Factors that influence scope-of-practice decisions of early-career family physicians: Focus group study in Canada.

OBJECTIVE: To explore perceptions of early-career family physicians on the personal, educational, organizational, community, and system factors that had influenced their scope-of-practice decisions and to compare the similarities and differences among these factors across all 13 Canadian jurisdictions. DESIGN: Qualitative descriptive study. SETTING: Canada. PARTICIPANTS: Fifty-nine early-career family physicians who were 2 to 5 years into independent practice. METHODS: Data were collected using focus groups and were analyzed using deductive and inductive analysis techniques to identify patterns in the data within and across jurisdictions. MAIN FINDINGS: Participants across all jurisdictions highlighted that personal factors (ie, interest, work-life balance and family life, financial considerations, and self-perceived competence and confidence) were most influential on scope-of-practice decisions. Educational (ie, exposure during training, mentorship), organizational (ie, collegial support), community (ie, needs), and system (ie, payment models, funding for team-based care, governance) factors also influenced decisions about scope of practice. Experiences were similar across all jurisdictions for personal factors. Differences in experiences were reported across jurisdictions for educational, organizational, community, and system factors. CONCLUSION: Decisions about scope of practice by early-career family physicians are highly influenced by personal factors followed by organizational, educational, community, and system factors. These findings suggest numerous strategies are needed to increase individuals' interest in providing comprehensive care in Canada. Educators should cultivate interest in comprehensive care among learners, strategically recruit trainees, provide targeted exposure and experiences, ensure competence and confidence are evaluated throughout and at the end of training, and introduce formal mentorship programs. Policy-makers should invest in the spread of effective team models and alternative payment models. Together, these strategies could broaden the scopes of practice of family physicians and their capacity to deliver accessible and comprehensive care to Canadians.

The Conceptualization and Measurement of Research Impact in Primary Health Care: Protocol for a Rapid Scoping Review.

BACKGROUND: The generation of research evidence and knowledge in primary health care (PHC) is crucial for informing the development and implementation of interventions and innovations and driving health policy, health service improvements, and potential societal changes. PHC research has broad effects on patients, practices, services, population health, community, and policy formulation. The in-depth exploration of the definition and measures of research impact within PHC is essential for broadening our understanding of research impact in the discipline and how it compares to other health services research. OBJECTIVE: The objectives of the study are (1) to understand the conceptualizations and measures of research impact within the realm of PHC and (2) to identify methodological frameworks for evaluation and research impact and the benefits and challenges of using these approaches. The forthcoming review seeks to guide future research endeavors and enhance methodologies used in assessing research impact within PHC. METHODS: The protocol outlines the rapid review and environmental scan approach that will be used to explore research impact in PHC and will be guided by established frameworks such as the Canadian Academy of Health Sciences Impact Framework and the Canadian Health Services and Policy Research Alliance. The rapid review follows scoping review guidelines (PRISMA-ScR; Preferred Reporting Items for Systematic Review and Meta-Analysis Extension for Scoping Reviews). The environmental scan will be done by consulting with professional organizations, academic institutions, information science, and PHC experts. The search strategy will involve multiple databases, citation and forward citation searching, and manual searches of gray literature databases, think tank websites, and relevant catalogs. We will include gray and scientific literature focusing explicitly on research impact in PHC from high-income countries using the World Bank classification. Publications published in English from 1978 will be considered. The collected papers will undergo a 2-stage independent review process based on predetermined inclusion criteria. The research team will extract data from selected studies based on the research questions and the CRISP (Consensus Reporting Items for Studies in Primary Care) protocol statement. The team will discuss the extracted data, enabling the identification and categorization of key themes regarding research impact conceptualization and measurement in PHC. The narrative synthesis will evolve iteratively based on the identified literature. RESULTS: The results of this study are expected at the end of 2024. CONCLUSIONS: The forthcoming review will explore the conceptualization and measurement of research impact in PHC. The synthesis will offer crucial insights that will guide subsequent research, emphasizing the need for a standardized approach that incorporates diverse perspectives to comprehensively gauge the true impact of PHC research. Furthermore, trends and gaps in current methodologies will set the stage for future studies aimed at enhancing our understanding and measurement of research impact in PHC. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/55860.

