmed by qRT-PCR. The Chi-square test and multivariate regression analyses were conducted. The ratio of uptake of vitamin C:vitamin D:zinc was 1:1:0.95. Uptake of vitamin C, vitamin D and zinc were significantly associated with the reduced risk of infection and severity of COVID-19 (OR: 0.006 (95% CI: 0.03-0.11) (p = 0.004)) and (OR: 0.03 (95% CI: 0.01-0.22) (p = 0.005)). The tendency of taking supplements was associated with the presence of infection of COVID-19 (p = 0.001), age (p = 0.02), sex (p = 0.05) and residence (p = 0.04). The duration of supplementation and medication was significantly associated with reduced hospitalization (p = 0.0001). Vitamins C, D and zinc were not significantly (p = 0.9) associated with a reduced risk of severity when taken through the diet. Hospitalization (p = 0.000001) and access to health facilities (p = 0.0097) were significantly associated with the survival period of the participants. Participants with better access to health facilities recovered early (OR: 6.21, 95% CI 1.56-24.7). This study will add knowledge in the field of treatment of COVID-19 by using vitamins and zinc supplements.

[Fe4S4] cubane in sulfite reductases: new insights into bonding properties and reactivity.

The dissimilatory sulfite reductase enzyme has very characteristic active site where the substrate binds to an iron site, ligated by a siroheme macrocycle and a thiol directly connected to a [Fe4S4] cluster. This arrangement gives the enzyme remarkable efficiency in reducing sulfite and nitrite all the way to hydrogen sulfide and ammonia. For the first time we present a theoretical study where substrate binding modalities and activation are elucidated using active site models containing proton supply side chains and the [Fe4S4] cluster. Density functional theory (DFT) was deployed in conjunction with the energy decomposition scheme (as implemented in AMS), the quantum theory of atoms in molecules (QTAIM), and conceptual DFT (cDFT) descriptors. We quantified the role of the electrostatic interactions inside the active site created by the side chains as well as the influence of the [Fe4S4] cluster on the substrate binding. Furthermore, using conceptual DFT results we shed light of the activation process, thus, laying foundation for further mechanistic studies. We found that the bonding of the ligands to the iron complex is dominated by electrostatic interactions, but the presence of the [Fe4S4] cubane leads to substantial changes in electronic interaction. The spin state of the cubane, however, affects the binding energy only marginally. The conceptual DFT results show that the presence of the [Fe4S4] cubane affects the reactivity of the active site as it is involved in electron transfer. This is corroborated by an increase in the electrophilicity index, thus making the active site more prone to react with the ligands. The interaction energies between the ligand and the siroheme group are also increased upon the presence of the cubane group, thus, suggesting that the siroheme group is not an innocent spectator but plays an active role in the reactivity of the dSIR active site.

Impact of Graphene Quantum Dot Edge Morphologies on Their Optical Properties.

The optoelectronic properties of functionalized graphene quantum dots (GQDs) have been explored by simulating electronic structure of three different shapes of GQDs containing exclusively zigzag or armchair edges in both pristine and functionalized forms. Absorption spectra and transition densities for the low-lying excited states are evaluated by using time-dependent density functional theory and compared for different functionalization species. The functionalization position dictates the optical properties of square GQDs, where isomers with CH2 in the intermediate positions (excluding corner and center positions) have higher electronic transition energies and exciton delocalization than other isomers. Rhombic GQDs with all armchair edges exhibit high steric flexibility, and their complete passivation results in the largest structural deformation from planarity and strongest red-shifts. A steady red-shift in the absorption energy is observed following the order F, CH3, Cl, and Br substitutions. This suggests that the steric effects due to large van der Waals radii overcome electronegative effects.

Electronic Structure of RhO2+, Its Ammoniated Complexes (NH3)1-5RhO2+, and Mechanistic Exploration of CH4 Activation by Them.

