Changes over time in patient visits and continuity of care among graduating cohorts of family physicians in 4 Canadian provinces

BACKGROUND

Lack of patient access to family physicians in Canada is a concern. The role of recent physician graduates in this problem of supply of primary care services has not been established. We sought to establish whether career stage or graduation cohort were related to family physician practice volume and continuity of care over time.

METHODS

We conducted a retrospective cohort study of family physician practice from 1997/98 to 2017/18. We collected administrative health and physician claims data in British Columbia, Manitoba, Ontario and Nova Scotia. We included all physicians who registered with their respective provincial regulatory colleges as having a medical specialty of family practice or who had billed the provincial health insurance system for patient care as family physicians, or both. We used regression models to isolate the effects of 3-year categories of years in practice (at all career stages), time period and cohort on patient contacts and physician-level continuity of care.

RESULTS

Between 1997/98 and 2017/18, the median number of patient contacts per provider per year fell by between 515 and 1736 contacts in the 4 provinces examined. Median contacts peaked at 27-29 years in practice in all provinces, and median physician-level continuity of care increased until 30 or more years in practice. We found no association between graduation cohort and patient contacts or physician-level continuity of care.

INTERPRETATION

Recent cohorts of family physicians practise similarly to their predecessors in terms of practice volumes and continuity of care. Because family physicians of all career stages showed declining patient contacts, we suggest that system-wide solutions to recent challenges in the accessibility of primary care in Canada are needed.

What We Have Heard: Next Steps for Long-Term Care Pandemic Preparedness in Canada

In this concluding article, Healthcare Excellence Canada and the Canadian Institutes of Health Research reflect upon and respond to the lessons learned from the contributing articles in the special issue and summarize key takeaways for the next steps in evidence-informed pandemic preparedness in long-term care in Canada. The implications of their cross-organizational partnership for achieving collective impact now and in the future are also discussed.

Family Physicians Stopping Practice During the COVID-19 Pandemic in Ontario, Canada

We conducted 2 analyses using administrative data to understand whether more family physicians in Ontario, Canada stopped working during the COVID-19 pandemic compared with previous years. First, we found 3.1% of physicians working in 2019 (n = 385/12,247) reported no billings in the first 6 months of the pandemic; compared with other family physicians, a higher portion were aged 75 years or older (13.0% vs 3.4%, P <0.001), had fee-for-service reimbursement (37.7% vs 24.9%, P <0.001), and had a panel size under 500 patients (40.0% vs 25.8%, P <0.001). Second, a fitted regression line found the absolute increase in the percentage of family physicians stopping work was 0.03% per year from 2010 to 2019 (P = 0.042) but 1.2% between 2019 to 2020 (P <0.001). More research is needed to understand the impact of physicians stopping work on primary care attachment and access to care.

Association of Early Physician Follow-up With Readmission Among Patients Hospitalized for Acute Myocardial Infarction, Congestive Heart Failure, or Chronic Obstructive Pulmonary Disease

IMPORTANCE

A better understanding of the association between early physician follow-up after discharge and adverse outcomes among hospitalized patients may inform interventions aimed at reducing readmission for common chronic conditions.

OBJECTIVE

To assess whether hospitalized patients with early physician follow-up after discharge had lower rates of overall and condition-specific readmissions within 30 days and 90 days of discharge.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study was conducted among Ontario, Canada, adults with first admission for acute myocardial infarction (AMI), congestive heart failure (CHF), or chronic obstructive pulmonary disease (COPD) during 2005 to 2019. The exposure was follow-up visit with a primary care physician or relevant specialist within 7 days of discharge. Cox proportional hazards models were used to compare patients with vs without early follow-up, adjusting for sociodemographic factors and comorbidities, weighting by propensity score-based overlap weights. Data were analyzed from January through July 2021.

MAIN OUTCOMES AND MEASURES

Primary outcomes were 30-day and 90-day readmissions, cardiac readmissions (readmission for AMI, CHF, or angina) for patients with cardiac conditions, and COPD-related readmissions for patients with COPD. Mortality at 30 days and 90 days was a secondary outcome. All percentages reported in Results are unweighted.