What factors are associated with the research productivity of primary care researchers in Canada? A qualitative study.

BACKGROUND: Research evidence to inform primary care policy and practice is essential for building high-performing primary care systems. Nevertheless, research output relating to primary care remains low worldwide. This study describes the factors associated with the research productivity of primary care researchers. METHODS: A qualitative, descriptive key informant study approach was used to conduct semi-structured interviews with twenty-three primary care researchers across Canada. Qualitative data were analyzed using reflexive thematic analysis. RESULTS: Twenty-three primary care researchers participated in the study. An interplay of personal (psychological characteristics, gender, race, parenthood, education, spousal occupation, and support), professional (mentorship before appointment, national collaborations, type of research, career length), institutional (leadership, culture, resources, protected time, mentorship, type), and system (funding, systematic bias, environment, international collaborations, research data infrastructure) factors were perceived to be associated with research productivity. Research institutes and mentors facilitated collaborations, and mentors and type of research enabled funding success. Jurisdictions with fewer primary care researchers had more national collaborations but fewer funding opportunities. The combination of institutional, professional, and system factors were barriers to the research productivity of female and/or racialized researchers. CONCLUSIONS: This study illuminates the intersecting and multifaceted influences on the research productivity of primary care researchers. By exploring individual, professional, institutional, and systemic factors, we underscore the pivotal role of diverse elements in shaping RP. Understanding these intricate influencers is imperative for tailored, evidence-based interventions and policies at the level of academic institutions and funding agencies to optimize resources, promote fair evaluation metrics, and cultivate inclusive environments conducive to diverse research pursuits within the PC discipline in Canada.

Dietary Composition, Angiographic Coronary Disease, and Cardiovascular Outcomes in the WISE Study (Women's Ischemia Syndrome Evaluation).

BACKGROUND: Studies relating diet to angiographic coronary artery disease (CAD) and subsequent major adverse cardiac events (MACE) in women are limited. Information on diet was collected in the Women's Ischemia Syndrome Evaluation (WISE), a prospective cohort study of symptomatic women referred for coronary angiography to evaluate suspected ischemic heart disease. METHODS: A consecutive subgroup (n = 201 of 936) of enrolled women completed the modified Block food frequency questionnaire (FFQ). Data on outcomes were collected and adjudicated after 8-year follow-up. A set of logistic regression models were fitted for non-obstructive versus obstructive coronary stenosis (<50% versus ≥50%). Cox proportional hazard regression models were fitted for outcomes, with each dietary composition variable adjusted for the degree of coronary stenosis. RESULTS: At baseline, the subgroup cohort was 58 ± 12 years old with a body mass index (BMI) of 30 ± 7 kg/m2. An increased proportion of calories consumed from protein was associated with higher levels of baseline obstructive coronary stenosis. Those individuals who ate a higher amount of protein, carotene, and servings of vegetables and meat, however, were each associated with lower subsequent adverse outcomes, respectively. CONCLUSIONS: Among women undergoing coronary angiography for suspected CAD, a higher percentage of protein intake was associated with higher baseline stenosis severity; however, the amount of protein intake, vegetable, meat, and carotene intake, was conversely associated with subsequent lower adverse cardiovascular outcome risk.

What are effective vaccine distribution approaches for equity-deserving and high-risk populations during COVID-19? Exploring best practices and recommendations in Canada: protocol for a mixed-methods multiple case codesign study.

