Public experiences and perspectives of primary care in Canada: results from a cross-sectional survey.

BACKGROUND: Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people's experience with and priorities for primary care. METHODS: We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada's population and adjusted for sociodemographic characteristics using regression models. RESULTS: We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who "knows me as a person and considers all the factors that affect my health." After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use. INTERPRETATION: More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting.

Home-based primary care in Canada: Five innovative urban practices.

PROBLEM ADDRESSED: While the home-based primary care model offers potential patient and system-level benefits, implementation of interprofessional home-based primary care teams has not been widespread. When caring for homebound patients, family physicians are often not included as regular contributors or participants in the team that coordinates and plans much of the care for these patients. OBJECTIVE OF PROGRAM: To describe a selection of home-based primary care practices and to identify barriers to and facilitators of the creation and sustainability of these models within the publicly funded health care system. PROGRAM DESCRIPTION: Five existing home-based primary care practices were examined: 1 each in Victoria and Vancouver in BC; 1 in Winnipeg, Man; and 2 in Toronto, Ont. The research team conducted semistructured team interviews, interviews with the physician leads, and informal observation of elements of team-based care planning at these 5 sites. From these sources, descriptions of each practice were developed in terms of practice history, context, and initiating factors; practice goals and performance management; and practice design elements, including target population, referral sources, and team composition. A qualitative thematic content analysis was used to extract and distil implementation barriers and facilitators across the 5 practices. Members of each practice team validated the interpretation of thematic information. Substantial heterogeneity was found in the composition of the interprofessional teams. The overarching initiating factor for the home-based component of all practices could be described as identifying and addressing unmet community need. Physician leadership, creative funding models, team camaraderie, and community partnerships were the main facilitators. Limited health system support, geography, and lack of existing models of care were the main barriers. CONCLUSION: Substantial barriers to wider implementation of home-based primary care practices persist. Examination of existing practices identifies the importance of physician leadership and commitment to meeting community need.

Pharmacist involvement in clinical assessment and laboratory testing for heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia (HIT) is a rare adverse drug reaction. The anti-PF4 antibody assay (ELISA) is utilized to assist in the clinical evaluation of HIT due to its high negative predictability and wide-spread availability. However, it also associated with false positive results. The 4T score can assist in predicting an individual's risk for HIT and the need for further laboratory testing. This was a single-center prospective observational cohort study. Orders for HIT testing were sent via page to a clinical pharmacist to calculate a 4T score. If low risk, the pharmacist contacted the ordering prescriber to recommend discontinuation of laboratory testing. During the study, a clinical support tool was implemented to assist prescribers with ordering HIT tests. The study was divided into a pharmacist intervention group and a control group. A total of 303 pages were received. One hundred nine were missed due to unavailability of the pharmacist at time of page. A pharmacist reviewed 194 pages and intervened on 132. One hundred seven were scored as low risk, 70 as intermediate risk and 9 as high risk. Pharmacist intervention resulted in discontinuing 64 ELISA and 11 serotonin release assay tests. The clinical support tool resulted in a yearly decrease of HIT testing by 27%. Laboratory cost savings totaled $11,000 but did not include avoidance of laboratory technician or drug cost. Pharmacist involvement in the clinical assessment of HIT and the use of a support tool resulted in the reduction of HIT tests in low risk patients.

Aging at Home: A Portrait of Home-Based Primary Care Across Canada.

Older adults and their families often struggle in navigating an increasingly fragmented healthcare system when it becomes increasingly difficult to receive care beyond their homes in the face of advanced illness, frailty and complex care needs. The provision of integrated home-based primary care has demonstrated improved patient and caregiver experiences and reduced healthcare costs when primary care providers collaborate in delivering care as part of larger interprofessional teams. In this trans-Canada portrait of five urban home-based primary care programs, their core features are highlighted to provide a roadmap on how to integrate this form of care into a Patient's Medical Home in partnership with acute and home-care providers.

Soins primaires à domicile au Canada: Cinq cabinets novateurs en milieu urbain.