RESULTS

The study cohort comprised 450 746 patients, including 198 854 patients with AMI, 133 058 patients with CHF, and 118 834 patients with COPD; the median (IQR) age was 66 (56-77) years for AMI, 78 (68-85) years for CHF, and 73 (64-81) years for COPD, and there were 64 339 (32.35%) women, 62 575 (47.03%) women, and 59 179 (49.80%) women, respectively. There were 91 182 patients (45.85%), 56 491 patients (42.46%), and 40 159 patients (33.79%), respectively, who received an early follow-up visit. Overall, patients with early follow-up had higher rates of collaborative care (eg, CHF: 20 931 patients [37.85%] vs 11 101 of 76 567 patients [14.85%]) and visits to a specialist within 30 days (eg, CHF: 25 797 patients [45.67%] vs 20 548 patients [26.84%]). Those with early follow-up had lower 90-day readmission rates among patients with CHF (15 934 patients [28.21%] vs 23 121 patients [30.20%]; adjusted hazard ratio [aHR], 0.98; 95% CI, 0.96-0.99) and among those with COPD (8784 patients [21.87%] vs 18 097 of 78 675 patients [23.00%]; aHR, 0.95; 95% CI, 0.93-0.98). Among patients with COPD, those with early follow-up had lower 90-day COPD-related readmission rates (4015 patients [10.00%] vs 8449 patients [10.74%]; aHR, 0.93; 95% CI, 0.89-0.96), and among patients with CHF, those with early follow-up had lower 90-day mortality rates (4044 patients [7.16%] vs 6281 patients [8.20%]; aHR, 0.93; 95% CI, 0.90-0.97). There were no significant benefits at 30 days or for patients with AMI.

CONCLUSIONS AND RELEVANCE

These findings suggest that early follow-up in conjunction with a comprehensive transitional care strategy for hospitalized patients with medically complex conditions coupled with ongoing effective chronic disease management may be associated with reduced 90-day readmissions.

From Strategy to Implementation: Optimizing the Contribution of Health Services and Policy Research to Equitable Healthcare System Transformation

The Canadian Institutes of Health Research - Institute of Health Services and Policy Research's (IHSPR) Strategic Plan 2021-2026 (CIHR IHSPR 2021) aims to accelerate healthcare system transformation to achieve the Quadruple Aim and health equity through research. This special issue features a collection of commentaries from academic and health system leaders who were invited to respond to IHSPR's strategic plan and share insights regarding the opportunities the plan presents and areas where more attention may be needed. The present paper features a response from the IHSPR team and outlines the next steps regarding implementation. IHSPR is deeply grateful to the commentary authors for their insight, advice and recommendations, which will help to inform the implementation of the plan.

Accelerating Health System Transformation through Research to Achieve the Quadruple Aim and Health Equity

The Canadian Institutes of Health Research - Institute of Health Services and Policy Research's (IHSPR's) Strategic Plan 2021-2026: Accelerate Health Care System Transformation through Research to Achieve the Quadruple Aim and Health Equity for All (CIHR IHSPR 2021) outlines the Institute's key priority areas for investment and activity over the next five years. IHSPR used an evidence-informed strategic planning process that was pan-Canadian in scope and designed to elicit the health services and policy research priorities of decision makers, providers, researchers, patients, communities and the public. This paper outlines IHSPR's four key strategic priorities for supporting and optimizing research in transforming Canada's healthcare delivery systems over the next five years.

Practice Profiles and Patterns of Ontario Family Medicine Residents 5 Years After Residency Examinations: An Exploratory Study

Background and Objectives: The primary goal of family medicine residency training is for graduates to provide high-quality, safe, and effective patient care for the population they serve when they enter practice. This study explores (a) the practice profiles, 5 years into practice, of residents who completed family medicine training in Ontario, Canada; and (b) relationships between performance on the College of Family Physicians of Canada’s (CFPC) Certification Examination in Family Medicine and quality of care provided 5 years into practice. Methods: We performed a retrospective study with secondary data analysis. We merged CFPC examination data sets with the ICES (Institute for Clinical Evaluative Sciences) administrative database. We included physicians who passed the examination between the years 2000 and 2010 and practiced in Ontario after graduation. Practice profile indicators included practice type, continuity and comprehensiveness of care, patient rostering and panel size, and rurality index. We explored 11 indicators related to management of diabetes and cancer screening. Results: We included a total of 1,983 physicians in the analyses. Five years after the examinations, 74.3% of the physicians were working in major urban centers, and 67.3% of the physicians were providing comprehensive primary care. We noted significant differences across the six medical schools in multiple practice profile indicators, and three indicators showed significant differences across the examination score quintiles. Conclusions: Graduates of Ontario family medicine residency programs were providing care to a broad spectrum of the population 5 years after passing the examination, and they performed similarly across quality-of-care indicators regardless of examination scores.

