A modeling study exploring the impact of homelessness on rostered primary care utilization in Calgary, Canada.

OBJECTIVE: For patients who belonged to physician rosters at a family medicine practice in the core of Calgary, Canada, we compared primary care utilization for those who were stably housed and those experiencing homelessness. METHODS: This retrospective chart review accessed electronic medical record data for rostered patients who visited their family physician between July 1, 2015 and August 31, 2016. We assessed the association between homelessness status (defined as having been sheltered in overnight shelters and/or emergency/provisional housing during the study period) and the rate of visits to primary care (defined as the count of visits associated with a patient accounting for the length of the patient's relationship with their family physician) using multivariate negative binomial regression. RESULTS: We analyzed 1013 patients belonging to three family physician rosters, of whom 112 experienced homelessness during the study period (11.1%). The mean number of visits for patients who experienced homelessness was 9.6 (SD 10.5), compared to 4.2 (SD 3.6) visits for stably housed patients (p < 0.0001). The rate of accessing primary care for patients experiencing homelessness was 2.02 times greater than the rate for stably housed individuals (rate ratio [RR] 2.02, 95% confidence interval [95% CI] 1.74-2.35; p < 0.0001). CONCLUSION: In the context of an inner-city primary care clinic in Calgary, Canada, homelessness status is associated with an increased rate of visits to primary care. This work has implications for public health and health systems decision-makers involved in developing equitable health policy, as well as for frontline care providers who serve this vulnerable population.

Multisource Feedback and Narrative Comments: Polarity, Specificity, Actionability, and CanMEDS Roles.

INTRODUCTION: Multisource feedback is a questionnaire-based assessment tool that provides physicians with data about workplace behaviors and may combine numeric and narrative (free-text) comments. Little attention has been paid to wording of requests for comments, potentially limiting its utility to support physician performance. This study tested the phrasing of two different sets of questions. METHODS: Two sets of questions were tested with family physicians, medical and surgical specialists, and their medical colleague and coworker respondents. One set asked respondents to identify one thing the participant physician does well and one thing the physician could target for action. Set 2 questions asked what does the physician do well and what might the physician do to enhance practice. Resulting free-text comments provided by respondents were coded for polarity (positive, neutral, or negative), specificity (precision and detail), actionability (ability to use the feedback to direct future activity), and CanMEDS roles (competencies) and analyzed descriptively. RESULTS: Data for 222 physicians (111 physicians per set) were analyzed. A total of 1824 comments (8.2/physician) were submitted, with more comments from coworkers than medical colleagues. Set 1 yielded more comments and were more likely to be positive, semi specific, and very actionable than set 2. However, set 2 generated more very specific comments. Comments covered all CanMEDS roles with more comments for collaborator and leader roles. DISCUSSION: The wording of questions inviting free-text responses influences the volume and nature of the comments provided. Individuals designing multisource feedback tools should carefully consider wording of items soliciting narrative responses.

Evaluation of the ability of standardized supports to improve public health response to syndromic surveillance for respiratory diseases in Canada.

BACKGROUND: Despite widespread implementation of syndromic surveillance systems within public health agencies, previous studies of the implementation and use of these systems have indicated that the functions and responses taken in response to syndromic surveillance data vary widely according to local context and preferences. The objective of the Syndromic Surveillance Evaluation Study was to develop and implement standardized supports in local public health agencies in Ontario, Canada, and evaluate the ability of these supports to affect actions taken as part of public health communicable disease control programs. METHODS: Local public health agencies (LPHA) in Ontario, which used syndromic surveillance based on emergency department visits for respiratory disease, were recruited and randomly allocated to the study intervention or control group. The intervention group health agencies received standardized supports in terms of a standardized aberrant event detection algorithm and a response protocol dictating steps to investigate and assess the public health significance of syndromic surveillance alerts. The control group continued with their pre-existing syndromic surveillance infrastructure and processes. Outcomes were assessed using logbooks, which collected quantitative and qualitative information about alerts received, investigation steps taken, and public health responses. The study was conducted prospectively for 15 months (October 2013 to February 2015). RESULTS: Fifteen LPHAs participated in the study (n = 9 intervention group, n = 6 control group). A total of 1,969 syndromic surveillance alerts were received by all LPHAs. Variations in the types and amount of responses varied by LPHA, in particularly differences were noted by the size of the health unit. Smaller health units had more challenges to both detect and mount a response to any alerts. LPHAs in the control group were more likely to declare alerts to have public health significance and to initiate any action. Regression models using repeated measures showed an interaction between the year (Year 1 versus Year 2) and the intervention as well as an interaction between year and sustained nature of the alert. Both of these were linked to the control health units reporting more "watchful waiting". CONCLUSIONS: This study raises questions about the effectiveness of using standardized protocols to improve the performance of syndromic surveillance in a decentralized public health system. Despite efforts to create standardized protocols and engage public health agencies in the process, no significant differences in the effective use of syndromic alerts were observed beyond year 1. It also raises questions about the minimum capacity of the agency and minimum population size that are required for an effective response.

The influence of socioeconomic status on future risk for developing Type 2 diabetes in the Canadian population between 2011 and 2022: differential associations by sex.

BACKGROUND: Articulating future risk of diabetes at the population level can inform prevention strategies. While previous studies have characterized diabetes burden according to socioeconomic status (SES), none have studied future risk. METHODS: We quantified the influence of multiple constructs of SES on future diabetes risk using the Diabetes Population Risk Tool (DPoRT), a validated risk prediction algorithm that generates 10-year rates of new diabetes cases. We applied DPoRT to adults aged 30-64 in the 2011-2012 Canadian Community Health Survey (n = 65,372) and calculated risk for 2021-22. A multi-category outcome was created classifying risk as low (≤5%), moderate (greater than 5% and less than 20%), and high (≥20%), then assessed the impact of individual-level SES indicators, and area-level measures of marginalization on being moderate or high risk using multinomial logistic regression, stratified by sex. RESULTS: We found nuanced profiles of social determinants by sex, where women are more sensitive to social context. Women living in households where highest educational attainment was less than secondary school were at greater risk [odds ratio (OR) of high compared to low diabetes risk 3.10, 95% confidence interval (CI) 2.19-4.40, p < 0.0001). The same relationship was less pronounced for males (OR 2.17, 95% CI 1.42-3.32, p = 0.0004). Lower household income and being food insecure predicted high future diabetes risk for women (OR 1.37, 95% CI 1.01-1.86, p = 0.0418 comparing quintile 1 to quintile 5; OR 2.64, 95% CI 1.78-3.92, p < 0.0001 comparing severely food insecure to food secure), but not men (OR 1.15, 95% CI 0.84-1.57, p = 0.3818 and OR 1.22, 95% CI 0.71-2.10, p = 0.4815). At the area-level, material deprivation was significantly associated with increased future risk comparing the most to the least deprived (OR females 2.39, 95% CI 1.77-3.23; OR males 1.61, 95% CI 1.22-2.14). Additionally, a strong protective effect was observed for women living in ethnically dense areas (OR 0.75, 95% CI 0.63-0.89, p = 0.0011) which was not as pronounced for men (OR 0.95, 95% CI 0.76-1.18, p = 0.6351). CONCLUSIONS: This study characterized socio-contextual predictors for future diabetes risk, showing sex-specific effects. Diabetes prevention must consider factors beyond individual-level behavioral lifestyle change and actively take steps to mitigate the adverse impacts of socio-contextual factors.