Social determinants of unmet need for primary care: a systematic review

BACKGROUND

Despite primary care being largely free at the point of delivery, many Canadians experience challenges in accessing the services they need. A systematic review was conducted to summarize the evidence on the level of unmet need for primary care in Canada and its social determinants.

METHODS

MEDLINE, Embase, Cochrane, and Web of Science databases were screened from inception to December 2023 using relevant search terms for primary care and unmet healthcare needs. Quantitative observational studies in the English language that included Canadian adults aged 18 years and older and focused on unmet needs for primary care were included. The risk of bias in the studies was assessed using either the Joanna Briggs Institute (JBI) critical appraisal checklist or the Newcastle-Ottawa Scale. The included studies were synthesized narratively.

RESULTS

Forty-six studies met the inclusion criteria for this review. Of the included studies, 96% were cross-sectional in design and 91% had low risk of bias. The prevalence of unmet need, mostly self-reported, varied between 6.6% and 25.2% in national studies. Social determinants of unmet needs were heterogeneous across studies. Findings suggest that unmet need for primary care is related to having low income, mental health diagnoses, and chronic conditions, and negatively associated with older age, having better-perceived health, and having a family physician.

CONCLUSIONS

Universal access to primary care is the founding principle of the Canadian healthcare system. However, we found evidence suggesting that the extent to which primary care needs are met is influenced by social determinants of health. Further research is needed to improve our understanding of the mechanisms of unmet primary care needs in Canada.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021285074.

[Unmet health care needs of younger and older people in socially deprived regions: A qualitative interview study in the Ruhr area]

INTRODUCTION

Unmet health care needs are considered a key indicator of equity in access to health care. For younger people, they can lead to poorer health outcomes in adulthood, for older people, they are associated with an increased risk of mortality. Unmet needs were therefore investigated as part of a research project on "Improving the health-related life situation of young and old people in the Ruhr area."

METHOD

Unmet health care needs were surveyed with the help of semi-structured guideline interviews with younger and older people in the Ruhr area (n=29). Due to the spatial and social structure of the study region, the aim was to recruit especially people with a low subjective social status (SSS) for the study. The interviews were recorded, transcribed, and subjected to a qualitative content analysis and a supplementary frequency analysis. The reporting is based on the Standards for Qualitative Research (SRQR).

RESULTS

The respondents reported deficiencies in treatment and doctor-patient communication with GPs and specialists. The feeling of not being taken seriously due to age is cited several times by both age groups as a reason for unmet health care needs. Waiting times are particularly relevant in the case of specialist consultations, while co-payments for services mainly play a role in dentistry and orthodontics. Unmet needs are primarily reported by people with a medium SSS. Overall, almost two thirds of the respondents stated that they have or have had at least one unmet need. Participants with a low SSS report fewer unmet needs and do not mention any financial aspects as a cause. Explanations for this range from lower health literacy to the fear of being discredited.

CONCLUSIONS

The results provide indications of deficits in regional health care provision for younger and older people in the Ruhr region. Corresponding fields of action result from the areas of care and reasons identified as relevant for unmet health care needs. The reported findings also provide a basis for differentiated quantitative surveys with representative samples.

Assessing new patient attachment to an integrated, virtual care programme in rural primary care

INTRODUCTION

An estimated 20% of residents of Renfrew County, a rural and underserved community in Ontario, do not have a family physician or alternative primary care provider. Integrated virtual care (IVC) aims to address this crisis by enrolling individuals who are not currently attached to a primary care provider, to a named family physician who works predominantly remotely. The physician is embedded within an existing, local family health team. The aim of this study was to assess and describe the IVC model's capacity to enrol previously unattached patients in Renfrew County and provide adequate primary care.

METHODS

We conducted a cross-sectional, descriptive study of data collected from patients enrolled for at least 3 months to an IVC family physician from 15 November 2021 (earliest appointment date for first IVC patients) to 30 June 2022 inclusive.

RESULTS

N = 790 patients were successfully attached to a family physician and received at least 3 months of care through IVC within the study period. Of the study population, 65% were female and over 75% were under the age of 55. Among patients who were current smokers at the time of IVC enrolment (n = 115), approximately 1 in 5 (18.3%) started a smoking cessation programme following referral by their IVC physician. In addition, IVC physicians and allied health professionals performed 66 colorectal cancer screenings, 164 cervical cancer screenings and 39 breast cancer screenings during the study period, bringing many overdue patients up to date for routine testing.