Impact of Team-Based Care on Emergency Department Use

PURPOSE

We sought to assess the impact of team-based care on emergency department (ED) use in the context of physicians transitioning from fee-for-service payment to capitation payment in Ontario, Canada.

METHODS

We conducted an interrupted time series analysis to assess annual ED visit rates before and after transition from an enhanced fee-for-service model to either a team capitation model or a nonteam capitation model. We included Ontario residents aged 19 years and older who had at least 3 years of outcome data both pretransition and post-transition (N = 2,524,124). We adjusted for age, sex, income quintile, immigration status, comorbidity, and morbidity, and we stratified by rurality. A sensitivity analysis compared outcomes for team vs nonteam patients matched on year of transition, age, sex, rurality, and health region.

RESULTS

We compared 387,607 team and 1,399,103 nonteam patients in big cities, 213,394 team and 380,009 nonteam patients in small towns, and 65,289 team and 78,722 nonteam patients in rural areas. In big cities, after adjustment, the ED visit rate increased by 2.4% (95% CI, 2.2% to 2.6%) per year for team patients and 5.2% (95% CI, 5.1% to 5.3%) per year for nonteam patients in the years after transition (P <.001). Similarly, there was a slower increase in ED visits for team relative to nonteam patients in small towns (0.9% [95% CI, 0.7% to 1.1%] vs 2.9% [95% CI, 2.8% to 3.1%], P <.001) and rural areas (‒0.5% [95% CI, -0.8% to 0.2%] vs 1.3% [95% CI, 1.0% to 1.6%], P <.001). Results were much the same in the matched analysis.

CONCLUSIONS

Adoption of team-based primary care may reduce ED use. Further research is needed to understand optimal team composition and roles.

Primary care bonus payments and patient-reported access in urban Ontario: a cross-sectional study

BACKGROUND

Rurality strongly correlates with higher pay-for-performance access bonuses, despite higher emergency department use and fewer primary care services than in urban settings. We sought to evaluate the relation between patient-reported access to primary care and access bonus payments in urban settings.

METHODS

We conducted a cross-sectional, secondary data analysis using Ontario survey and health administrative data from 2013 to 2017. We used administrative data to calculate annual access bonuses for eligible urban family physicians. We linked this payment data to adult (≥ 16 yr) patient data from the Health Care Experiences Survey to examine the relation between access bonus achievement (in quintiles of the proportion of bonus achieved, from lowest [Q1, reference category] to highest [Q5]) and 4 patient-reported access outcomes. The average survey response rate to the patient survey during the study period was 51%. We stratified urban geography into large, medium and small settings. In a multilevel regression model, we adjusted for patient-, physician- and practice-level covariates. We tested linear trends, adjusted for clustering, for each outcome.

RESULTS

We linked 18 893 respondents to 3940 physicians in 414 bonus-eligible practices. Physicians in small urban settings earned the highest proportion of their maximum potential access bonuses. Access bonus achievement was positively associated with telephone access (Q2 odds ratio [OR] 1.18, 95% confidence interval [CI] 0.98-1.42; Q3 OR 1.34, 95% CI 1.10-1.63; Q4 OR 1.46, 95% CI 1.19-1.79; Q5 OR 1.87, 95% CI 1.50-2.33), after hours access (Q2 OR 1.26, 95% CI 1.09-1.47; Q3 OR 1.46, 95% CI 1.23-1.74; Q4 OR 1.77, 95% CI 1.46-2.15; Q5 OR 1.88, 95% CI 1.52-2.32), wait time for care (Q2 OR 1.01, 95% CI 0.85-1.20; Q3 OR 1.17, 95% CI 0.97-1.41; Q4 OR 1.27, 95% CI 1.05-1.55; Q5 OR 1.63, 95% CI 1.32-2.00) and timeliness (Q2 OR 1.29, 95% CI 0.98-1.69; Q3 OR 1.29, 95% CI 0.94-1.77; Q4 OR 1.58, 95% CI 1.16-2.13; Q5 OR 1.98, 95% CI 1.38-2.82). When stratified by geography, we observed several of these associations in large urban settings, but not in small urban settings. Trend tests were statistically significant for all 4 outcomes.

INTERPRETATION

Although the access bonus correlated with access in larger urban settings, it did not in smaller settings, aligning with previous research questioning its utility in smaller geographies. The access bonus may benefit from a redesign that considers geography and patient experience.

