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Smithman MA, Haggerty J, Gaboury I, Breton M. 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. BMC PRIMARY CARE 2022; 23:238. [PMID: 36114464 PMCID: PMC9482231 DOI: 10.1186/s12875-022-01850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 09/08/2022] [Indexed: 11/10/2022]
Abstract
Abstract
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.
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Smithman MA, Brousselle A, Touati N, Boivin A, Nour K, Dubois CA, Loignon C, Berbiche D, Breton M. Area deprivation and attachment to a general practitioner through centralized waiting lists: a cross-sectional study in Quebec, Canada. Int J Equity Health 2018; 17:176. [PMID: 30509274 PMCID: PMC6277998 DOI: 10.1186/s12939-018-0887-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2018] [Accepted: 11/05/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Access to primary healthcare is an important social determinant of health and having a regular general practitioner (GP) has been shown to improve access. In Canada, socio-economically disadvantaged patients are more likely to be unattached (i.e. not have a regular GP). In the province of Quebec, where over 30% of the population is unattached, centralized waiting lists were implemented to help patients find a GP. Our objectives were to examine the association between social and material deprivation and 1) likelihood of attachment, and 2) wait time for attachment to a GP through centralized waiting lists. METHODS A cross-sectional study was conducted in five local health networks in Quebec, Canada, using clinical administrative data of patients attached to a GP between June 2013 and May 2015 (n = 24, 958 patients) and patients remaining on the waiting list as of May 2015 (n = 49, 901), using clinical administrative data. Social and material area deprivation indexes were used as proxies for patients' socio-economic status. Multiple regressions were carried out to assess the association between deprivation indexes and 1) likelihood of attachment to a GP and 2) wait time for attachment. Analyses controlled for sex, age, local health network and variables related to health needs. RESULTS Patients from materially medium, disadvantaged and very disadvantaged areas were underrepresented on the centralized waiting lists, while patients from socially disadvantaged and very disadvantaged areas were overrepresented. Patients from very materially advantaged and advantaged areas were less likely to be attached to a GP than patients from very disadvantaged areas. With the exception of patients from socially disadvantaged areas, all other categories of social deprivation were more likely to be attached to a GP compared to patients from very disadvantaged areas. We found a pro-rich gradient in wait time for attachment to a GP, with patients from more materially advantaged areas waiting less than those from disadvantaged areas. CONCLUSION Our findings suggest that there are socio-economic inequities in attachment to a GP through centralized waiting lists. Policy makers should take these findings into consideration to adjust centralized waiting list processes to avoid further exacerbation of health inequities.
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Affiliation(s)
- Mélanie Ann Smithman
- Centre de recherche Charles-Le Moyne - Saguenay Lac-St-Jean sur les innovations en santé, Université de Sherbrooke, Longueuil Campus, 150 Place Charles-Le Moyne, Suite 200, Longueuil, Quebec, J4K 0A8, Canada
| | - Astrid Brousselle
- School of Public Administration, University of Victoria, 3800 Finnerty Rd, Suite A302, Victoria, British Columbia, V8P 5C2, Canada
| | - Nassera Touati
- Centre de recherche sur la gouvernance, École nationale d'administration publique, 4750, Avenue Henri-Julien, Office 5117, Montreal, Quebec, H2T 3E5, Canada
| | - Antoine Boivin
- Centre de recherche du Centre Hospitalier de l'Université de Montréal, Université de Montréal, 900 Rue Saint-Denis, Montreal, Quebec, H2X 0A9, Canada
| | - Kareen Nour
- Direction de santé publique, Centre intégré de santé et des services sociaux - Montérégie-Centre, 1255 rue Beauregard, Longueuil, Quebec, J4K 2M3, Canada
| | - Carl-Ardy Dubois
- Faculty of Nursing, Université de Montréal, 2375, chemin de la Côte Ste-Catherine, Office 5103, Montreal, Quebec, H3T 1A8, Canada
| | - Christine Loignon
- Centre de recherche Charles-Le Moyne - Saguenay Lac-St-Jean sur les innovations en santé, Université de Sherbrooke, Longueuil Campus, 150 Place Charles-Le Moyne, Suite 200, Longueuil, Quebec, J4K 0A8, Canada
| | - Djamal Berbiche
- Centre de recherche Charles-Le Moyne - Saguenay Lac-St-Jean sur les innovations en santé, Université de Sherbrooke, Longueuil Campus, 150 Place Charles-Le Moyne, Suite 200, Longueuil, Quebec, J4K 0A8, Canada
| | - Mylaine Breton
- Centre de recherche Charles-Le Moyne - Saguenay Lac-St-Jean sur les innovations en santé, Université de Sherbrooke, Longueuil Campus, 150 Place Charles-Le Moyne, Suite 200, Longueuil, Quebec, J4K 0A8, Canada.