High-level electronic structure calculations are initially performed to investigate the electronic structure of RhO2+. The construction of potential energy curves for the ground and low-lying excited states allowed the calculation of spectroscopic constants, including harmonic and anharmonic vibrational frequencies, bond lengths, spin-orbit constants, and excitation energies. The equilibrium electronic configurations were used for the interpretation of the chemical bonding. We further monitored how the Rh-O bonding scheme changes with the gradual addition of ammonia ligands. The nature of this bond remains unaffected up to four ammonia ligands but adopts a different electronic configuration in the pseudo-octahedral geometry of (NH3)5RhO2+. This has consequences in the activation mechanism of the C-H bond of methane by these complexes, especially (NH3)4RhO2+. We show that the [2 + 2] mechanism in the (NH3)4RhO2+ case has a very low energy barrier comparable to that of a radical mechanism. We also demonstrate that methane can coordinate to the metal in a similar fashion to ammonia and that knowledge of the electronic structure of the pure ammonia complexes provides qualitative insights into the optimal reaction mechanism.

Development and validation of an algorithm using health administrative data to define patient attachment to primary care providers.

PURPOSE: The authors developed and validated an algorithm using health administrative data to identify patients who are attached or uncertainly attached to a primary care provider (PCP) using patient responses to a survey conducted in Ontario, Canada. DESIGN/METHODOLOGY/APPROACH: The authors conducted a validation study using as a reference standard respondents to a community-based survey who indicated they did or did not have a PCP. The authors developed and tested health administrative algorithms against this reference standard. The authors calculated the sensitivity, specificity positive predictive value (PPV) and negative predictive value (NPV) on the final patient attachment algorithm. The authors then applied the attachment algorithm to the 2017 Ontario population. FINDINGS: The patient attachment algorithm had an excellent sensitivity (90.5%) and PPV (96.8%), though modest specificity (46.1%) and a low NPV (21.3%). This means that the algorithm assigned survey respondents as being attached to a PCP and when in fact they said they had a PCP, yet a significant proportion of those found to be uncertainly attached had indicated they did have a PCP. In 2017, most people in Ontario, Canada (85.4%) were attached to a PCP but 14.6% were uncertainly attached. RESEARCH LIMITATIONS/IMPLICATIONS: Administrative data for nurse practitioner's encounters and other interprofessional care providers are not currently available. The authors also cannot separately identify primary care visits conducted in walk in clinics using our health administrative data. Finally, the definition of hospital-based healthcare use did not include outpatient specialty care. PRACTICAL IMPLICATIONS: Uncertain attachment to a primary health care provider is a recurrent problem that results in inequitable access in health services delivery. Providing annual reports on uncertainly attached patients can help evaluate primary care system changes developed to improve access. This algorithm can be used by health care planners and policy makers to examine the geographic variability and time trends of the uncertainly attached population to inform the development of programs to improve primary care access. SOCIAL IMPLICATIONS: As primary care is an essential component of a person's medical home, identifying regions or high need populations that have higher levels of uncertainly attached patients will help target programs to support their primary care access and needs. Furthermore, this approach will be useful in future research to determine the health impacts of uncertain attachment to primary care, especially in view of a growing body of the literature highlighting the importance of primary care continuity. ORIGINALITY/VALUE: This patient attachment algorithm is the first to use existing health administrative data validated with responses from a patient survey. Using patient surveys alone to assess attachment levels is expensive and time consuming to complete. They can also be subject to poor response rates and recall bias. Utilizing existing health administrative data provides more accurate, timely estimates of patient attachment for everyone in the population.

Prevalence and impact of comorbidities on disease prognosis among patients with COVID-19 in Bangladesh: A nationwide study amid the second wave.