CONCLUSION

IVC has been successful in attaching previously unattached patients to a family physician and providing, comprehensive, team-based primary care during its initial 7 months of operation. Similar integrated primary care delivery concepts can also use these results to guide their own development and quality improvement.

INTRODUCTION

On estime que 20% des habitants du comté de Renfrew, une communauté rurale et mal desservie de l'Ontario, n'ont pas de médecin de famille ou d'autre prestataire de soins primaires. Le programme de Soins virtuels intégrés (SVI) vise à résoudre cette crise en proposant aux personnes qui n'ont pas de prestataire de soins primaires de consulter un médecin de famille désigné qui travaille principalement à distance. Le médecin est intégré à une équipe de santé familiale locale existante. L'objectif de cette étude était d'évaluer et de décrire la capacité du modèle de SVI à inscrire des patients qui n'étaient pas rattachés à un prestataire de soins primaires dans le comté de Renfrew et à leur fournir des soins primaires adéquats.

MTHODES

Nous avons mené une étude transversale et descriptive des données recueillies auprès des patients inscrits depuis au moins trois mois auprès d'un médecin de famille IVC entre le 15 novembre 2021 (date de rendez-vous la plus proche pour les premiers patients SVI) et le 30 juin 2022 inclus.

RSULTATS

N = 790 patients ont été rattachés avec succès à un médecin de famille et ont reçu au moins 3 mois de soins par l'intermédiaire des SVI au cours de la période d'étude. Parmi la population étudiée, 65% étaient des femmes et plus de 75% avaient moins de 55 ans. Parmi les patients qui fumaient au moment de leur inscription aux SVI (n = 115), environ 1 sur 5 (18,3%) a entamé un programme de sevrage tabagique après avoir été orienté par son médecin en SVI. En outre, les médecins du centre et les professionnels paramédicaux ont effectué 66 dépistages du cancer colorectal, 164 dépistages du cancer du col de l'utérus et 39 dépistages du cancer du sein au cours de la période d'étude, ce qui a permis à de nombreux patients en retard de SE soumettre à des tests de routine.

CONCLUSION

Le programme de SVI a réussi à mettre en relation des patients qui ne l'étaient pas auparavant avec un médecin de famille et à fournir des soins primaires complets en équipe au cours de ses sept premiers mois d'activité. Des concepts similaires de prestation de soins primaires intégrés peuvent également utiliser ces résultats pour guider leur propre développement et l'amélioration de la qualité.

Telephone outreach by volunteer navigators: a theory-based evaluation of an intervention to improve access to appropriate primary care

BACKGROUND

A pilot intervention in a participatory research programme in Québec, Canada, used telephone outreach by volunteer patient navigators to help unattached persons from deprived neighbourhoods attach successfully to a family doctor newly-assigned to them from a centralized waiting list. According to our theory-based program logic model we evaluated the extent to which the volunteer navigator outreach helped patients reach and engage with their newly-assigned primary care team, have a positive healthcare experience, develop an enduring doctor-patient relationship, and reduce forgone care and emergency room use.

METHOD

For the mixed-method evaluation, indicators were developed for all domains in the logic model and measured in a telephone-administered patient survey at baseline and three months later to determine if there was a significant difference. Interviews with a subsample of 13 survey respondents explored the mechanisms and nuances of intended effects.

RESULTS

Five active volunteers provided the service to 108 persons, of whom 60 agreed to participate in the evaluation. All surveyed participants attended the first visit, where 90% attached successfully to the new doctor. Indicators of abilities to access healthcare increased statistically significantly as did ability to explain health needs to professionals. The telephone outreach predisposed patients to have a positive first visit and have trust in their new care team, establishing a basis for an enduring relationship. Patient-reported access difficulties, forgone care and use of hospital emergency rooms decreased dramatically after patients attached to their new doctors.

CONCLUSIONS

As per the logic model, telephone outreach by volunteer navigators significantly increased patients' abilities to seek, reach and engage with care and helped them attach successfully to newly-assigned family doctors. This light-touch intervention may have promise to achieve of the intended policy goals for the centralized waiting list to increase population access to appropriate primary care and reduce forgone care.

The relationship between mood disorder diagnosis and experiencing an unmet health-care need in Canada: findings from the 2014 Canadian Community Health Survey

BACKGROUND

Despite Canada's universal health-care system, millions of Canadians experience unmet health-care needs (UHCN). People with mood disorders may be at higher risk of UHCN due to barriers such as stigma and gaps in health-care services.