INTRODUCTION: The WHO has stated that vaccine hesitancy is a serious threat to overcoming COVID-19. Vaccine hesitancy among underserved and at-risk communities is an ongoing challenge in Canada. Public confidence in vaccine safety and effectiveness and the principles of equity need to be considered in vaccine distribution. In Canada, governments of each province or territory manage their own healthcare system, providing an opportunity to compare and contrast distribution strategies. The overarching objective of this study is to identify effective vaccine distribution approaches and advance knowledge on how to design and implement various strategies to meet the different needs of underserved communities. METHODS AND ANALYSIS: Multiple case studies in seven Canadian provinces will be conducted using a mixed-methods design. The study will be informed by Experience-Based CoDesign techniques and theoretically guided by the Socio-Ecological Model and the Vaccine Hesitancy Matrix frameworks. Phase 1 will involve a policy document review to systematically explore the vaccine distribution strategy over time in each jurisdiction. This will inform the second phase, which will involve (2a) semistructured, in-depth interviews with policymakers, public health officials, researchers, providers, groups representing patients, researchers and stakeholders and (2b) an analysis of population-based administrative health data of vaccine administration. Integration of qualitative and quantitative data will inform the identification of effective vaccine distribution approaches for various populations. Informed by this evidence, phase 3 of the study will involve conducting focus groups with multiple stakeholders to codesign recommendations for the design and implementation of effective vaccine delivery strategies for equity-deserving and at-risk populations. ETHICS AND DISSEMINATION: This study is approved by the University of Toronto's Health Sciences Research Ethics Board (#42643), University of British Columbia Behavioural Research Ethics Board (#H22-01750-A002), Research Ethics Board of the Nova Scotia Health Authority (#48272), Newfoundland and Labrador Health Research Ethics Board (#2022.126), Conjoint Health Research Ethics Board, University of Calgary (REB22-0207), and University of Manitoba Health Research Board (H2022-239). The outcome of this study will be to produce a series of recommendations for implementing future vaccine distribution approaches from the perspective of various stakeholders, including equity-deserving and at-risk populations.

Distinguishing Lysosomal Acid Lipase Deficiency From Familial Hypercholesterolemia.

Lysosomal acid lipase deficiency (LAL-D) is underrecognized because it manifests clinically with lipid and lipoprotein values similar to those observed in heterozygous familial hypercholesterolemia (FH). Although LAL-D is uncommon, understanding the differences between the 2 diseases has significant management implications. We present a case of LAL-D that masqueraded as FH. (Level of Difficulty: Advanced.).

Understanding the influence of medical education on physician geographic disposition: A qualitative study of family physician perspectives in Canada.

RATIONALE: Primary care access challenges are experienced by many communities. In several jurisdictions, including Canada, family physicians (FP) have the professional autonomy to organize their practice in alignment with professional and personal interests. Although system-level interventions are tremendously important, investment in upstream interventions associated with the medical education of graduating FPs is a promising strategy for ameliorating primary healthcare access challenges. AIMS AND OBJECTIVES: This study investigates the medical education experiences that influence FP's decisions about practice locations in Canada. METHODS: We conducted semistructured interviews with FPs who completed undergraduate and postgraduate medical training in Canada and now have a practice in Ontario, Canada. Interview data were coded and analysed using an unconstrained descriptive approach. RESULTS: FPs preferred practice locations are intimately tied to their desired practice scope. Practice preferences were shaped through training experiences with patient populations, heightened clinical responsibilities, practice models and locations, professional mentorships and networks. Proximity to family, partner and lifestyle preferences, cultural connections and the available practice opportunities also shaped practice location decisions. CONCLUSION: Medical education influences the identification and refinement of professional family practice preferences. Health workforce policies and interventions should leverage medical education to promote more equitable primary healthcare access.

Building High-Performing Primary Care Systems: After a Decade of Policy Change, Is Canada "Walking the Talk?"

