A shifting terrain: Understanding the perspectives of walk-in physicians on their roles amid worsening primary care access in Ontario, Canada.

BACKGROUND: High-quality primary care is associated with better health outcomes and more efficient and equitable health system performance. However, the rate of primary care attachment is falling, and timely access to primary care is worsening, driving many patients to use walk-in clinics for their comprehensive primary care needs. This study sought to explore the experiences and perceived roles and responsibilities of walk-in physicians in this current climate. Methods: Qualitative interviews were conducted with nineteen physicians currently providing walk-in care in Ontario, Canada between May and December 2022. RESULTS: Limited capacity for continuity and comprehensiveness of care were identified as major sources of professional tension for walk-in physicians. Divergent perspectives on their roles were anchored in how physicians viewed their professional identity. Some saw providing continuous and comprehensive care as an infringement on their professional role; others saw their professional role as more flexible and responsive to population needs. Regardless of their professional identity, participants reported feeling ill-equipped to manage the swell of unattached patients, citing a lack of time, resources, connectivity to the system, and remuneration flexibility. Conclusions: As practice demands of walk-in clinics change, an evolution in the professional roles and responsibilities of walk-in physicians follows. However, the resources, structure, and incentives of walk-in care have not evolved to reflect this, leaving physicians to set their own professional boundaries with patients. This results in increasing variations in care and confusion across the primary care sector around who is responsible for what, when, and how.

Virtual Visits With Own Family Physician vs Outside Family Physician and Emergency Department Use.

Importance: Virtual visits became more common after the COVID-19 pandemic, but it is unclear in what context they are best used. Objective: To investigate whether there was a difference in subsequent emergency department use between patients who had a virtual visit with their own family physician vs those who had virtual visits with an outside physician. Design, Setting, and Participants: This propensity score-matched cohort study was conducted among all Ontario residents attached to a family physician as of April 1, 2021, who had a virtual family physician visit in the subsequent year (to March 31, 2022). Exposure: The type of virtual family physician visit, with own or outside physician, was determined. In a secondary analysis, own physician visits were compared with visits with a physician working in direct-to-consumer telemedicine. Main Outcome and Measure: The primary outcome was an emergency department visit within 7 days after the virtual visit. Results: Among 5 229 240 Ontario residents with a family physician and virtual visit, 4 173 869 patients (79.8%) had a virtual encounter with their own physician (mean [SD] age, 49.3 [21.5] years; 2 420 712 females [58.0%]) and 1 055 371 patients (20.2%) had an encounter with an outside physician (mean [SD] age, 41.8 [20.9] years; 605 614 females [57.4%]). In the matched cohort of 1 885 966 patients, those who saw an outside physician were 66% more likely to visit an emergency department within 7 days than those who had a virtual visit with their own physician (30 748 of 942 983 patients [3.3%] vs 18 519 of 942 983 patients [2.0%]; risk difference, 1.3% [95% CI, 1.2%-1.3%]; relative risk, 1.66 [95% CI, 1.63-1.69]). The increase in the risk of emergency department visits was greater when comparing 30 216 patients with definite direct-to-consumer telemedicine visits with 30 216 patients with own physician visits (risk difference, 4.1% [95% CI, 3.8%-4.5%]; relative risk, 2.99 [95% CI, 2.74-3.27]). Conclusions and Relevance: In this study, patients whose virtual visit was with an outside physician were more likely to visit an emergency department in the next 7 days than those whose virtual visit was with their own family physician. These findings suggest that primary care virtual visits may be best used within an existing clinical relationship.

Up-to-date on cancer screening among Ontario patients seen by walk-in clinic physicians: A retrospective cohort study.

Walk-in clinics are typically viewed as high-volume locations for managing acute issues but also may serve as a location for primary care, including cancer screening, for patients without a family physician. In this population-based cohort study, we compared breast, cervical and colorectal cancer screening up-to-date status for people living in the Canadian province of Ontario who were formally enrolled to a family physician versus those not enrolled but who had at least one encounter with a walk-in clinic physician in the previous year. Using provincial administrative databases, we created two mutually exclusive groups: i) those who were formally enrolled to a family physician, ii) those who were not enrolled but had at least one visit with a walk-in clinic physician from April 1, 2019 to March 31, 2020. We compared up to date status for three cancer screenings as of April 1, 2020 among screen-eligible people. We found that people who were not enrolled and had seen a walk-in clinic physician in the previous year consistently were less likely to be up to date on cancer screening than Ontarians who were formally enrolled with a family physician (46.1% vs. 67.4% for breast, 45.8% vs. 67.4% for cervical, 49.5% vs. 73.1% for colorectal). They were also more likely to be foreign-born and to live in structurally marginalized neighbourhoods. New methods are needed to enable screening for people who are reliant on walk-in clinics and to address the urgent need in Ontario for more primary care providers who deliver comprehensive, longitudinal care.

