Effect of payment incentives on cancer screening in Ontario primary care

Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: A Propensity Score Weighted Cohort Study

BACKGROUND

Unplanned hospital readmissions are associated with adverse patient outcomes and substantial healthcare costs. It remains unknown whether physician financial incentives for enhanced discharge planning can reduce readmission risk.

METHODS

In 2012, policymakers in British Columbia, Canada, introduced a $75 fee-for-service physician payment to incentivize enhanced discharge planning (the "G78717" fee code). We used population-based administrative health data to compare outcomes among G78717-exposed and G78717-unexposed patients. We identified all nonelective hospitalizations potentially eligible for the incentive over a 5-year study interval. We examined the composite risk of unplanned readmission or death and total direct healthcare costs accrued within 30 days of discharge. Propensity score overlap weights and adjustment were used to account for differences between exposed and unexposed patients.

RESULTS

A total of 5262 of 24,787 G78717-exposed and 28,096 of 136,541 unexposed patients experienced subsequent unplanned readmission or death, suggesting exposure to the G78717 incentive did not reduce the risk of adverse outcomes after discharge (crude percent, 21.1% vs 20.6%; adjusted odds ratio, 0.97; 95% CI, 0.93-1.01; P = .23). Mean direct healthcare costs within 30 days of discharge were $3082 and $2993, respectively (adjusted cost ratio, 1.00; 95% CI, 0.95-1.05; P = .93).

CONCLUSIONS

A physician financial incentive that encouraged enhanced hospital discharge planning did not reduced the risk of readmission or death, and did not significantly decrease direct healthcare costs. Policymakers should consider the baseline prevalence and effectiveness of enhanced discharge planning, the magnitude and design of financial incentives, and whether auditing of incentivized activities is required when implementing similar incentives elsewhere.

TRIAL REGISTRATION

ClinicalTrials.gov ID, NCT03256734.

Impact of government-issued financial incentive to medical facilities on management of secondary dysmenorrhea

AIM

In April 2020, the Japanese government introduced a Specific Medical Fee for managing secondary dysmenorrhea (SD). This initiative provided financial incentives to medical facilities that provide appropriate management of SD with hormonal therapies. We aimed to assess how this policy affects the management processes and outcomes of patients with SD.

METHODS

Using a large Japanese administrative claims database, we identified outpatient visits of patients diagnosed with SD from April 2018 to March 2022. We used an interrupted time-series analysis and defined before April 2020 as the pre-introduction period and after April 2020 as the post-introduction period. Outcomes were the monthly proportions of outpatient visits due to SD and hormonal therapy among women in the database and the proportions of outpatient visits for hormonal therapy and continuous outpatient visits among patients with SD.

RESULTS

We identified 815 477 outpatient visits of patients diagnosed with SD during the pre-introduction period and 920 183 outpatient visits during the post-introduction period. There were significant upward slope changes after the introduction of financial incentives in the outpatient visits due to SD (+0.29% yearly; 95% confidence interval, +0.20% to +0.38%) and hormonal therapies (+0.038% yearly; 95% confidence interval, +0.030% to +0.045%) among the women in the database. Similarly, a significant level change was observed after the introduction of continuous outpatient visits among patients with SD (+2.68% monthly; 95% confidence interval, +0.87% to +4.49%).

CONCLUSIONS

Government-issued financial incentives were associated with an increase in the number of patients diagnosed with SD, hormonal therapies, and continuous outpatient visits.

Primary care practice-based interventions and their effect on participation in population-based cancer screening programs: a systematic narrative review

AIM

To provide a systematic synthesis of primary care practice-based interventions and their effect on participation in population-based cancer screening programs.

BACKGROUND

Globally, population-based cancer screening programs (bowel, breast, and cervical) have sub-optimal participation rates. Primary healthcare workers (PHCWs) have an important role in facilitating a patient's decision to screen; however, barriers exist to their engagement. It remains unclear how to best optimize the role of PHCWs to increase screening participation.

METHODS

A comprehensive search was conducted from January 2010 until November 2023 in the following databases: Medline (OVID), EMBASE, and CINAHL. Data extraction, quality assessment, and synthesis were conducted. Studies were separated by whether they assessed the effect of a single-component or multi-component intervention and study type.

FINDINGS

Forty-nine studies were identified, of which 36 originated from the USA. Fifteen studies were investigations of single-component interventions, and 34 studies were of multi-component interventions. Interventions with a positive effect on screening participation were predominantly multi-component, and most included combinations of audit and feedback, provider reminders, practice-facilitated assessment and improvement, and patient education across all screening programs. Regarding bowel screening, provision of screening kits at point-of-care was an effective strategy to increase participation. Taking a 'whole-of-practice approach' and identifying a 'practice champion' were found to be contextual factors of effective interventions.The findings suggest that complex interventions comprised of practitioner-focused and patient-focused components are required to increase cancer screening participation in primary care settings. This study provides novel understanding as to what components and contextual factors should be included in primary care practice-based interventions.