A Master Class in Family Doctor Leadership: Evaluating an Innovative Program

BACKGROUND AND OBJECTIVES

In family medicine, leadership is critical for health care delivery, advancing curricula, research, and quality improvement. Systematic reviews of leadership development programs in health care identify limitations, calling for innovative designs and rigorous assessment. Our objective was to evaluate the impact of applying master class principles to leadership development in academic family medicine.

METHODS

We used mixed methods to assess the impact of an innovative master class program on 15 emerging leaders in a large academic department of family medicine. The program consisted of five sessions where family physician masters shared their wisdom, techniques, and feedback with promising leaders. Quantitative evaluation involved participants' ratings of each session's content and delivery using a 5-point Likert scale. We assessed postcourse semistructured interviews with participants qualitatively using descriptive thematic content analysis.

RESULTS

Individual sessions were highly evaluated, with a combined mean of 4.82/5. Qualitative thematic analysis identified self-perceived increased effectiveness in leadership activities; increased confidence as a leader; increased motivation to be a leader; and perceptions of value from the program, contributing to what participants described as unexpected potential change within themselves. Themes related to effectiveness of the program were practical advice; networking; diverse topics; accessible speakers sharing personal stories; and small-group, informal, early-evening format.

CONCLUSIONS

Master class concepts can be adapted to leadership development in academic family medicine, with evidence of early positive impact on participants' self-perception of leadership skills and confidence. Further research is warranted to assess organizational impact and applicability to other settings.

Comparing primary care Interprofessional and non-interprofessional teams on access to care and health services utilization in Ontario, Canada: a retrospective cohort study

Background

Many countries, including Canada, have introduced primary care reforms to improve health system functioning and value. The purpose of this study was to examine the association between receiving care from interprofessional primary care teams and after-hours access to care, patient-reported walk-in clinic visits and emergency department use.

Methods

We conducted a retrospective cohort study linking population-based administrative databases to Ontario’s Health Care Experience Survey (HCES) between 2012 and 2018. We adjusted for physician group characteristics as well as individual physician and patient characteristics while assessing the relationship between receiving care from interprofessional teams and the outcomes of interest.

Results

As of March 31st, 2015, there were 465 physician groups with HCES respondents of which 177 (38.0%) were interprofessional teams and 288 (62.0%) were non-interprofessional teams in the same blended capitation reimbursement model. In this period, there were 4518 physicians with HCES respondents, of whom 2131 (47.2%) were in interprofessional teams and 2387 (52.8%) were in non-interprofessional teams. There were 10,102 HCES respondents included in this study, of whom 42.4% were in interprofessional teams and 42.3% were in non-interprofessional teams. After adjustment, we found that being in an interprofessional team was associated with an increase in the odds of patients reporting same/next day access to care by 12.0% (OR = 1.12 CI = 1.00 to 1.24 p-value 0.0436) and a decrease in the odds of patients reporting walk-in clinic use by 16% (OR = 0.84 CI = 0.75 to 0.94 p-value 0.0019). After adjustment, there were no significant differences in patient-reported after-hours access to care and emergency department use.

Conclusions

Ontario has invested heavily in interprofessional primary care teams. As compared to patients in non-interprofessional teams, patients in interprofessional teams self-reported more timely access to care and less walk-in clinic use but no significant difference in self-reported access to after-hours care or in emergency department use. For jurisdictions aiming to expand physician voluntary participation in interprofessional teams, our study results inform expectations around access to care and health services utilization.

Building on existing tools to improve chronic disease prevention and screening in public health: a cluster randomized trial

BACKGROUND

The BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) intervention was designed to integrate the approach to chronic disease prevention and screening in primary care and demonstrated effective in a previous randomized trial.

METHODS

We tested the effectiveness of the BETTER HEALTH intervention, a public health adaptation of BETTER, at improving participation in chronic disease prevention and screening actions for residents of low-income neighbourhoods in a cluster randomized trial, with ten low-income neighbourhoods in Durham Region Ontario randomized to immediate intervention vs. wait-list. The unit of analysis was the individual, and eligible participants were adults age 40-64 years residing in the neighbourhoods. Public health nurses trained as "prevention practitioners" held one prevention-focused visit with each participant. They provided participants with a tailored prevention prescription and supported them to set health-related goals. The primary outcome was a composite index: the number of evidence-based actions achieved at six months as a proportion of those for which participants were eligible at baseline.

RESULTS

Of 126 participants (60 in immediate arm; 66 in wait-list arm), 125 were included in analyses (1 participant withdrew consent). In both arms, participants were eligible for a mean of 8.6 actions at baseline. At follow-up, participants in the immediate intervention arm met 64.5% of actions for which they were eligible versus 42.1% in the wait-list arm (rate ratio 1.53 [95% confidence interval 1.22-1.84]).