AIM

We aimed to examine the relationship between having a diagnosed mood disorder and experiencing UHCN using a recent, nationally representative survey.

METHODS

Using the 2014 Canadian Community Health Survey, we used multivariate logistic regression to estimate the association between mood disorder and UHCN in the past 12 months, adjusting for sociodemographic variables and health status.

RESULTS

Among 52,825 respondents, 11.8% reported UHCN. Respondents with a diagnosed mood disorder were more likely to report UHCN [adjusted odds ratio (OR) 1.61, 95% confidence interval (CI) 1.38, 1.89]. Among respondents with a regular doctor, people with mood disorders were still more likely to report UHCN (OR 1.63, 95% CI 1.38, 1.93). Sensitivity analyses using propensity score and missing data imputation approaches resulted in similar estimates.

CONCLUSIONS

Adults diagnosed with a mood disorder are more likely to report UHCN in the past year, even those with a regular doctor. Our findings suggest that barriers beyond physician attachment may impact access to care for people with mood disorders.

“What do you mean I can’t have a doctor? this is Canada!” – a qualitative study of the myriad consequences for unattached patients awaiting primary care attachment

Background

Patient access to primary healthcare (PHC) is the foundation of a strong healthcare system and healthy populations. Attachment to a regular PHC provider, a key to healthcare access, has seen a decline in some jurisdictions. This study explored the consequences of unattachment from a patient perspective, an under-studied phenomenon to date.

Methods

A realist-informed qualitative study was conducted with unattached patients in Nova Scotia, Canada. Semi-structured interviews with nine participants were conducted and transcribed for analysis. The framework method was used to carry out analysis, which was guided by Donabedian’s model of assessing healthcare access and quality.

Results

Five key findings were noted in this study: 1) Participants experienced a range of consequences from not having a regular PHC provider. Participants used creative strategies to 2) attempt to gain attachment to a regular PHC provider, and, to 3) address their health needs in the absence of a regular PHC provider. 4) Participants experienced negative feelings about themselves and the healthcare system, and 5) stress related to the consequences and added work of being unattached and lost care.

Conclusions

Unattached patients experienced a burden of care related to lost care and managing their own health and related information, due to the download of medical record management and system navigation to them. These findings may underestimate the consequences for further at-risk populations who would not have been included in our recruitment. This may result in poorer health outcomes, which could be mitigated by interventions at the structural level, such as enhanced centralized waitlists to promote attachment. Such waitlists may benefit from a triage approach to appropriately attach patients based on need.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01671-5.

Improved access to and continuity of primary care after attachment to a family physician: longitudinal cohort study on centralized waiting lists for unattached patients in Quebec, Canada

Background

Having a regular family physician is associated with many benefits. Formal attachment – an administrative patient-family physician agreement – is a popular feature in primary care, intended to improve access to and continuity of care with a family physician. However, little evidence exists about its effectiveness. In Quebec, Canada, where over 20% of the population is unattached, centralized waiting lists help attach patients. This provides a unique opportunity to observe the influence of attachment in previously unattached patients. The aim was to evaluate changes in access to and continuity of primary care associated with attachment to a family physician through Quebec’s centralized waiting lists for unattached patients.

Methods

We conducted an observational longitudinal population cohort study, using medical services billing data from public health insurance in the province of Québec, Canada. We included patients attached through centralized waiting lists for unattached patients between 2012 and 2014 (n = 410,140). Our study was informed by Aday and Andersen’s framework for the study of access to health services. We compared outcomes during four 12-month periods: two periods before and two periods after attachment, with T0–2 years as the reference period. Outcome measures were number of primary care visits and Bice-Boxerman Concentration of Care Index at the physician and practice level (for patients with ≥2 visits in a given period). We included age, sex, region remoteness, medical vulnerability, and Charlson Comorbidity Index as covariates in regression models fitted with generalized estimating equations.

Results

The number of primary care visits increased by 103% in the first post attachment year and 29% in the second year (p < 0.001). The odds of having all primary care visits concentrated with a single physician increased by 53% in the first year and 22% (p < 0.001) in the second year after attachment. At the practice level, the odds of perfect concentration of care increased by 19% (p < 0.001) and 15% (p < 0.001) respectively, in first and second year after attachment.

Conclusion

Our results show an increase in patients’ number of primary care visits and concentration of care at the family physician and practice level after attachment to a family physician. This suggests that attachment may help improve access to and continuity of primary care.