Policy Points Considerable investments have been made to build high-performing primary care systems in Canada. However, little is known about the extent to which change has occurred over the last decade with implementing programs and policies across all 13 provincial and territorial jurisdictions. There is significant variation in the degree of implementation of structural features of high-performing primary care systems across Canada. This study provides evidence on the state of primary care reform in Canada and offers insights into the opportunities based on changes that governments elsewhere have made to advance primary care transformation. CONTEXT: Despite significant investments to transform primary care, Canada lags behind its peers in providing timely access to regular doctors or places of care, timely access to care, developing interprofessional teams, and communication across health care settings. This study examines changes over the last decade (2012 to 2021) in policies across 13 provincial and territorial jurisdictions that address the structural features of high-performing primary care systems. METHODS: A multiple comparative case study approach was used to explore changes in primary care delivery across 13 Canadian jurisdictions. Each case consisted of (1) qualitative interviews with academics, provincial health care leaders, and health care professionals and (2) a literature review of policies and innovations. Data for each case were thematically analyzed within and across cases, using 12 structural features of high-performing primary care systems to describe each case and assess changes over time. FINDINGS: The most significant changes include adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. The rate of change was slowest for patient engagement, leadership development, performance measurement, research capacity, and systematic evaluation of innovation. CONCLUSIONS: Progress toward building high-performing primary care systems in Canada has been slow and variable, with limited change in the organization and delivery of primary care. Canada's experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform, with progress less pronounced in the attributes that impact physician autonomy. To accelerate primary care transformation in Canada and abroad, a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous research.

Conceptualizing "Preparedness for Practice": Perspectives of Early-Career Family Physicians.

BACKGROUND AND OBJECTIVES: Competency based medical education (CBME) aims to produce graduates prepared for independent practice. Many equate the outcome of "preparedness for practice" with acquisition of competence. As educators evaluate the outcomes of CBME, being clear on the concept of preparedness for practice will clarify the results that are measured and assessed. This study examined how preparedness for practice is conceptualized in the literature and by family physicians (FPs) in Canada. METHODS: This multimethod qualitative descriptive study included (1) rapid review and narrative synthesis, and (2) focus groups with early-career FPs using maximum variation sampling until thematic saturation was reached. Focus groups explored the FPs' conceptualizations of preparedness for practice. Focus groups were audio-recorded, transcribed, and coded before content analysis. RESULTS: Thirty-four articles met the inclusion criteria, and 59 early-career FPs participated in the focus groups. We found no consensus on the conceptualization of preparedness for practice in the literature; however, the concept often was described as acquiring competencies for program requirements. In the literature and focus groups, we identified four themes for the conceptualization of preparedness for practice. These themes included competence, self-confidence (self-efficacy, self-concept), capability, and adaptability. CONCLUSIONS: Preparedness for practice involves an interplay of dynamic and complex constructs from competence, self-confidence, capability, and adaptability. Preparedness is more than possessing several competencies; it calls for integrating and applying competencies in complex and changing environments. This study aimed to start a discussion on what end point is desirable for residency education and proposed that the end point needs to move beyond competencies.

Defining the capabilities and competencies of high-performing family physicians: a mixed methods study.

INTRODUCTION: High-performing primary care is recognised as the foundation of an effective and efficient healthcare system. Many medical graduates report they are not prepared for independent practice. To date, no research has been conducted to identify the key capabilities and competencies of high-performing family medicine graduates in Canada. This pilot project aims to identify the capabilities and competencies of high-performing early-career family physicians in Ontario, Canada, and explore opportunities for enhancing learning, teaching and assessment within family medicine residency programmes. METHODS AND ANALYSIS: Employing a mixed-methods explanatory sequential study design, this research will use a theory-driven Professional Capability Framework, previously validated in studies across nine professions, to guide the investigation. The first (quantitative) phase involves surveying ~50 high-performing early-career family physicians identified as high performing by educators, colleagues and leaders. The objective of the survey is to identify the key competencies and personal, interpersonal and cognitive capabilities of high-performing family physicians. The second (qualitative) phase involves conducting workshops with stakeholders, including educators, professional associations, regulators and colleges, to test the veracity of the results. Quantitative data will be analysed using descriptive statistics, and qualitative data will be analysed using Braun and Clarke's thematic analysis. The first and second phases will identify the key capabilities and competencies required to confidently adapt to the independent practice of comprehensive family medicine and inform fit-for-purpose educational strategies for teaching, learning and assessment. ETHICS AND DISSEMINATION: The study is approved by the University of Toronto's Health Sciences Research Ethics Board (#41799). Research findings will be discussed with professional bodies, educators responsible for family medicine curricula and universities. Study findings will also be disseminated through academic conferences and academic publications in peer-reviewed journals. Project summaries and infographics will be developed and disseminated to key stakeholders.