Walk-in clinic patient characteristics and utilization patterns in Ontario, Canada: a cross-sectional study.

BACKGROUND: Walk-in clinics are common in North America and are designed to provide acute episodic care without an appointment. We sought to describe a sample of walk-in clinic patients in Ontario, Canada, which is a setting with high levels of primary care attachment. METHODS: We performed a cross-sectional study using health administrative data from 2019. We compared the sociodemographic characteristics and health care utilization patterns of patients attending 1 of 72 walk-in clinics with those of the general Ontario population. We examined the subset of patients who were enrolled with a family physician and compared walk-in clinic visits to family physician visits. RESULTS: Our study found that 562 781 patients made 1 148 151 visits to the included walk-in clinics. Most (70%) patients who attended a walk-in clinic had an enrolling family physician. Walk-in clinic patients were younger (mean age 36 yr v. 41 yr, standardized mean difference [SMD] 0.24), yet had greater health care utilization (moderate and high use group 74% v. 65%, SMD 0.20) than the general Ontario population. Among enrolled Ontarians, walk-in patients had more comorbidities (moderate and high count 50% v. 45%, SMD 0.10), lived farther from their enrolling physician (median 8 km v. 6 km, SMD 0.21) and saw their enrolling physician less in the previous year (any visit 67% v. 80%, SMD 0.30). Walk-in encounters happened more often after hours (16% v. 9%, SMD 0.20) and on weekends (18% v. 5%, SMD 0.45). Walk-in clinics were more often within 3 km of patients' homes than enrolling physicians' offices (0 to < 3 km: 32% v. 22%, SMD 0.21). INTERPRETATION: Our findings suggest that proximity of walk-in clinics and after-hours access may be contributing to walk-in clinic use among patients enrolled with a family physician. These findings have implications for policy development to improve the integration of walk-in clinics and longitudinal primary care.

Characteristics and practice patterns of family physicians who provide home visits in Ontario, Canada: a cross-sectional study.

BACKGROUND: Physician home visits are essential for populations who cannot easily access office-based primary care. The objective of this study was to describe the characteristics, practice patterns and physician-level patient characteristics of Ontario physicians who provide home visits. METHODS: This was a retrospective cross-sectional study, based on health administrative data, of Ontario physicians who provided home visits and their patients, between Jan. 1, 2019, and Dec. 31, 2019. We selected family physicians who had at least 1 home visit in 2019. Physician demographic characteristics, practice patterns and aggregated patient characteristics were compared between high-volume home visit physicians (the top 5%) and low-volume home visit physicians (bottom 95%). RESULTS: A total of 6572 family physicians had at least 1 home visit in 2019. The top 5% of home visit physicians (n = 330) performed 58.6% of all home visits (n = 227 321 out of 387 139). Compared with low-volume home visit physicians (n = 6242), the top 5% were more likely to be male and practise in large urban areas, and rarely saw patients who were enrolled to them (median 4% v. 87.5%, standardized mean difference 1.12). High-volume physicians' home visit patients were younger, had greater levels of health care resource utilization, resided in lower-income and large urban neighbourhoods, and were less likely to have a medical home. INTERPRETATION: A small subset of home visit physicians provided a large proportion of home visits in Ontario. These home visits may be addressing a gap in access to primary care for certain patients, but could be contributing to lower continuity of care.

Characteristics and Health Care Use of Patients Attending Virtual Walk-in Clinics in Ontario, Canada: Cross-sectional Analysis.