Provincial variations in not having a regular medical doctor and having unmet healthcare needs among Canadians

BACKGROUND

Despite spending 11.0% of the total gross domestic product, the quality of healthcare services in Canada has received mixed reviews. We first separately examined provincial variations in not having a regular medical doctor and having unmet healthcare needs among Canadians. Second, we evaluated provincial variations in the impact of not having a regular medical doctor on having unmet healthcare needs among Canadians.

METHODS

We applied logistic regressions using data from the 2014 and 2017-2018 Canadian Community Health Surveys (CCHS). The total sample size for this study was 120,345 individuals aged 12 years and older: 61,240 from the 2014 CCHS and 59,105 from the 2017-2018 CCHS.

RESULTS

We found significant provincial variations in not having a regular medical doctor and having unmet healthcare needs among Canadians. People in Quebec and the Territories were more likely not to have a regular medical doctor than their peers in Alberta. People in Quebec and the Territories were also more likely to have unmet healthcare needs than their counterparts in Alberta. Not having a regular medical doctor impacted whether Canadians reported having unmet healthcare needs to varying degrees across provinces.

CONCLUSION

Findings from this study may contribute to designing province-specific policy interventions and inform efforts that seek to address barriers to having a regular medical doctor and reducing unmet healthcare needs among Canadians.

Designing centralized waiting lists for attachment to a primary care provider: Considerations from a logic analysis

Access to a regular primary care provider is essential to quality care. In Canada, where 15 % of patients are unattached (i.e., without a regular provider), centralized waiting lists (CWLs) help attach patients to a primary care provider (family physician or nurse practitioner). Previous studies reveal mechanisms needed for CWLs to work, but focus mostly on CWLs for specialized health care. We aim to better understand how to design CWLs for unattached patients in primary care. In this study, a logic analysis compares empirical evidence from a qualitative case study of CWLs for unattached patients in seven Canadian provinces to programme theory derived from a realist review on CWLs. Data is analyzed using context-intervention-mechanism-outcome configurations. Results identify mechanisms involved in three components of CWL design: patient registration, patient prioritization, and patient assignment to a provider for attachment. CWL programme theory is revised to integrate mechanisms specific to primary care, where patients, rather than referring providers, are responsible for registering on the CWL, where prioritization must consider a broad range of conditions and characteristics, and where long-term acceptability of attachment is important. The study provides new insight into mechanisms that enable CWLs for unattached patients to work.

Unmet Healthcare Needs and Associated Factors Among Korean Enlisted Soldiers

INTRODUCTION

The purpose of this study was to explore the rate of unmet healthcare needs among Korean enlisted soldiers and to examine the factors associated with unmet healthcare needs, based on Andersen's Health Service Behavior Model.

METHOD

This study employed secondary data analysis using the dataset of the military health survey for two years, 2014 and 2015, conducted by the Republic of Korea School of Military Medicine. Of all military health survey participants, 3,636 enlisted soldiers who answered the question "In the last year, have you ever been unable to go to a hospital or a clinic when you wanted to go to a hospital or a clinic?"-the dependent variable in this study-were included in this study.

RESULT

The rate of unmet healthcare needs among Korean enlisted soldiers was 23.7% (n = 860) in the current study. Among the individual characteristics, on-duty stress (Odds ratio (OR) = 1.59, 95% Confidence Interval (95% CI): 1.25-2.03) and need for treatment by a mental health specialist (OR = 1.40, 95% Confidence Interval (CI): 1.00-1.95) were associated with unmet healthcare needs. Among the contextual characteristics, perception of injury-prevention effort (OR = 0.61, 95% CI: 0.52-0.71), support from superiors (OR = 0.81, 95% CI: 0.71-0.93), and possibility of accident or injury of military unit (OR = 0.73, 95% CI: 0.64-0.82) were significant factors associated with unmet healthcare needs. The subjective health condition which was a proxy of the health outcome was significantly associated with unmet healthcare needs (OR = 1.58, 95% CI: 1.13-2.22). The results indicate that the safety awareness of troops and social support of superiors were the contextual military characteristics associated with unmet healthcare needs of enlisted soldiers.

CONCLUSIONS

The strengthening of aspect of organizational culture, such as injury-prevention efforts at the military level, or support from superior officers, will contribute to a reduction of the unmet healthcare needs of Korean enlisted soldiers.