Associations between education policies and the geographic disposition of family physicians: a retrospective observational study of McMaster University education data.

The maldistribution of family physicians challenges equitable primary care access in Canada. The Theory of Social Attachment suggests that preferential selection and distributed training interventions have potential in influencing physician disposition. However, evaluations of these approaches have focused predominantly on rural underservedness, with little research considering physician disposition in other underserved communities. Accordingly, this study investigated the association between the locations from which medical graduates apply to medical school, their undergraduate preclerkship, clerkship, residency experiences, and practice as indexed across an array of markers of underservedness. We built association models concerning the practice location of 347 family physicians who graduated from McMaster University's MD Program between 2010 and 2015. Postal code data of medical graduates' residence during secondary school, pre-clerkship, clerkship, residency and eventual practice locations were coded according to five Statistics Canada indices related to primary care underservedness: relative rurality, employment rate, proportion of visible minorities, proportion of Indigenous peoples, and neighbourhood socioeconomic status. Univariate and multivariable logistic regression models were then developed for each dependent variable (i.e., practice location expressed in terms of each index). Residency training locations were significantly associated with practice locations across all indices. The place of secondary school education also yielded significant relationships to practice location when indexed by employment rate and relative rurality. Education interventions that leverage residency training locations may be particularly influential in promoting family physician practice location. The findings are interpreted with respect to how investment in education policies can promote physician practice in underserved communities.

Comparing Practice Intentions and Patterns of Family Physicians in Canada.

BACKGROUND AND OBJECTIVES: In Canada, competency-based medical education prepares family medicine (FM) graduates to provide a broad scope of practice (SoP). We compared the practice intentions of FM residents at the end of training with actual practice patterns of early career family physicians (FPs) for SoP activities reflective of comprehensive family medicine. METHODS: We collected self-reported data from cross-sectional family medicine longitudinal surveys for exiting FM residents in 2015 and 2016 and from a separate cohort of FPs who were 3 years into practice in 2018 and 2019 from 15 programs. We measured outcomes from exiting FM residents intending to participate in SoP activities and FPs participating in 15 SoP domains of family medicine. RESULTS: A total of 1,409 exiting FM residents (58.2% response rate) and 523 early career FPs (21% response rate) responded to the surveys. A high correlation existed between the percentage of exiting residents who intended to participate in each SoP activity and the percentage of FPs who participated in those activities (r2=0.95). However, we found statistically significant declines in the percentage of FPs reporting involvement in the SoP activities compared to their reported practice intentions for 14 of the 15 domains. We saw the greatest declines in providing care in long-term care facilities, rural communities, emergency departments, intrapartum care, and care for Indigenous populations (P<.001). CONCLUSIONS: While SoP patterns are highly correlated with practice intentions, early-career FPs are less likely to provide care as intended for all SoP activities. Further research is needed on the factors influencing practice patterns in specific areas to determine how FP graduates can be supported to provide comprehensive care.

Impact of remuneration, extrinsic and intrinsic incentives on interprofessional primary care teams: protocol for a rapid scoping review.