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Breton M, Green M, Kreindler S, Sutherland J, Jbilou J, Wong ST, Shaw J, Crooks VA, Contandriopoulos D, Smithman MA, Brousselle A. A comparative analysis of centralized waiting lists for patients without a primary care provider implemented in six Canadian provinces: study protocol. BMC Health Serv Res 2017; 17:60. [PMID: 28109279 PMCID: PMC5251310 DOI: 10.1186/s12913-017-2007-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 01/12/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Having a regular primary care provider (i.e., family physician or nurse practitioner) is widely considered to be a prerequisite for obtaining healthcare that is timely, accessible, continuous, comprehensive, and well-coordinated with other parts of the healthcare system. Yet, 4.6 million Canadians, approximately 15% of Canada's population, are unattached; that is, they do not have a regular primary care provider. To address the critical need for attachment, especially for more vulnerable patients, six Canadian provinces have implemented centralized waiting lists for unattached patients. These waiting lists centralize unattached patients' requests for a primary care provider in a given territory and match patients with providers. From the little information we have on each province's centralized waiting list, we know the way they work varies significantly from province to province. The main objective of this study is to compare the different models of centralized waiting lists for unattached patients implemented in six provinces of Canada to each other and to available scientific knowledge to make recommendations on ways to improve their design in an effort to increase attachment of patients to a primary care provider. METHODS A logic analysis approach developed in three steps will be used. Step 1: build logic models that describe each province's centralized waiting list through interviews with key stakeholders in each province; step 2: develop a conceptual framework, separate from the provincially informed logic models, that identifies key characteristics of centralized waiting lists for unattached patients and factors influencing their implementation through a literature review and interviews with experts; step 3: compare the logic models to the conceptual framework to make recommendations to improve centralized waiting lists in different provinces during a pan Canadian face-to-face exchange with decision-makers, clinicians and researchers. DISCUSSION This study is based on an inter-provincial learning exchange approach where we propose to compare centralized waiting lists and analyze variations in strategies used to increase attachment to a regular primary care provider. Fostering inter-provincial healthcare systems connectivity to improve centralized waiting lists' practices across Canada can lever attachment to a regular provider for timely access to continuous, comprehensive and coordinated healthcare for all Canadians and particular for those who are vulnerable.