BACKGROUND: Socio-demographics and comorbidities are involved in determining the severity and fatality in patients with COVID-19 suggested by studies in various countries, but study in Bangladesh is insufficient. AIMS: We designed the study to evaluate the association of sociodemographic and comorbidities with the prognosis of adverse health outcomes in patients with COVID-19 in Bangladesh. METHODS: A multivariate retrospective cohort study was conducted on data from 966 RT-PCR positive patients from eight divisions during December 13, 2020, to February 13, 2021. Variables included sociodemographic, comorbidities, symptoms, Charlson comorbidity index (CCI) and access to health facilities. Major outcome was fatality. Secondary outcomes included hospitalization, duration of hospital stay, requirement of mechanical ventilation and severity. RESULTS: Male (65.8%, 636 of 966) was predominant and mean age was 39.8 ± 12.6 years. Fever (79%), dry cough (55%), and loss of test/smell (51%) were frequent and 74% patients had >3 symptoms. Fatality was recorded in 10.5% patients. Comorbidities were found in 44% patients. Hypertension (21.5%) diabetes (14.6%), and cardiovascular diseases (11.3%) were most prevalent. Age >60 years (OR: 4.83, 95% CI: 2.45-6.49), and CCI >3 (OR: 5.48, 95% CI: 3.95-7.24) were predictors of hospitalizations. CCI >4 (aOR: 3.41, 95% CI: 2.57-6.09) was predictor of severity. Age >60 years (aOR: 3.77, 95% CI: 1.07-6.34), >3 symptoms (aOR: 2.14, 95% CI: 0.97-4.91) and CCI >3 vs. CCI <3 (aOR: 5.23, 95% CI: 3.77-8.09) were independently associated with fatality. CONCLUSIONS: Increased age, >3 symptoms, increasing comorbidities, higher CCI were associated with increased hospitalization, severity and fatality in patients with COVID-19.

Impact of meteorological parameters and population density on variants of SARS-CoV-2 and outcome of COVID-19 pandemic in Japan.

Although vaccines have become available, emergence and rapid transmission of new variants have added new paradigm in the coronavirus disease-2019 (COVID-19) pandemic. Weather, population and host immunity have been detected as the regulatory elements of COVID-19. This study aims to investigate the effects of weather, population and host factors on the outcome of COVID-19 and mutation frequency in Japan. Data were collected during January 2020 to February 2021. About 92% isolates were form GR clades. Variants 501Y.V1 (53%) and 452R.V1 (24%) were most prevalent in Japan. The strongest correlation was detected between fatalities and population density (rs = 0.81) followed by total population (rs = 0.72). Relative humidity had the highest correlation (rs = -0.71) with the case fatality rate. Cluster mutations namely N501Y (45%), E484K (30%), N439K (16%), K417N (6%) and T478I (3%) at spike protein have increased during January to February 2021. Above 90% fatality was detected in patients aged >60 years. The ratio of male to female patients of COVID-19 was 1.35:1. This study will help to understand the seasonality of COVID-19 and impact of weather on the outcome which will add knowledge to reduce the health burden of COVID-19 by the international organisations and policy makers.

Monitoring, treatment and control of blood glucose and lipids in Ontario First Nations people with diabetes.

BACKGROUND: Indigenous people worldwide are disproportionately affected by diabetes and its complications. We aimed to assess the monitoring, treatment and control of blood glucose and lipids in First Nations people in Ontario. METHODS: We conducted a longitudinal population-based study using administrative data for all people in Ontario with diabetes, stratified by First Nations status. We assessed age- and sex-specific rates of completion of recommended monitoring for low-density lipoprotein (LDL) and glycated hemoglobin (A1c) from 2001/02 to 2014/15. We used data from 2014/15 to conduct a cross-sectional analysis of rates of achievement of A1c and LDL targets and use of glucose-lowering medications. RESULTS: The study included 22 240 First Nations people and 1 319 503 other people in Ontario with diabetes. Rates of monitoring according to guidelines were 20%-50% for A1c and 30%-70% for lipids and were lowest for younger First Nations men. The mean age- and sex-adjusted A1c level was higher among First Nations people than other people (7.59 [95% confidence interval (CI) 7.57 to 7.61] v. 7.03 [95% CI 7.02 to 7.03]). An A1c level of 8.5% or higher was observed in 24.7% (95% CI 23.6 to 25.0) of First Nations people, compared to 12.8% (95% CI 12.1 to 13.5) of other people in Ontario. An LDL level of 2.0 mmol/L or less was observed in 60.3% (95% CI 59.7 to 61.6) of First Nations people, compared to 52.0% (95% CI 51.1 to 52.9) of other people in Ontario. Among those aged 65 or older, a higher proportion of First Nations people than other Ontarians were using insulin (28.1% v. 15.1%), and fewer were taking no medications (28.3% v. 40.1%). INTERPRETATION: As of 2014/15, monitoring and achievement of glycemic control in both First Nations people and other people in Ontario with diabetes remained suboptimal. Interventions to support First Nations patients to reach their treatment goals and reduce the risk of complications need further development and study.