BACKGROUND: Funding changes in response to the COVID-19 pandemic supported the growth of direct-to-consumer virtual walk-in clinics in several countries. Little is known about patients who attend virtual walk-in clinics or how these clinics contribute to care continuity and subsequent health care use. OBJECTIVE: The objective of the present study was to describe the characteristics and measure the health care use of patients who attended virtual walk-in clinics compared to the general population and a subset that received any virtual family physician visit. METHODS: This was a retrospective, cross-sectional study in Ontario, Canada. Patients who had received a family physician visit at 1 of 13 selected virtual walk-in clinics from April 1 to December 31, 2020, were compared to Ontario residents who had any virtual family physician visit. The main outcome was postvisit health care use. RESULTS: Virtual walk-in patients (n=132,168) had fewer comorbidities and lower previous health care use than Ontarians with any virtual family physician visit. Virtual walk-in patients were also less likely to have a subsequent in-person visit with the same physician (309/132,168, 0.2% vs 704,759/6,412,304, 11%; standardized mean difference [SMD] 0.48), more likely to have a subsequent virtual visit (40,030/132,168, 30.3% vs 1,403,778/6,412,304, 21.9%; SMD 0.19), and twice as likely to have an emergency department visit within 30 days (11,003/132,168, 8.3% vs 262,509/6,412,304, 4.1%; SMD 0.18), an effect that persisted after adjustment and across urban/rural resident groups. CONCLUSIONS: Compared to Ontarians attending any family physician virtual visit, virtual walk-in patients were less likely to have a subsequent in-person physician visit and were more likely to visit the emergency department. These findings will inform policy makers aiming to ensure the integration of virtual visits with longitudinal primary care.

Sensory Delay Activity: More than an Electrophysiological Index of Working Memory Load.

Sustained contralateral delay activity emerges in the retention period of working memory (WM) tasks and has been commonly interpreted as an electrophysiological index of the number of items held in a discrete-capacity WM resource. More recent findings indicate that these visual and tactile components are sensitive to various cognitive operations beyond the storage of discrete items in WM. In this Perspective, we present recent evidence from unisensory and multisensory visual and tactile WM tasks suggesting that, in addition to memory load, sensory delay activity may also be indicative of attentional and executive processes, as well as reflecting the flexible, rather than discrete, allocation of a continuous WM resource. Together, these findings challenge the traditional model of the functional significance of the contralateral delay activity as a pure measure of item load, and suggest that it may also reflect executive, attentional, and perceptual mechanisms operating in hierarchically organized WM systems.

Melatonin for Insomnia in Medical Inpatients: A Narrative Review.

In this narrative review, we describe what is known about non-pharmacological and pharmacological treatments for insomnia in medical inpatients, with a focus on melatonin. Hospital-acquired insomnia is common, resulting in shortened total sleep time and more nighttime awakenings. Sleep disturbance has been shown to increase systemic inflammation, pain, and the likelihood of developing delirium in hospital. Treatment for insomnia includes both non-pharmacological and pharmacological interventions, the latter of which requires careful consideration of risks and benefits given the known adverse effects. Though benzodiazepines and non-benzodiazepine benzodiazepine receptor agonists are commonly prescribed (i.e., sedative-hypnotics), they are relatively contraindicated for patients over the age of 65 due to the risk of increased falls, cognitive decline, and potential for withdrawal symptoms after long-term use. Exogenous melatonin has a comparatively low likelihood of adverse effects and drug-drug interactions and is at least as effective as other sedative-hypnotics. Though more research is needed on both its effectiveness and relative safety for inpatients, small doses of melatonin before bedtime may be an appropriate choice for inpatients when insomnia persists despite non-pharmacological interventions.

Drawn to Distraction: Anxiety Impairs Neural Suppression of Known Distractor Features in Visual Search.

When searching for a target, it is possible to suppress the features of a known distractor. This suppression may prevent distractor processing altogether or only after the distractor initially captures attention (i.e., search and destroy). However, suppression may be impaired in individuals with attentional control deficits, such as in high anxiety. In this study (n = 48), we used ERPs to examine the time course of attentional enhancement and suppression when participants were given pretrial information about target or distractor features. Consistent with our hypothesis, we found that individuals with higher levels of anxiety had lower neural measures of suppressing the template-matching distractor, instead showing enhanced processing. These findings indicate that individuals with anxiety are more likely to use a search-and-destroy mechanism of negative templates-highlighting the importance of attentional control abilities in distractor-guided search.

Fear not! Anxiety biases attentional enhancement of threat without impairing working memory filtering.