CONCLUSION

Public health nurses using the BETTER HEALTH intervention led to a higher proportion of identified evidence-based prevention and screening actions achieved at six months for people living with socioeconomic disadvantage.

TRIAL REGISTRATION

NCT03052959 , registered February 10, 2017.

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.

Examine the association between key determinants identified by the chronic disease indicator framework and multimorbidity by rural and urban settings

Background

Multimorbidity, often defined as having two or more chronic conditions is a global phenomenon. This study examined the association between key determinants identified by the chronic disease indicator framework and multimorbidity by rural and urban settings. The prevalence of individual diseases was also investigated by age and sex.

Methods

The Canada Community Health Survey and linked health administrative databases were used to examine the association between multimorbidity, sociodemographic, behavioral, and other risk factors in the province of Ontario. A multivariable logistic regression model was used to conduct the main analysis.

Results

Analyses were stratified by age (20-64 and 65-95) and area of residence (rural and urban). A total sample of n = 174,938 residents between the ages of 20-95 were examined in the Ontario province, of which 18.2% (n = 31,896) were multimorbid with 2 chronic conditions, and 23.4% (n = 40,883) with 3+ chronic conditions. Females had a higher prevalence of 2 conditions (17.9% versus 14.6%) and 3+ conditions (19.7% vs. 15.6%) relative to males. Out of all examined variables, poor self-perception of health, age, Body Mass Index, and income were most significantly associated with multimorbidity. Smoking was a significant risk factor in urban settings but not rural, while drinking was significant in rural and not urban settings. Income inequality was associated with multimorbidity with greater magnitude in rural areas. Prevalence of multimorbidity and having three or more chronic conditions were highest among low-income populations.

Conclusion

Interventions targeting population weight, age/sex specific disease burdens, and additional focus on stable income are encouraged.

Inequities in access to primary care among opioid recipients in Ontario, Canada: A population-based cohort study

BACKGROUND

Stigma and high-care needs can present barriers to the provision of high-quality primary care for people with opioid use disorder (OUD) and those prescribed opioids for chronic pain. We explored the likelihood of securing a new primary care provider (PCP) among people with varying histories of opioid use who had recently lost access to their PCP.

METHODS AND FINDINGS

We conducted a retrospective cohort study using linked administrative data among residents of Ontario, Canada whose enrolment with a physician practicing in a primary care enrolment model (PEM) was terminated between January 2016 and December 2017. We assigned individuals to 3 groups based upon their opioid use on the date enrolment ended: long-term opioid pain therapy (OPT), opioid agonist therapy (OAT), or no opioid. We fit multivariable models assessing the primary outcome of primary care reattachment within 1 year, adjusting for demographic characteristics, clinical comorbidities, and health services utilization. Secondary outcomes included rates of emergency department (ED) visits and opioid toxicity events. Among 154,970 Ontarians who lost their PCP, 1,727 (1.1%) were OAT recipients, 3,644 (2.4%) were receiving long-term OPT, and 149,599 (96.5%) had no recent prescription opioid exposure. In general, OAT recipients were younger (median age 36) than those receiving long-term OPT (59 years) and those with no recent prescription opioid exposure (44 years). In all exposure groups, the majority of individuals had their enrolment terminated by their physician (range 78.1% to 88.8%). In the primary analysis, as compared to those not receiving opioids, OAT recipients were significantly less likely to find a PCP within 1 year (adjusted hazard ratio [aHR] 0.55, 95% confidence interval [CI] 0.50 to 0.61, p < 0.0001). We observed no significant difference between long-term OPT and opioid unexposed individuals (aHR 0.96; 95% CI 0.92 to 1.01, p = 0.12). In our secondary analysis comparing the period of PCP loss to the year prior, we found that rates of ED visits were elevated among people not receiving opioids (adjusted rate ratio (aRR) 1.20, 95% CI 1.18 to 1.22, p < 0.0001) and people receiving long-term OPT (aRR 1.37, 95% CI 1.28 to 1.48, p < 0.0001). We found no such increase among OAT recipients, and no significant increase in opioid toxicity events in the period following provider loss for any exposure group. The main limitation of our findings relates to their generalizability outside of PEMs and in jurisdictions with different financial incentives incorporated into primary care provision.