INTRODUCTION: Interprofessional teams and funding and payment provider arrangements are key attributes of high-performing primary care. Several Canadian jurisdictions have introduced team-based models with different payment models. Despite these investments, the evidence of impact is mixed. This has raised questions about whether team-based primary care models are being implemented to facilitate team collaboration and effectiveness. Thus, we present a protocol for a rapid scoping review to systematically map, synthesise and summarise the existing literature on the impact of provider remuneration mechanisms and extrinsic and intrinsic incentives in team-based primary care. This review will answer three research questions: (1) What is the impact of provider remuneration models on team, patient, provider and system outcomes in primary care?; (2) What extrinsic and intrinsic incentives have been used in interprofessional primary care teams?; and (3) What is the impact of extrinsic and intrinsic team-based incentives on team, patient, provider and system outcomes? METHODS AND ANALYSIS: We will conduct a rapid scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. We will search electronic databases (Medline, Embase, CINAHL, PsycINFO, EconLit) and grey literature sources (Google Scholar, Google). This review will consider all empirical studies and full-text English-language articles published between 2000 and 2022. Reviewers will independently perform the literature search, data extraction and synthesis of included studies. The Mixed Methods Appraisal Tool will be used to appraise the quality of evidence. The literature will be synthesised, summarised and mapped to themes that answer the research question of this review. ETHICS AND DISSEMINATION: Ethics approval is not required. Findings from this study will be written for publication in an open-access peer-review journal and presented at national and international conferences. Knowledge users are part of the research team and will assist with disseminating findings to the public, clinicians, funders and professional associations.

Identify and classify interprofessional primary care performance indicators: a scoping review protocol.

INTRODUCTION: Measuring the performance of interprofessional primary care is needed to examine whether this model of care is achieving its desired outcomes on patient care and health system effectiveness as well as to guide quality improvement initiatives. The aim of this scoping review is to map the literature on primary care performance measurement indicators to determine the extent to which current indicators capture or could be adapted to capture processes, outputs and outcomes that reflect interprofessional primary care. METHODS AND ANALYSIS: The review will be guided by the six-stage framework by Arksey and O'Malley (2005). MEDLINE, Embase, CINAHL, grey literature and the reference list of key studies will be searched to identify any study, published in English or French between 2000 and 2022, related to the concepts of performance indicators, frameworks, interprofessional teams and primary care. Two reviewers will independently screen all abstracts and full-text studies for inclusion. Eligible indicators will be classified according to process, output and outcome domains proposed by two validated frameworks. This study started in November 2022 and is expected to be completed by July 2023. ETHICS AND DISSEMINATION: This review does not require ethical approval. The results will be disseminated through a peer-reviewed publication, conference presentations and presentations to stakeholders.

Are early career family physicians prepared for practice in Canada? A qualitative study.

BACKGROUND: In Canada, the College of Family Physicians of Canada (CFPC) introduced Competency Based Medical Education to prepare and train family medicine residents to be competent to enter and adapt to the independent practice of comprehensive family medicine. Despite its implementation, the scope of practice is narrowing. This study aims to understand the degree to which early career Family Physicians (FPs) are prepared for independent practice. METHOD: A qualitative design was used for this study. A survey and focus groups were conducted with early-career FPs who completed residency training in Canada. The survey and focus groups examined the degree of preparedness of early career FPs in relation to 37 core professional activities identified by the CFPC's Residency Training Profile. Descriptive statistics and qualitative content analysis were conducted. RESULTS: Seventy-five participants from across Canada participated in the survey, and 59 participated in the focus groups. Early career FPs reported being well prepared to provide continuous and coordinated care for patients with common presentations and deliver various services to different populations. FPs were also well prepared to manage the electronic medical record, participate in team-based care, provide regular and after-hours coverage, and assume leadership and teaching roles. However, FPs reported being less prepared for virtual care, business management, providing culturally safe care, delivering specific services in emergency care hospitals, obstetrics, self-care, engaging with the local communities, and conducting research activities. CONCLUSIONS: Early career FPs do not feel fully prepared for practice in all 37 core activities in the Residency Training Profile. As part of the introduction of the three-year program by the CFPC, the postgraduate family medicine training should consider providing more exposure to learning opportunities and developing curricula in the areas where FPs are unprepared for practice. These changes could facilitate the production of a FP workforce better prepared to manage the dynamic and complex challenges and dilemmas faced in independent practice.