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Affiliation(s)
- Mylaine Breton
- Charles-LeMoyne Hospital Research Centre, Sherbrooke University, Longueuil Campus, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC J4K 0A8 Canada
| | - Michael Green
- Family Medicine and Public Health Sciences and CHSPR, Queen’s University, Abramsky Hall, 3rd Floor 21 Arch St., Kingston, ON K7L 3N6 Canada
| | - Sara Kreindler
- Manitoba Research Chair in Health System Innovation and Community Health Sciences, University of Manitoba, 200-1155 Concordia Ave., Winnipeg, MB R2K 2M9 Canada
| | - Jason Sutherland
- Centre for Health Services and Policy Research, University of British Columbia, 201-2206 East Mall, Vancouver, BC V6T 1Z3 Canada
| | - Jalila Jbilou
- School of psychology, Université de Moncton, Centre de formation médicale du Nouveau-Brunswick, Pavillon Léopold-Taillon Université de Moncton, 18 Ave Antonine-Maillet, Moncton, NB E1A 3E9 Canada
| | - Sabrina T. Wong
- School of Nursing and Centre for Health Services and Policy Research in the School of Population and Public Health, University of British Columbia, 2211 Wesbrook Mall, Vancouver, BC V6T 2B5 Canada
| | - Jay Shaw
- Institute for Health System Solutions and Virtual Care, Women’s College Hospital, 76 Grenville Street, Toronto, ON M5S1B2 Canada
| | - Valorie A. Crooks
- Canada Research Chair in Health Service Geographies, Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
| | - Damien Contandriopoulos
- Faculty of nursing, University of Montréal, 2375, chemin de la Côte-Ste-Catherine, Montréal, Québec H3T 1A8 Canada
| | - Mélanie Ann Smithman
- Charles-LeMoyne Hospital Research Centre, Sherbrooke University, Longueuil Campus, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC J4K 0A8 Canada
| | - Astrid Brousselle
- Charles-LeMoyne Hospital Research Centre, Sherbrooke University, Longueuil Campus, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC J4K 0A8 Canada
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Romo ML, Chan PY, Lurie-Moroni E, Perlman SE, Newton-Dame R, Thorpe LE, McVeigh KH. Characterizing Adults Receiving Primary Medical Care in New York City: Implications for Using Electronic Health Records for Chronic Disease Surveillance. Prev Chronic Dis 2016; 13:E56. [PMID: 27126554 PMCID: PMC4856483 DOI: 10.5888/pcd13.150500] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Introduction Electronic health records (EHRs) from primary care providers can be used for chronic disease surveillance; however, EHR-based prevalence estimates may be biased toward people who seek care. This study sought to describe the characteristics of an in-care population and compare them with those of a not-in-care population to inform interpretation of EHR data. Methods We used data from the 2013–2014 New York City Health and Nutrition Examination Survey (NYC HANES), considered the gold standard for estimating disease prevalence, and the 2013 Community Health Survey, and classified participants as in care or not in care, on the basis of their report of seeing a health care provider in the previous year. We used χ2 tests to compare the distribution of demographic characteristics, health care coverage and access, and chronic conditions between the 2 populations. Results According to the Community Health Survey, approximately 4.1 million (71.7%) adults aged 20 or older had seen a health care provider in the previous year; according to NYC HANES, approximately 4.7 million (75.1%) had. In both surveys, the in-care population was more likely to be older, female, non-Hispanic, and insured compared with the not-in-care population. The in-care population from the NYC HANES also had a higher prevalence of diabetes (16.7% vs 6.9%; P < .001), hypercholesterolemia (35.7% vs 22.3%; P < .001), and hypertension (35.5% vs 26.4%; P < .001) than the not-in-care population. Conclusion Systematic differences between in-care and not-in-care populations warrant caution in using primary care data to generalize to the population at large. Future efforts to use primary care data for chronic disease surveillance need to consider the intended purpose of data collected in these systems as well as the characteristics of the population using primary care.
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Affiliation(s)
- Matthew L Romo
- New York City Department of Health and Mental Hygiene, Long Island City, New York, and City University of New York School of Public Health, New York, New York
| | - Pui Ying Chan
- Bureau of Epidemiology Services, New York City Department of Health and Mental Hygiene, 42-09 28th St, 07-99, Long Island City, New York, 11101-4132.