CONCLUSIONS

In this study, we observed gaps in access to primary care among people who receive prescription opioids, particularly among OAT recipients. Ongoing efforts are needed to address the stigma, discrimination, and financial disincentives that may introduce barriers to the healthcare system, and to facilitate access to high-quality, consistent primary care services for chronic pain patients and those with OUD.

Adherence at 2 years with distribution of essential medicines at no charge: The CLEAN Meds randomized clinical trial

BACKGROUND

Adherence to medicines is low for a variety of reasons, including the cost borne by patients. Some jurisdictions publicly fund medicines for the general population, but many jurisdictions do not, and such policies are contentious. To our knowledge, no trials studying free access to a wide range of medicines have been conducted.

METHODS AND FINDINGS

We randomly assigned 786 primary care patients who reported not taking medicines due to cost between June 1, 2016 and April 28, 2017 to either free distribution of essential medicines (n = 395) or to usual medicine access (n = 391). The trial was conducted in Ontario, Canada, where hospital care and physician services are publicly funded for the general population but medicines are not. The trial population was mostly female (56%), younger than 65 years (83%), white (66%), and had a low income from wages as the primary source (56%). The primary outcome was medicine adherence after 2 years. Secondary outcomes included control of diabetes, blood pressure, and low-density lipoprotein (LDL) cholesterol in patients taking relevant treatments and healthcare costs over 2 years. Adherence to all appropriate prescribed medicines was 38.7% in the free distribution group and 28.6% in the usual access group after 2 years (absolute difference 10.1%; 95% confidence interval (CI) 3.3 to 16.9, p = 0.004). There were no statistically significant differences in control of diabetes (hemoglobin A1c 0.27; 95% CI -0.25 to 0.79, p = 0.302), systolic blood pressure (-3.9; 95% CI -9.9 to 2.2, p = 0.210), or LDL cholesterol (0.26; 95% CI -0.08 to 0.60, p = 0.130) based on available data. Total healthcare costs over 2 years were lower with free distribution (difference in median CAN$1,117; 95% CI CAN$445 to CAN$1,778, p = 0.006). In the free distribution group, 51 participants experienced a serious adverse event, while 68 participants in the usual access group experienced a serious adverse event (p = 0.091). Participants were not blinded, and some outcomes depended on participant reports.

CONCLUSIONS

In this study, we observed that free distribution of essential medicines to patients with cost-related nonadherence substantially increased adherence, did not affect surrogate health outcomes, and reduced total healthcare costs over 2 years.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02744963.

Impact of neighbourhood walkability on the onset of multimorbidity: a cohort study

Multimorbidity has become highly prevalent around the globe and been associated with adverse health outcomes and cost of care. The built environment has become an important dimension in response to obesity and associated chronic diseases by addressing population sedentariness and low physical activity.

OBJECTIVE

The aim of the following study was to examine whether there was an increased risk for multimorbidity for those living in less walkable neighbourhoods. It was hypothesised that participants residing in less walkable neighbourhoods would have a higher risk for multimorbidity.

SETTING

City of Toronto and 14 neighbouring regions/municipalities within Ontario, Canada.

PARTICIPANTS

Study participants who had completed the Canadian Community Health Survey between the year 2000 and 2012, between 20 and 64 and 65 and 95 years of age, residing within a neighbourhood captured in the Walkability Index, and who were not multimorbid at the time of interview, were selected.

INTERVENTION

The Walkability Index was the key exposure in the study, which is divided into quintiles (1-least, 5-most walkable neighbourhoods). Participants were retrospectively allocated to one of five quintiles based on their area of residency (at the time of interview) and followed for a maximum of 16 years.

PRIMARY OUTCOME MEASURE

Becoming multimorbid with two chronic conditions.

SECONDARY OUTCOME MEASURE

Becoming multimorbid with three chronic conditions.

RESULTS

Risk for multimorbidity (two chronic conditions) was highest in least compared with most walkable neighbourhoods with an HR of 1.14 (95% CI: 1.02 to 1.28, p=0.0230). While results showed an overall gradient response between decreased walkability and increased risk for multimorbidity, they were not statistically significant across all quintiles or in the older-adult cohort (65-95 years of age).

CONCLUSION

Study results seem to suggest that low neighbourhood walkability may be a risk factor for multimorbidity over time. More studies are needed to examine whether neighbourhood walkability is a potential solution for multimorbidity prevention at the population level.