Methods, Detection Rates, and Survival Outcomes of Screening for Head and Neck Cancers: A Systematic Review

Importance

Head and neck cancers (HNCs) are often diagnosed at advanced clinical stages during their symptomatic phase, leading to a reduced treatment window and poor survival. Screening programs have been suggested as a mitigation strategy.

Objective

To examine the effectiveness of current HNC screening programs in improving diagnosis and survival in adults.

Evidence Review

This Preferred Reporting Items for Systematic Reviews and Meta-analyses-guided systematic review involved use of peer-reviewed, English-language journal articles identified from MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials between January 1, 2001, and July 15, 2022. Snowballing was applied to retrieve more studies. Eligible articles were original clinical trials and observational studies presenting a universal or risk-targeted screening program of primary HNC in the adult population. Reporting quality was assessed using the JBI's critical appraisal tools.

Findings

Database searches yielded 3646 unique citations with an additional 8 studies found via snowballing. Five reviewers assessed the full text of 106 studies. Sixteen articles were ultimately included in the review, involving 4.7 million adults (34.1%-100% male; median age, 30-59 years). Fifteen studies were based in Asia and 1 in Europe (Portugal). Five reported data from randomized clinical trials. An oral inspection conducted once or once every 2 to 3 years was described in 11 studies for screening oral cancer, while multistep screening involving Epstein-Barr virus serologic testing for nasopharyngeal carcinoma delivered every 1 to 4 years was presented in 5. In 4 trials and 6 observational studies, screening significantly increased the detection of localized (stage I/II) tumor or was associated with an increased proportion of diagnoses, respectively, regardless of the population and cancer subsites. Universal screening of asymptomatic adults improved 3- to 5-year overall survival but did not increase cancer-specific survival in 4 trials. Targeted screening improved overall and cancer-specific survival or was associated with improved survival outcomes in 2 trials and 2 observational studies, respectively. Studies had low to medium risks of bias.

Conclusions and Relevance

Evidence from the existing literature suggests that a risk-targeted screening program for oral and nasopharyngeal cancers could improve diagnosis and patient survival. Screening adherence, societal cost-effectiveness, and optimal risk stratification of such a program warrant future research, especially in low-incidence settings outside Asia.

Breast Cancer Screening Among Females With and Without Schizophrenia

Importance

Breast cancer screening with mammography is recommended in Ontario, Canada, for females 50 years or older. Females with schizophrenia are at higher risk of breast cancer, but in Ontario it is currently unknown whether breast cancer screening completion differs between those with vs without schizophrenia and whether primary care payment models are a factor.

Objective

To compare breast cancer screening completion within 2 years after the 50th birthday among females with and without schizophrenia, and to identify the association between breast cancer screening completion and different primary care payment models.

Design, Setting, and Participants

This case-control study analyzed Ontario-wide administrative data on females with and without schizophrenia who turned 50 years of age between January 1, 2010, and December 31, 2019. Those with schizophrenia (cases) were matched 1:10 to those without schizophrenia (controls) on local health integration network, income quintile, rural residence, birth dates, and weighted Aggregated Diagnosis Group score. Data analysis was performed from November 2021 to February 2023.

Exposures

Exposures were schizophrenia and primary care payment models.

Main Outcomes and Measures

Outcomes included breast cancer screening completion among cases and controls within 2 years after their 50th birthday and the association with receipt of care from primary care physicians enrolled in different primary care payment models, which were analyzed using logistic regression and reported as odds ratios (ORs) and 95% CIs.

Results

The study included 11 631 females with schizophrenia who turned 50 years of age during the study period and a matched cohort of 115 959 females without schizophrenia, for a total of 127 590 patients. Overall, 69.3% of cases and 77.1% of controls had a mammogram within 2 years after their 50th birthday. Cases had lower odds of breast cancer screening completion within 2 years after their 50th birthday (OR, 0.67; 95% CI, 0.64-0.70). Cases who received care from a primary care physician in a fee-for-service (OR, 0.57; 95% CI, 0.53-0.60) or enhanced fee-for-service (OR, 0.79; 95% CI, 0.75-0.82) payment model had lower odds of having a mammogram than cases whose physicians were paid under a Family Health Team model.

Conclusions and Relevance

This case-control study found that, in Ontario, Canada, breast cancer screening completion was lower among females with schizophrenia, and differences from those without schizophrenia may partially be explained by differences in primary care payment models. Widening the availability of team-based primary care for females with schizophrenia may play a role in increased breast cancer screening rates.