Individuals with anxiety have attentional biases toward threat-related distractors. This deficit in attentional control has been shown to impact visual working memory (VWM) filtering efficiency, as anxious individuals inappropriately store threatening distractors in VWM. It remains unclear, however, whether this mis-allocation of memory resources is due to inappropriate attentional enhancement of threatening distractors, or to a failure in suppression. Here, we used a systematically lateralized VWM task with fearful and neutral faces to examine event-related potentials related to attentional selection (N2pc), suppression (PD), and working memory maintenance (CDA). We found that state anxiety correlated with attentional enhancement of threat-related distractors, such that more anxious individuals had larger N2pc amplitudes toward fearful distractors than neutral distractors. However, there was no correlation between anxiety and memory storage of fearful distractors (CDA). These findings demonstrate that anxiety biases attention toward fearful distractors, but that this bias does not always guarantee increased memory storage of threat-related distractors.

Electrophysiological correlates of the flexible allocation of visual working memory resources.

Visual working memory is a brief, capacity-limited store of visual information that is involved in a large number of cognitive functions. To guide one's behavior effectively, one must efficiently allocate these limited memory resources across memory items. Previous research has suggested that items are either stored in memory or completely blocked from memory access. However, recent behavioral work proposes that memory resources can be flexibly split across items based on their level of task importance. Here, we investigated the electrophysiological correlates of flexible resource allocation by manipulating the distribution of resources amongst systematically lateralized memory items. We examined the contralateral delay activity (CDA), a waveform typically associated with the number of items held in memory. Across three experiments, we found that, in addition to memory load, the CDA flexibly tracks memory resource allocation. This allocation occurred as early as attentional selection, as indicated by the N2pc. Additionally, CDA amplitude was better-described when fit with a continuous model predicted by load and resources together than when fit with either alone. Our findings show that electrophysiological markers of attentional selection and memory maintenance not only track memory load, but also the proportion of memory resources those items receive.

ERP evidence for temporal independence of set size and object updating in object substitution masking.

To keep track of dynamically changing objects in one's environment, it is necessary to individuate them from other objects, both temporally and spatially. Spatially, objects can be selected from nearby distractors using selective attention. Temporally, object updating processes incorporate new information into existing representations over time. Both of these processes have been implicated in a type of visual masking called object-substitution masking (OSM). Previous studies have found that the number of distractors (impacting selective attention) interacts with the strength of OSM. However, it has been suggested that this interaction is an artifact of ceiling performance at low set sizes, rather than necessitating a failure of attention during masking. Using event-related potentials (ERPs), we examined whether set size and masking interact as measured by markers of selective attention (N2pc) and visual working memory consolidation/maintenance (SPCN). Set size was found to affect the N2pc (200-350 ms) and late SPCN (500-650 ms), reflecting increased demands on selective attention and unnecessary storage respectively. An early window of the SPCN (350-500 ms) was affected by masking, suggesting that OSM influences object consolidation processes in this window, independent of the number of distractors. Overall, it was found that selective attention and visual awareness are dissociable neural processes in OSM, and that they are independently affected by set size and masking manipulations. Moreover, we found that the early SPCN may reflect disruptions to object consolidation, potentially revealing a neural mechanism supporting an object individuation-through-updating account of OSM.

Tuning perception: Visual working memory biases the quality of visual awareness.

Studies of consciousness reveal that it is possible to manipulate subjective awareness of a visual stimulus. For example, items held in visual working memory (VWM) that match target features increase the speed with which the target reaches visual awareness. To examine the effect of VWM on perception, previous studies have mainly used coarse measures of awareness, such as present/absent or forced-choice judgments. These methods can reveal whether or not an individual has seen an item, but they do not provide information about the quality with which the item was seen. Using continuous report methods it has been shown that the fidelity of a perceived item can be affected by whether or not that item is masked. In the present study, we used an object-substitution masking task to examine whether items held in VWM would influence the quality with which a masked target reached awareness, or whether the threshold for awareness was instead affected by stimuli held in memory. We observed that targets matching the contents of VWM were recalled with greater precision compared to items that did not match the contents of VWM. Importantly, this effect occurred without affecting the likelihood of the target being perceived. These results suggest that VWM plays a greater role in modulating the fidelity of perceived representations than in lowering the overall threshold of awareness.