The Promise of Science, Knowledge Mobilization, and Rapid Learning Systems for COVID-19 Recovery

The health, economic, and social crises created by the coronavirus disease 2019 (COVID-19) pandemic have been global in scope and inequitable in impact. The global road to recovery can be enhanced with robust, relevant, and timely scientific evidence. This commentary seeks to illustrate the power of science, scientific collaboration, and innovative research funding programs to inform pandemic recovery and inspire transformational changes for a more equitable, resilient, and sustainable future. Specifically, this commentary provides an introduction to the United Nations (UN) Research Roadmap for the COVID-19 Recovery that was published in November 2020. It introduces 5 scoping reviews that helped inform the UN Research Roadmap and that are now available open access within this series of special papers, and it provides an overview of an innovative research funding program that facilitated rapid mobilization and collaboration to produce the scoping reviews. The publication of the scoping reviews in this journal series will help complement and amplify the UN Research Roadmap by furthering knowledge mobilization efforts and informing COVID-19 recovery around the world, to ensure a more equitable, resilient, and sustainable postpandemic future.

Primary care physician volume and quality of care for older adults with dementia: a retrospective cohort study

Background

Some jurisdictions restrict primary care physicians’ daily patient volume to safeguard quality of care for complex patients. Our objective was to determine whether people with dementia receive lower-quality care if their primary care physician sees many patients daily.

Methods

Population-based retrospective cohort study using health administrative data from 100,256 community-living adults with dementia aged 66 years or older, and the 8,368 primary care physicians who cared for them in Ontario, Canada. Multivariable Poisson GEE regression models tested whether physicians’ daily patient volume was associated with the adjusted likelihood of people with dementia receiving vaccinations, prescriptions for cholinesterase inhibitors, benzodiazepines, and antipsychotics from their primary care physician.

Results

People with dementia whose primary care physicians saw ≥ 30 patients daily were 32% (95% CI: 23% to 41%, p < 0.0001) and 25% (95% CI: 17% to 33%, p < 0.0001) more likely to be prescribed benzodiazepines and antipsychotic medications, respectively, than patients of primary care physicians who saw < 20 patients daily. Patients were 3% (95% CI: 0.4% to 6%, p = 0.02) less likely to receive influenza vaccination and 8% (95% CI: 4% to 13%, p = 0.0001) more likely to be prescribed cholinesterase inhibitors if their primary care physician saw ≥ 30 versus < 20 patients daily.

Conclusions

People with dementia were more likely to receive both potentially harmful and potentially beneficial medications, and slightly less likely to be vaccinated by high-volume primary care physicians.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-021-01398-9.

Combined Associations of Work and Leisure Time Physical Activity on Incident Diabetes Risk

INTRODUCTION

This study examines the separate and combined relationships between occupational physical activity (characterized by nonaerobic activities such as heavy lifting and prolonged standing) and leisure time physical activity on future diabetes incidence.

METHODS

Data from Ontario respondents aged 35-74 years from the 2003 Canadian Community Health Survey (N=40,507) were prospectively linked to the Ontario Diabetes Database for diabetes cases until 2017, with statistical analysis performed in 2019. Leisure time physical activity was self-reported and occupational physical activity estimated from occupation titles. The analytical sample consisted of 7,026 employed people without previous diabetes diagnoses, with 846 diabetes cases recorded. Cox proportional hazard models were constructed to evaluate relationships over a median follow-up time of 13.7 years.

RESULTS

No relationships were observed between occupational physical activity and diabetes. High leisure time physical activity was associated with lower diabetes risk for low occupational physical activity and stationary jobs (hazard ratio=0.63, 95% CI=0.47, 0.85). No association was found for high leisure time physical activity on diabetes risk for high occupational physical activity (hazard ratio=1.07, 95% CI=0.73, 1.56) or low occupational physical activity with movement (hazard ratio=0.92, 95% CI=0.55, 1.55).

CONCLUSIONS

This study suggests that physical activity recommendations exclusively recommending increased physical activity may only be effective for the sedentary part of the working population in reducing diabetes risk. Findings await confirmation in comparable prospective studies in other populations.

Shifts in office and virtual primary care during the early COVID-19 pandemic in Ontario, Canada

BACKGROUND

Globally, primary care changed dramatically as a result of the coronavirus disease 2019 (COVID-19) pandemic. We aimed to understand the degree to which office and virtual primary care changed, and for which patients and physicians, during the initial months of the pandemic in Ontario, Canada.