| | | | - Sharon E Perlman
- New York City Department of Health and Mental Hygiene, Long Island City, New York
| | - Remle Newton-Dame
- New York City Department of Health and Mental Hygiene, Long Island City, New York
| | - Lorna E Thorpe
- City University of New York School of Public Health, New York, New York
| | - Katharine H McVeigh
- New York City Department of Health and Mental Hygiene, Long Island City, New York
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Slater T, Matheson A, Ellison-Loschmann L, Davies C, Earp R, Gellatly K, Holdaway M. Exploring Māori cancer patients', their families', community and hospice views of hospice care. Int J Palliat Nurs 2016; 21:439-45. [PMID: 26412274 DOI: 10.12968/ijpn.2015.21.9.439] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Despite poor cancer survival statistics, Māori do not readily access hospice services. This study aims to explore how hospice services respond to Māori by investigating the different influences and interactions between three perspectives of hospice care. METHOD The authors conducted a Māori-centred, cross-sectional qualitative study by undertaking semi-structured interviews with hospice patients and whānau (families) (n=8), hospice representatives (n=4), and representatives from three Māori health provider organisations (n=5). CONCLUSIONS The study found that negative perceptions of hospice are being changed by hospices' relationships with other organisations and positive stories from whānau. Involvement from whānau, continuity of care and after-hours care with a greater Māori workforce and a further emphasis on culturally safe care are critical for this work to gain momentum. Findings can be of use to further develop quality of care indicators that reflect the perspectives of patients and whānau, and those who provide their care.
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Affiliation(s)
| | | | - Lis Ellison-Loschmann
- Senior Research Fellow, Public Health Research, all above at the Centre for Public Health Research, Massey University, Wellington, New Zealand
| | | | - Ria Earp
- Chief Executive, Mary Potter Hospice, Wellington
| | - Kate Gellatly
- Clinical Nurse Specialist Educator, Te Omanga Hospice, Lower Hutt
| | - Maureen Holdaway
- Associate Director, Research Centre for Māori Health and Development, Massey University, Palmerston North
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Reid J, Cormack D, Crowe M. The significance of relational continuity of care for Māori patient engagement with predominantly non-Māori doctors: findings from a qualitative study. Aust N Z J Public Health 2015; 40:120-5. [PMID: 26337777 DOI: 10.1111/1753-6405.12447] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 11/01/2014] [Accepted: 05/01/2015] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE This qualitative study explored self-reported experiences of primary healthcare among a sample of urban Māori adults. This paper specifically focuses on the theme of relational continuity of care identified in participant discussions of access and engagement with their predominantly non-Māori general practitioners (GPs). METHODS The study involved a purposively selected subsample (n=42) of the Christchurch Māori cohort of the Hauora Manawa Community Heart Study (n=244). Participants took part in in-depth interviews, which were transcribed and analysed thematically. RESULTS Analysis identified compromised access to a preferred GP as a principal barrier to receiving quality and non-discriminatory care from predominantly non-Māori clinicians. In contrast to discussions of healthcare provided by usual GPs, episodic encounters with non-regular clinicians were commonly framed as experiences discouraging utilisation and the perceived value of primary healthcare. CONCLUSIONS Facilitating relational continuity of care for Māori patients and their clinicians may contribute towards mediating determinants of inequality at the clinical interface. IMPLICATIONS Reducing significant health disparities between Māori and non-Māori was a key goal of the reconfiguration of primary healthcare in the early 2000s. The role of relational continuity of care in achieving equitable inter-ethnic health outcomes in primary healthcare settings is an important consideration.