Physician Financial Incentives for Use of Outpatient Intravenous Antimicrobial Therapy: An Interrupted Time Series Analysis

BACKGROUND

In 2011, policymakers in British Columbia introduced a fee-for-service payment to incentivize infectious diseases physicians to supervise outpatient parenteral antimicrobial therapy (OPAT). Whether this policy increased use of OPAT remains uncertain.

METHODS

We conducted a retrospective cohort study using population-based administrative data over a 14-year period (2004-2018). We focused on infections that required intravenous antimicrobials for ≥10 days (eg, osteomyelitis, joint infection, endocarditis) and used the monthly proportion of index hospitalizations with a length of stay shorter than the guideline-recommended "usual duration of intravenous antimicrobials" (LOS < UDIVA) as a surrogate for population-level OPAT use. We used interrupted time series analysis to determine whether policy introduction increased the proportion of hospitalizations with LOS < UDIVA.

RESULTS

We identified 18 513 eligible hospitalizations. In the pre-policy period, 82.3% of hospitalizations exhibited LOS < UDIVA. Introduction of the incentive was not associated with a change in the proportion of hospitalizations with LOS < UDIVA, suggesting that the policy intervention did not increase OPAT use (step change, -0.06%; 95% confidence interval [CI], -2.69% to 2.58%; P = .97 and slope change, -0.001% per month; 95% CI, -.056% to .055%; P = .98).

CONCLUSIONS

The introduction of a financial incentive for physicians did not appear to increase OPAT use. Policymakers should consider modifying the incentive design or addressing organizational barriers to expanded OPAT use.

Primary care for individuals with serious mental illness (PriSMI): protocol for a convergent mixed methods study

INTRODUCTION

People with serious mental illness (SMI) have poor health outcomes, in part because of inequitable access to quality health services. Primary care is well suited to coordinate and manage care for this population; however, providers may feel ill-equipped to do so and patients may not have the support and resources required to coordinate their care. We lack a strong understanding of prevention and management of chronic disease in primary care among people with SMI as well as the context-specific barriers that exist at the patient, provider and system levels. This mixed methods study will answer three research questions: (1) How do primary care services received by people living with SMI differ from those received by the general population? (2) What are the experiences of people with SMI in accessing and receiving chronic disease prevention and management in primary care? (3) What are the experiences of primary care providers in caring for individuals with SMI?

METHODS AND ANALYSIS

We will conduct a concurrent mixed methods study in Ontario and British Columbia, Canada, including quantitative analyses of linked administrative data and in-depth qualitative interviews with people living with SMI and primary care providers. By comparing across two provinces, each with varying degrees of mental health service investment and different primary care models, results will shed light on individual and system-level factors that facilitate or impede quality preventive and chronic disease care for people with SMI in the primary care setting.

ETHICS AND DISSEMINATION

This study was approved by the University of Ottawa Research Ethics Board and partner institutions. An integrated knowledge translation approach brings together researchers, providers, policymakers, decision-makers, patient and caregiver partners and knowledge users. Working with this team, we will develop policy-relevant recommendations for improvements to primary care systems that will better support providers and reduce health inequities.

Health care system factors influencing primary healthcare workers' engagement in national cancer screening programs: a qualitative study

OBJECTIVE

This study aimed to explore factors across the environment, organisation and care team levels of the health care system that influence the engagement of primary healthcare workers (PHCWs) in Australia's national cancer screening programs.

METHODS

A cross-sectional qualitative study involving semi-structured interviews with PHCWs - general practitioners (n=10), practices nurses (n=10), and practice managers (n=10) from settings across Australia. Transcripts were analysed using the Framework Method.

RESULTS

Two environment-level factors were found to influence several organisation and care team level factors. Firstly, the financial structure of primary health care, impacting on practitioner: time, practice culture, screening knowledge and opportunistic conversations. Secondly, the structure of screening programs had flow-on effects for: access to patient screening records, recall and reminder systems, and sense of program ownership.

CONCLUSIONS

Encouraging more effective PHCW engagement in the screening programs requires the consideration and mitigation of overarching financial and structural barriers. Up-to-date and easy-to-use recall and reminder systems, whole-of-practice approaches which optimise the role of each PHCW and the identification of a 'champion' to drive implementation should be considered.

IMPLICATIONS FOR PUBLIC HEALTH

This study offers insights into what elements practice and practitioner targeted initiatives in Australia should incorporate, potentially leading to improved engagement of PHCWs and increased cancer screening participation rates.

Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: an Interrupted Time Series Analysis

BACKGROUND

In 2012, the Ministry of Health in British Columbia, Canada, introduced a $75 incentive payment that could be claimed by hospital physicians each time they produced a written post-discharge care plan for a complex patient at the time of hospital discharge.