METHODS

This population-based study compared comprehensive, linked primary care physician billing data from Jan. 1 to July 28, 2020, with the same period in 2019. We identified Ontario residents with at least 1 office or virtual (telephone or video) visit during the study period. We compared trends in total physician visits, office visits and virtual visits before COVID-19 with trends after pandemic-related public health measures changed the delivery of care, according to various patient and physician characteristics. We used interrupted time series analysis to compare trends in the early and later halves of the COVID-19 period.

RESULTS

Compared with 2019, total primary care visits between March and July 2020 decreased by 28.0%, from 7.66 to 5.51 per 1000 people/day. The smallest declines were among patients with the highest expected health care use (8.3%), those who could not be attributed to a primary care physician (10.2%), and older adults (19.1%). In contrast, total visits in rural areas increased by 6.4%. Office visits declined by 79.1% and virtual care increased 56-fold, comprising 71.1% of primary care physician visits. The lowest uptake of virtual care was among children (57.6%), rural residents (60.6%) and physicians with panels of ≥ 2500 patients (66.0%).

INTERPRETATION

Primary care in Ontario saw large shifts from office to virtual care over the first 4 months of the COVID-19 pandemic. Total visits declined least among those with higher health care needs. The determinants and consequences of these major shifts in care require further study.

Correlates of non-adherence to breast, cervical, and colorectal cancer screening among screen-eligible women: a population-based cohort study in Ontario, Canada

PURPOSE

Breast, cervical, and colorectal cancers are cancers that can be detected early through screening. Despite organized cancer screening programs in Ontario, Canada participation remains low among marginalized populations. Although extensive research has been done about factors contributing to under-screening by cancer site, the predictors of under/never screened conjointly for all three types of cancer remain unknown.

METHODS

Using provincial-level linked administrative data sets, we examined Ontario women who were screen-eligible for all three types of cancer over a 36-month period (i.e., April 2014-March 2017) and determined how many were up to date on 0, 1, 2, and all three types of screenings. Multivariate logistic regression was utilized to examine individual and structural predictors of screening with the group overdue for all screening being the reference group.

RESULTS

Of the 1,204,551 screen-eligible women, 15% were overdue for all. Living in the lowest income neighborhoods (AOR 0.46 [95% CI 0.45-0.47]), being recent immigrants (AOR 0.54 [95% CI 0.53-0.55]), having no primary care provider (AOR 0.17 [95% CI 0.16-0.17]), and having no contact with health care services (AOR 0.09 [95% CI 0.09-0.09]) significantly increased the likelihood of being overdue for all versus no screening type.

CONCLUSIONS

Considering that more than 15% of screen-eligible women in Ontario were overdue for all types of cancer screening, it is imperative to address structural barriers such as lack of a primary care provider. Innovative interventions like "one-stop shopping" where screening for different cancers can be offered at the same time could promote screening uptake.

Mood Disorders in Late Life: A Population-based Analysis of Prevalence, Risk Factors, and Consequences in Community-dwelling Older Adults in Ontario: Troubles de l'humeur en âge avancé : Une analyse dans la population de la prévalence, des facteurs de risque et des conséquences chez des adultes âgés vivant en milieu communautaire en Ontario

OBJECTIVE

Mental health issues in late life are a growing public health challenge as the population aged 65 and older rapidly increases worldwide. An updated understanding of the causes of mood disorders and their consequences in late life could guide interventions for this underrecognized and undertreated problem. We undertook a population-based analysis to quantify the prevalence of mood disorders in late life in Ontario, Canada, and to identify potential risk factors and consequences.

METHOD

Individuals aged 65 or older participating in 4 cycles of a nationally representative survey were included. Self-report of a diagnosed mood disorder was used as the outcome measure. Using linked administrative data, we quantified associations between mood disorder and potential risk factors such as demographic/socioeconomic factors, substance use, and comorbidity. We also determined associations between mood disorders and 5-year outcomes including health service utilization and mortality.

RESULTS

The prevalence of mood disorders was 6.1% (4.9% among males, 7.1% among females). Statistically significant associations with mood disorders included younger age, female sex, food insecurity, chronic opioid use, smoking, and morbidity. Individuals with mood disorders had increased odds of all consequences examined, including placement in long-term care (adjusted odds ratio [OR] =2.28; 95% confidence interval [CI], 1.71 to 3.02) and death (adjusted OR = 1.35; 95% CI, 1.13 to 1.63).

CONCLUSIONS

Mood disorders in late life were strongly correlated with demographic and social/behavioral factors, health care use, institutionalization, and mortality. Understanding these relationships provides a basis for potential interventions to reduce the occurrence of mood disorders in late life and their consequences.