What is the role of primary care in the COVID-19 vaccine roll-out and the barriers and facilitators to an equitable vaccine roll-out? A rapid scoping review of nine jurisdictions.

OBJECTIVES: This study aimed to: (1) examine the experience of nine global jurisdictions that engaged primary care providers (PCPs) to administer COVID-19 vaccines during the pandemic; (2) describe how vaccine hesitancy and principles of equity were incorporated in the COVID-19 vaccine roll-out strategies and (3) identify the barriers and facilitators to the vaccine roll-out. DESIGN: Rapid scoping review. DATA SOURCES: Searches took place in MEDLINE, CINAHL, Embase, the Cochrane Library, SCOPUS and PsycINFO, Google, and the websites of national health departments. Searches and analyses took place from May 2021 to July 2021. RESULTS: Sixty-two documents met the inclusion criteria (35=grey literature; 56% and 27=peer reviewed; 44%). This review found that the vaccine distribution approach started at hospitals in almost all jurisdictions. In some jurisdictions, PCPs were engaged at the beginning, and the majority included PCPs over time. In many jurisdictions, equity was considered in the prioritisation policies for various marginalised communities. However, vaccine hesitancy was not explicitly considered in the design of vaccine distribution approaches. The barriers to the roll-out of vaccines included personal, organisational and contextual factors. The vaccine roll-out strategy was facilitated by establishing policies and processes for pandemic preparedness, well-established and coordinated information systems, primary care interventions, adequate supply of providers, education and training of providers, and effective communications strategy. CONCLUSIONS: Empirical evidence is lacking on the impact of a primary care-led vaccine distribution approach on vaccine hesitancy, adoption and equity. Future vaccine distribution approaches need to be informed by further research evaluating vaccine distribution approaches and their impact on patient and population outcomes.

Integrating Coronary Atherosclerosis Burden and Progression with Coronary Artery Disease Risk Factors to Guide Therapeutic Decision Making.

IMPORTANCE: Although atherosclerosis represents the primary driver of coronary artery disease, evaluation and treatment approaches have historically relied upon indirect markers of atherosclerosis that include surrogates (cholesterol), signs (angina), and sequelae (ischemia) of atherosclerosis. Direct quantification and characterization of atherosclerosis may encourage a precision heart care paradigm that improves diagnosis, risk stratification, therapeutic decision-making, and longitudinal disease tracking in a personalized fashion. OBSERVATIONS: The American College of Cardiology Innovations in Prevention Working Group introduce the Atherosclerosis Treatment Algorithms that personalize medical interventions based upon atherosclerosis findings from coronary computed tomography angiography (CTA) and cardiovascular risk factors. Through integration of coronary CTA-based atherosclerosis evaluation, clinical practice guidelines, and contemporary randomized controlled trial evidence, the Atherosclerosis Treatment Algorithms leverage patient-specific atherosclerosis burden and progression as primary targets for therapeutic intervention. After defining stages of atherosclerosis severity by coronary CTA, Atherosclerosis Treatment Algorithms are described for worsening stages of atherosclerosis for patients with lipid disorders, diabetes, hypertension, obesity, and tobacco use. The authors anticipate a rapid pace of research in the field, and conclude by providing perspectives on future needs that may improve efforts to optimize precision prevention of coronary artery disease. Importantly, the Atherosclerosis Treatment Algorithms are not endorsed by the American College of Cardiology, and should not be interpreted as a statement of American College of Cardiology policy. CONCLUSIONS AND RELEVANCE: We describe a precision heart care approach that emphasizes atherosclerosis as the primary disease target for evaluation and treatment. To our knowledge, this is the first proposal to use coronary atherosclerosis burden and progression to personalize therapy selection and therapy changes, respectively. DISCLOSURE: The American College of Cardiology Foundation has made an investment in Cleerly, Inc., makers of a software solution that utilizes coronary CT angiography findings to evaluate coronary artery disease.