PROBLÈME À L'ÉTUDE: Bien que le modèle de prestation de soins primaires à domicile puisse être avantageux tant pour les patients que pour le système, la mise sur pied d'équipes interprofessionnelles offrant ce type de soins n'est pas répandue. Dans le cadre de la prestation des soins aux patients confinés à domicile, les médecins de famille ne font pas souvent partie, que ce soit de façon régulière ou ponctuelle, de l'équipe qui coordonne et planifie la plupart des soins destinés à ces patients. OBJECTIF DU PROGRAMME: Décrire quelques modèles de prestation de soins primaires à domicile et déterminer les obstacles et les facilitateurs relativement à la mise sur pied et à la viabilité de ces modèles dans le système de santé public. DESCRIPTION DU PROGRAMME: Cinq cabinets de prestation de soins primaires à domicile ont fait l'objet d'un examen : 2 en Colombie-Britannique, soit à Victoria et Vancouver; 1 à Winnipeg au Manitoba; et 2 à Toronto en Ontario. L'équipe de recherche a mené à ces 5 sites des entrevues d'équipe semi-structurées, des entretiens avec les médecins dirigeants, de même que des séances d'observation informelles sur les aspects de la planification des soins en équipe. L'information ainsi recueillie a permis d'élaborer une description de chaque cabinet en fonction de l'historique, du contexte et des facteurs déclencheurs liés au modèle; les objectifs et la gestion de la performance; et les éléments conceptuels du cabinet, notamment la population cible, les sources de l'aiguillage et la composition de l'équipe. Une analyse thématique qualitative du contenu a servi à extraire et recenser les obstacles et les facilitateurs de la mise en œuvre à l'échelle des 5 cabinets. Les membres de chaque équipe ont validé l'interprétation de l'information thématique. Une importante hétérogénéité a été observée dans la composition des équipes interprofessionnelles. Le facteur déclencheur déterminant de la prestation des soins à domicile pour chacun des cabinets peut se résumer par la reconnaissance d'un besoin communautaire non comblé. Les principaux facilitateurs étaient le leadership médical, les modèles de financement novateurs, la camaraderie au sein de l'équipe de même que les partenariats communautaires. Les principaux obstacles comprenaient le mince soutien venant du système de santé, l'aspect géographique et l'absence de modèles actuels pour ce type de soins. CONCLUSION: La mise en œuvre élargie des soins primaires à domicile continue de faire face à des obstacles significatifs. L'examen des pratiques en cours permet de relever l'importance du leadership des médecins et de répondre aux besoins de la communauté.

Does it work? Resident selection and implicit bias training for postgraduate program directors.

One element to address health disparities and historical injustices of systemically excluded groups is to examine selection processes. Implicit association testing for selection committees is suggested as one intervention to address bias in selection and is used for Undergraduate Medical Education at the University of Manitoba. Our study demonstrated that implicit bias training for PDs in isolation has minimal impact on addressing bias within resident selection. This training must occur as part of a systemic institutional approach to address bias in resident selection. Programs should consider a multipronged and sustained approach when committing to diversifying postgraduate medical education programs.

Le processus de sélection est un des éléments à revoir pour lutter contre les inégalités en matière de santé et les injustices historiques dont souffrent les populations victimes d'exclusion systémique. Une des mesures suggérées pour contrer le biais de sélection est de soumettre les membres des comités de sélection à des tests d'association implicite. Ils sont utilisés à l'Université du Manitoba au programme d'études médicales de premier cycle. Or, notre étude montre qu'une formation en matière de biais implicites, lorsqu'elle est offerte de manière isolée aux directeurs de programme, a peu d'impact sur l'élimination des préjugés dans la sélection des résidents. Les programmes qui désirent favoriser la diversité doivent envisager une approche multidimensionnelle et soutenue.

Education Standards for Pharmacists Providing Comprehensive Medication Management in Outpatient Nephrology Settings.

Chronic kidney disease is a public health problem that has generated renewed interest due to poor patient outcomes and high cost. The Advancing American Kidney Health initiative aimed to transform kidney care with goals of decreasing the incidence of kidney failure and increasing the number of patients receiving home dialysis or a kidney transplant. New value-based models of kidney care that specify inclusion of pharmacists as part of the kidney care team were developed to help achieve these goals. To support this Advancing American Kidney Health-catalyzed opportunity for pharmacist engagement, the pharmacy workforce must have a fundamental knowledge of the core principles needed to provide comprehensive medication management to address chronic kidney disease and the common comorbid conditions and secondary complications. The Advancing Kidney Health through Optimal Medication Management initiative was created by nephrology pharmacists with the vision that every person with kidney disease receives optimal medication management through team-based care that includes a pharmacist to ensure medications are safe, effective, and convenient. Here, we propose education standards for pharmacists providing care for individuals with kidney disease in the outpatient setting to complement proposed practice standards.

Acceptance of colonoscopy requires more than test tolerance.

BACKGROUND: Colon cancer screening, including colonoscopy, lags behind other forms of cancer screening for participation rates. The intrinsic nature of the endoscopic procedure may be an important barrier that limits patients from finding this test acceptable and affects willingness to undergo screening. With colon cancer screening programs emerging in Canada, test characteristics and their impact on acceptance warrant consideration. OBJECTIVES: To measure the acceptability of colonoscopy and define factors that contribute to procedural acceptability, in relation to another invasive gastrointestinal scope procedure, gastroscopy. PATIENTS AND METHODS: Consecutive patients undergoing a colonoscopy (n=55) or a gastroscopy (n=33) were recruited. Their procedural experience was evaluated and compared pre-endoscopy, immediately before testing and postendoscopy. Questionnaires were used to capture multiple domains of the endoscopy experience and patient characteristics. RESULTS: Patient scope groups did not differ preprocedurally for general or procedure-specific anxiety. However, the colonoscopy group did anticipate more pain. Those who had a gastroscopy demonstrated higher preprocedural acceptance than those who had a colonoscopy. The colonoscopy group had a significant decrease in scope concerns and anxiety postprocedurally. As well, they reported less pain than they anticipated. Regardless, postprocedurally, the colonoscopy group's acceptance did not increase significantly, whereas the gastroscopy group was almost unanimous in their test acceptance. The best predictor of pretest acceptability of colonoscopy was anticipated pain. CONCLUSIONS: The findings indicate that concerns that relate specifically to colonoscopy, including anticipated pain, influence acceptability of the procedure. However, the experience of a colonoscopy does not lead to improved test acceptance, despite decreases in procedural anxiety and pain. Patients' preprocedural views of the test are most important and should be addressed directly to potentially improve participation in colonoscopy.