Scandium in Neutral and Positively Charged Ammonia Complexes: Balancing between Sc2+ and Sc3.

High-level quantum chemical approaches are performed to study the stability and electronic structure of tri-, di-, monocationic, and neutral scandium ammonia complexes. The calculated binding energies of all Sc(NH3)1-83+,2+,+,0 complexes reveal the higher stability of hexa- and octacoordinated systems. The ground states of Sc(NH3)6,82+ and Sc(NH3)6,8 have a Sc2+(3d1) center, while there are two competitive electronic states for Sc(NH3)6,8+ with a Sc2+(3d1) or a Sc3+ center. The remaining electrons occupy an outer diffuse s-type orbital (1s). The lower lying states involve 3d-3d transitions for Sc(NH3)6,82+ but outer 1s-1p transitions for Sc(NH3)6,8+,0. The addition of one electron to Sc(NH3)6,83+,2+,+ reduces the binding energies but shortens the Sc-N bond lengths. The comparison with the vanadium and yttrium ammonia complexes (studied earlier) reveal the unique identity of scandium balancing between a d- and s-block element.

Association of physician payment model and team-based care with timely access in primary care: a population-based cross-sectional study.

BACKGROUND: It is unclear how patient-reported access to primary care differs by physician payment model and participation in team-based care. We examined the association between timely and after-hours access to primary care and physician payment model and participation in team-based care, and sought to assess how access varied by patient characteristics. METHODS: We conducted a cross-sectional analysis of adult (age ≥ 16 yr) Ontarians who responded to the Ontario Health Care Experience Survey between January 2013 and September 2015, reported having a primary care provider and agreed to have their responses linked to health administrative data. Access measures included the proportion of respondents who reported same-day or next-day access when sick, satisfaction with time to appointment when sick, telephone access and knowledge of an after-hours clinic. We tested the association between practice model and measures of access using logistic regression after stratifying for rurality. RESULTS: A total of 33 665 respondents met our inclusion criteria. In big cities, respondents in team and nonteam capitation models were less likely to report same-day or next-day access when sick than respondents in enhanced fee-for-service models (team capitation 43%, adjusted odds ratio [OR] 0.88, 95% confidence interval [CI] 0.79-0.98; nonteam capitation 39%, adjusted OR 0.78, 95% CI 0.70-0.87; enhanced fee-for-service 46% [reference]). Respondents in team and nonteam capitation models were more likely than those in enhanced fee-for-service models to report that their provider had an after-hours clinic (team capitation 59%, adjusted OR 2.59, 95% CI 2.39-2.81; nonteam capitation 51%, adjusted OR 1.90, 95% CI 1.76-2.04; enhanced fee-for service 34% [reference]). Patterns were similar for respondents in small towns. There was minimal to no difference by model for satisfaction with time to appointment or telephone access. INTERPRETATION: In our setting, there was an association between some types of access to primary care and physician payment model and team-based care, but the direction was not consistent. Different measures of timely access are needed to understand health care system performance.

Use of the health care system by Ontario First Nations people with diabetes: a population-based study.

BACKGROUND: First Nations people in Ontario have an increased prevalence of diabetes compared to other people in the province. This study examined use of health care services by First Nations people with diabetes and other people with diabetes in Ontario. METHODS: Using linked health administrative databases, we identified all people in Ontario with diabetes as of Apr. 1, 2014. We identified First Nations people using the Indian Register. We looked at outcomes from Apr. 1, 2014, to Mar. 31, 2015. We determined the proportion of people with a regular family physician and their continuity of care with that physician. We also examined visits with specialists for diabetes care, hospital admissions for ambulatory-care-sensitive conditions, and emergency department visits for hypo- or hyperglycemia. RESULTS: There were 1 380 529 people diagnosed with diabetes in Ontario as of Apr. 1, 2014, of whom 22 952 (1.7%) were First Nations people. First Nations people were less likely to have a regular family physician (85.3% v. 97.7%) and had lower continuity of care with that physician (mean score for continuity of care 74.6 v. 77.7) than other people in Ontario. They were also less likely to see specialists. First Nations people were more likely to be admitted to hospital for ambulatory-care-sensitive conditions (2.4% v. 1.2%) and to have an emergency department visit for hypo- or hyperglycemia (1.5% v. 0.8%). Disparities were particularly marked for those living in First Nations communities. INTERPRETATION: First Nations people with diabetes in Ontario had poorer access to and use of primary care than other people with diabetes in the province. These findings may help explain continued disparities in the rates of complications related to diabetes.