Association of sleep duration and insomnia with metabolic syndrome and its components in the Women's Health Initiative.

BACKGROUND: Epidemiological evidence suggests that inadequate sleep duration and insomnia may be associated with increased risk of metabolic syndrome (MetS). However, longitudinal data with repeated measures of sleep duration and insomnia and of MetS are limited. We examined the association of sleep duration and insomnia with MetS and its components using longitudinal data from the Women's Health Initiative (WHI). METHODS: The study included postmenopausal women (ages 50-79 years) diabetes-free at enrollment in the WHI, with baseline data on sleep duration (n = 5,159), insomnia (n = 5,063), MetS, and its components. Repeated measures of self-reported sleep duration and insomnia were available from years 1 or 3 of follow-up and of the MetS components from years 3, 6 and 9. Associations were assessed using logistic regression and generalized estimating equations models, and odds ratios and 95% confidence intervals (CI) adjusted for major risk factors were calculated. RESULTS: In cross-sectional analysis, baseline sleep duration ≥ 9 h was positively associated with MetS (OR = 1.51; 95%CI 1.12-2.04), while sleep duration of 8- < 9 h was associated with waist circumference > 88 cm and triglycerides ≥ 150 mg/dL (OR = 1.18; 95%CI 1.01-1.40 and OR = 1.23; 95%CI 1.05-1.46, respectively). Insomnia had a borderline positive association with MetS (OR = 1.14; 95%CI 0.99-1.31), and significant positive associations with waist circumference > 88 cm and glucose ≥ 100 mg/dL (OR = 1.18; 95%CI 1.03-1.34 and OR = 1.17; 95%CI 1.02-1.35, respectively). In the longitudinal analysis, change from restful sleep to insomnia over time was associated with increased odds of developing MetS (OR = 1.40; 95%CI 1.01-1.94), and of a triglyceride level ≥ 150 mg/dL (OR = 1.48; 95%CI 1.08-2.03). CONCLUSIONS: Among postmenopausal women in the WHI, sleep duration and insomnia were associated with current and future risk of MetS and some of its components.

The role of patients in the governance of a sustainable healthcare system: A scoping review.

Patients, healthcare providers and insurers need a governance framework to establish the 'rules of use' to deliver more responsible use of services. The objective of this review was to provide an overview of frameworks and analyze the definitions of patient accountability to identify themes and potential gaps in the literature. Fifteen bibliographic databases were searched until July 2021. This included: MEDLINE, EMBASE, CINAHL, PsycINFO, SPORTDiscus, Allied and Complementary Medicine Database, Web of Science, HealthSTAR, Scopus, ABI/INFORM Global, Cochrane Library, ERIC, International Bibliography of the Social Sciences, Sociological Abstracts, Worldwide Political Science Abstracts and International Political Science Abstracts. Searches were also completed in Google Scholar. Inclusion criteria included articles focused on accountability of patients, and exclusions included articles that were not available, not written in English, with missing information, and commentaries or editorials. In total, 85530 unique abstracts were identified, and 27 articles were included based on the inclusion criteria. The results showed that patient accountability is rarely used and poorly defined. Most studies focused on what patients should be held to account for and agreed that patients should be responsible for behaviours that may contribute to adverse health outcomes. Some studies promoted a punitive approach as a mechanism of enforcement. Most studies argued for positive incentives or written agreements and contracts. While many studies recognized the value of patient accountability frameworks, there was a concern that these frameworks could further exacerbate existing socioeconomic disparities and contribute to poor health-related behaviours and outcomes (e.g., stigmatizing marginalized groups). Shared models of accountability between patients and healthcare providers or patients and communities were preferred. Before committing to a patient accountability framework for improving patient health and sustaining a healthcare system, the concept must be acceptable and reasonable to patients, providers, and society as a whole.