Acute Rejection in 6-Antigen HLA-Matched Kidney Transplant Recipients: Risk Factors and Outcomes from the Wisconsin Allograft Recipient Database (WisARD).

Acute rejection in human leukocyte antigen (HLA)-matched kidney transplant recipients is uncommon and the mechanisms involved are not well understood. Data from 6-antigen HLA-matched recipients transplanted between 1994 and 2014 were analyzed to identify the incidence, risk factors, and outcomes associated with biopsy-proven acute rejection (BPAR). A total of 278 HLA-matched recipients were identified, of which, 155 (55.8%) received a graft from a sibling donor. Ten patients (3.6%) experienced BPAR over a median follow-up of 10 years (0.41 cases per 100 person-years). Median time to rejection was 36.5 months (standard deviation ±56.4). Recipients who experienced rejection did not differ from those who did not in terms of age, gender, ethnicity, induction agent, panel reactive antibody, or sensitizing events. Acute cellular, antibody-mediated, and mixed rejection occurred in 5, 3, and 2 patients, respectively. The most common biopsy classification was Banff IA (n=4). Four out of 10 patients had documented nonadherence to maintenance immunosuppression. Thirty percent of HLA-matched recipients who rejected had graft loss and 10% died, compared to 30.8% graft loss and 28.4% deaths in non-rejectors (p=0.57 and 0.20, respectively). In conclusion, acute cellular and antibody-mediated rejection are infrequent in HLA-matched kidney transplant recipients. Nonadherence appears to be relatively common among those experiencing rejection. Acute rejection was not associated with higher graft loss or death. The pathogenesis of acute rejection in HLA-matched recipients remains to be determined.

The dynamin-like GTPase Sey1p mediates homotypic ER fusion in S. cerevisiae.

The endoplasmic reticulum (ER) forms a network of tubules and sheets that requires homotypic membrane fusion to be maintained. In metazoans, this process is mediated by dynamin-like guanosine triphosphatases (GTPases) called atlastins (ATLs), which are also required to maintain ER morphology. Previous work suggested that the dynamin-like GTPase Sey1p was needed to maintain ER morphology in Saccharomyces cerevisiae. In this paper, we demonstrate that Sey1p, like ATLs, mediates homotypic ER fusion. The absence of Sey1p resulted in the ER undergoing delayed fusion in vivo and proteoliposomes containing purified Sey1p fused in a GTP-dependent manner in vitro. Sey1p could be partially replaced by ATL1 in vivo. Like ATL1, Sey1p underwent GTP-dependent dimerization. We found that the residual ER-ER fusion that occurred in cells lacking Sey1p required the ER SNARE Ufe1p. Collectively, our results show that Sey1p and its homologues function analogously to ATLs in mediating ER fusion. They also indicate that S. cerevisiae has an alternative fusion mechanism that requires ER SNAREs.

Bile acids in combination with low pH induce oxidative stress and oxidative DNA damage: relevance to the pathogenesis of Barrett's oesophagus.

BACKGROUND: Barrett's oesophagus is a premalignant condition associated with an increased risk for the development of oesophageal adenocarcinoma (ADCA). Previous studies indicated that oxidative damage contributes to the development of ADCA. OBJECTIVE: To test the hypothesis that bile acids and gastric acid, two components of refluxate, can induce oxidative stress and oxidative DNA damage. METHODS: Oxidative stress was evaluated by staining Barrett's oesophagus tissues with different degrees of dysplasia with 8-hydroxy-deoxyguanosine (8-OH-dG) antibody. The levels of 8-OH-dG were also evaluated ex vivo in Barrett's oesophagus tissues incubated for 10 min with control medium and medium acidified to pH 4 and supplemented with 0.5 mM bile acid cocktail. Furthermore, three oesophageal cell lines (Seg-1 cells, Barrett's oesophagus cells and HET-1A cells) were exposed to control media, media containing 0.1 mM bile acid cocktail, media acidified to pH 4, and media at pH 4 supplemented with 0.1 mM bile acid cocktail, and evaluated for induction of reactive oxygen species (ROS). RESULTS: Immunohistochemical analysis showed that 8-OH-dG is formed mainly in the epithelial cells in dysplastic Barrett's oesophagus. Importantly, incubation of Barrett's oesophagus tissues with the combination of bile acid cocktail and acid leads to increased formation of 8-OH-dG. An increase in ROS in oesophageal cells was detected after exposure to pH 4 and bile acid cocktail. CONCLUSIONS: Oxidative stress and oxidative DNA damage can be induced in oesophageal tissues and cells by short exposures to bile acids and low pH. These alterations may underlie the development of Barrett's oesophagus and tumour progression.