Diabetes-induced eye disease among First Nations people in Ontario: a longitudinal, population-based cohort study.

BACKGROUND: In Canada, First Nations populations experience a higher incidence of diabetes and diabetes-related complications than other people. Given the paucity of information on use of preventive eye examinations and the need for interventional care for severe retinopathy among First Nations people, we carried out a population-based study to compare rates of eye examinations and interventional therapies to treat vision-threatening stages of diabetic retinopathy among First Nations people and other people with diabetes in Ontario. METHODS: In collaboration with the Chiefs of Ontario, we carried out a population-based study to identify cohorts of First Nations people and other people with diabetes in Ontario from 1995/96 to 2014/15. We used linked health administrative databases to evaluate rates of eye examination (2005/06-2014/15) and severe diabetic retinopathy treatment and compared them between the 2 populations, and between First Nations people living in and outside of First Nations communities. RESULTS: We identified 23 013 First Nations people and 1 364 222 other people diagnosed with diabetes from 1995/96 to 2014/15, of whom 49.8% (95% confidence interval [CI] 48.9%-50.7%) and 53.8% (95% CI 53.7%-54.0%), respectively, received an eye examination in 2014/15. Eye examination rates were similar for First Nations people regardless of whether they lived in or outside a First Nations community. First Nations people developed severe diabetic retinopathy at a faster rate than other people (hazard ratio 1.19, 95% CI 1.02-1.38). The gap between First Nations people and other people in the proportion requiring therapy for severe diabetic retinopathy was especially prominent among younger people. There were no significant differences in rates of diabetic retinopathy treatment in First Nations people stratified by place of residence. INTERPRETATION: Eye examination rates remain suboptimal among people with diabetes in Ontario and were lower among First Nations people. This is particularly concerning in light of our other findings showing an increased risk of requiring treatment for advanced diabetic retinopathy and the accelerated rate of diabetic retinopathy progression among First Nations people with diabetes.

Diabetes prevalence, incidence and mortality in First Nations and other people in Ontario, 1995-2014: a population-based study using linked administrative data.

BACKGROUND: Diabetes mellitus is an established health concern in First Nations communities and is associated with complex influences of colonization. This study, a partnership between First Nations and academic researchers, was undertaken to determine patterns of diabetes prevalence, incidence and mortality in Ontario. METHODS: Using health services and population data from Ontario for 1995 to 2014, linked with the federal Indian Register, we calculated age- and sex-adjusted annual estimates of diabetes prevalence, incidence and mortality for First Nations people (living within and outside First Nations communities) and other people in Ontario. We also examined age- and sex-specific crude diabetes prevalence. RESULTS: Between 1995 and 2014, the prevalence of diabetes increased and the incidence decreased somewhat in all populations. Both prevalence and incidence were substantially higher among First Nations people than among other people in Ontario. In particular, First Nations women had higher prevalence than other women (4.2% v. 1.6% for ages 20-34 yr and 17.6% v. 6.0% for ages 35-49 yr). The lifetime risk of diabetes was higher among First Nations people than among other people in Ontario (57.0%, 95% confidence interval [CI] 56.3%-57.6% v. 44.5%, 95% CI 44.4%-44.6%). Over time, all-cause mortality for those with diabetes declined but remained consistently higher for First Nations people than for other people in Ontario. INTERPRETATION: Diabetes is more common among First Nations people than among other people in Ontario, particularly at younger ages and in women. First Nations-led approaches to address the high prevalence of diabetes in younger First Nations women have the potential to improve metabolic health across generations.