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Affiliation(s)
- Jennifer Reid
- Christchurch School of Medicine, University of Otago, New Zealand
| | - Donna Cormack
- Te Rōpū Rangahau Hauora a Eru Pōmare, University of Otago, New Zealand
| | - Marie Crowe
- Christchurch School of Medicine, University of Otago, New Zealand
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Breton M, Brousselle A, Boivin A, Loignon C, Touati N, Dubois CA, Nour K, Berbiche D, Roberge D. Evaluation of the implementation of centralized waiting lists for patients without a family physician and their effects across the province of Quebec. Implement Sci 2014; 9:117. [PMID: 25185703 PMCID: PMC4159553 DOI: 10.1186/s13012-014-0117-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2014] [Accepted: 08/25/2014] [Indexed: 12/05/2022] Open
Abstract
Background Most national and provincial commissions on healthcare services in Canada over the past decade have recommended that primary care services be strengthened in order to guarantee each citizen access to a family physician. Despite these recommendations, finding a family physician continues to be problematic. The issue of enrolment with a family physician is worrying in Canada, where nearly 21% of the country's population reported not having a family physician in the last Commonwealth Fund survey. To respond to this important need, centralized waiting lists have been implemented in four Canadian provinces to help `orphan,' or unaffiliated, patients find a family physician. These organizational mechanisms are intended to better coordinate the demand for and supply of family physicians. The objectives of this study are: to assess the effects of centralized waiting lists for orphan patients (GACOs) implemented in the province of Quebec and to explain the variation among their effects by analyzing factors influencing implementation process. Methods This study is based on two complementary and sequential research strategies. The first (objective 1) is a quantitative longitudinal design to assess the effects of all the GACOs (n = 93) in Quebec using clinical-administrative data. The second (objective 2) involves using four case studies to explain variations in effects through in-depth analysis of the various factors contributing to the observed effects. The primary source of data will be key actors involved in the GACOs. We expect to conduct around 40 semi-structured interviews. Discussion This will be the first study in Canada to evaluate the implementation of this innovation. It will provide an exhaustive picture of the effects of GACO implementation in Quebec and to assess their potential for generalization elsewhere in Canada. At the theoretical level, this study will produce new knowledge on the factors having the greatest influence on the implementation of primary care innovations in professional environments. Electronic supplementary material The online version of this article (doi:10.1186/s13012-014-0117-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Mylaine Breton
- Charles-LeMoyne Hospital Research Centre, Greenfield Park J4K 0A8, QC, Canada.
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Jatrana S, Richardson K, Crampton P. Is change in global self-rated health associated with change in affiliation with a primary care provider? Findings from a longitudinal study from New Zealand. Prev Med 2014; 64:32-6. [PMID: 24680875 DOI: 10.1016/j.ypmed.2014.03.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 02/19/2014] [Accepted: 03/10/2014] [Indexed: 10/25/2022]
Abstract
AIMS To investigate the association of self-rated health and affiliation with a primary care provider (PCP) in New Zealand. METHODS We used data from a New Zealand panel study of 22,000 adults. The main exposure was self-rated health, and the main outcome measure was affiliation with a PCP. Fixed effects conditional logistic models were used to control for observed time-varying and unobserved time-invariant confounding. RESULTS In any given wave, the odds of being affiliated with a PCP were higher for those in good and fair/poor health relative to those in excellent health. While affiliation for Europeans increased as reported health declined, the odds of being affiliated were lower for Māori respondents reporting very good or good health relative to those in excellent health. No significant differences in the association by age or gender were observed. CONCLUSIONS Our data support the hypothesis that those in poorer health are more likely to be affiliated with a PCP. Variations in affiliation for Māori could arise for several reasons, including differences in care-seeking behaviour and perceived need of care. It may also mean that the message about the benefits of primary health care is not getting through equally to all population groups.
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Affiliation(s)
- Santosh Jatrana
- Alfred Deakin Research Institute, Deakin University Waterfront Campus, Geelong, Victoria 3220, Australia.
| | - Ken Richardson
- Department of Public Health, Wellington School of Medicine and Health Sciences, University of Otago, PO Box 7343, Wellington, New Zealand
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McRae I, Yen L, Gillespie J, Douglas K. Patient affiliation with GPs in Australia—Who is and who is not and does it matter? Health Policy 2011; 103:16-23. [DOI: 10.1016/j.healthpol.2010.09.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Revised: 08/23/2010] [Accepted: 09/05/2010] [Indexed: 11/25/2022]
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