OBJECTIVE

To examine whether physician financial payments incentivizing enhanced discharge planning reduce subsequent unplanned hospital readmissions.

DESIGN

Interrupted time series analysis of population-based hospitalization data.

PARTICIPANTS

Individuals with one or more eligible hospitalizations occurring in British Columbia between 2007 and 2017.

MAIN MEASURES

The proportion of index hospital discharges with subsequent unplanned hospital readmission within 30 days, as measured each month of the 11-year study interval. We used interrupted time series analysis to determine if readmission risk changed after introduction of the incentive payment policy.

KEY RESULTS

A total of 40,588 unplanned hospital readmissions occurred among 409,289 eligible index hospitalizations (crude 30-day readmission risk, 9.92%). Policy introduction was not associated with a significant step change (0.393%; 95CI, - 0.190 to 0.975%; p = 0.182) or change-in-trend (p = 0.317) in monthly readmission risk. Policy introduction was associated with significantly fewer prescription fills for potentially inappropriate medications among older patients, but no improvement in prescription fills for beta-blockers after cardiovascular hospitalization and no change in 30-day mortality. Incentive payment uptake was incomplete, rising from 6.4 to 23.5% of eligible hospitalizations between the first and last year of the post-policy interval.

CONCLUSION

The introduction of a physician incentive payment was not associated with meaningful changes in hospital readmission rate, perhaps in part because of incomplete uptake by physicians. Policymakers should consider these results when designing similar interventions elsewhere.

TRIAL REGISTRATION

ClinicalTrials.gov ID, NCT03256734.

Changes in mammography screening in Ontario and Alberta following national guideline dissemination: an interrupted time series analysis

Background: In November 2011, the Canadian Task Force on Preventive Health Care released guidelines for screening women at average breast cancer risk. Weak recommendations (framed using GRADE methodology) were made for screening women aged 50 to 74 years every two to three years, and for not screening women aged 40 to 49 years. Methods: We conducted an interrupted time series analysis using administrative data to examine bilateral mammography use before and after a national guideline dissemination strategy targeting primary care physicians. Women aged 40 to 74 years living in Ontario or Alberta from 30 th November 2008 to 30 th November 2014 were included. Strata included age, region of residence, neighbourhood income quintile, immigration status, and education level. Results: In both provinces, mammography use rates were lower in the post-intervention period (527 vs. 556 and 428 vs. 465/1000 participant-months - the monthly screening rate/1000 - in Ontario and Alberta, respectively). In Ontario, mammography trends decreased following guideline release to align with recommendations for women aged 40 to 74 (decrease of 2.21/1000 women, SE 0.26/1000, p<0.0001). In Alberta, mammography trends decreased for women aged 40 to 49 years (3/1000 women, SE 0.32, p<0.001) and 50 to 69 (2.9/1000 women, SE 0.79, p<0.001), but did not change for women aged 70 to 74 (0.7/1000 women, SE 1.23, p=0.553). In both provinces, trends in mammography use rates were sustained for up to three years after guideline release. Conclusions: The guideline dissemination strategy appeared to increase uptake of guideline-concordant screening practice in women aged 40 to 49 years in Ontario and Alberta and for women aged 50 to 74 years in Ontario. Further work is required to understand these findings and whether shared decision making about mammography between women and providers increased among women considering mammography.

Changes in mammography screening in Ontario and Alberta following national guideline dissemination: an interrupted time series analysis

Background: In November 2011, the Canadian Task Force on Preventive Health Care released guidelines for screening women at average breast cancer risk. Weak recommendations (framed using GRADE methodology) were made for screening women aged 50 to 74 years every two to three years, and for not screening women aged 40 to 49 years. Methods: We conducted an interrupted time series analysis using administrative data to examine bilateral mammography use before and after a release of a national breast screening guideline. Women aged 40 to 74 years living in Ontario or Alberta from 30th November 2008 to 30th November 2014 were included. Strata included age, region of residence, neighbourhood income quintile, immigration status, and education level. Results: In both provinces, mammography use rates were lower in the post-intervention period (527 vs. 556 and 428 vs. 465/1000 women in Ontario and Alberta, respectively). In Ontario, mammography trends decreased following guideline release to align with recommendations for women aged 40 to 74 (decrease of 2.21/1000 women, SE 0.26/1000, p<0.0001). In Alberta, mammography trends decreased for women aged 40 to 49 years (3/1000 women, SE 0.32, p<0.001) and 50 to 69 (2.9/1000 women, SE 0.79, p<0.001), but did not change for women aged 70 to 74 (0.7/1000 women, SE 1.23, p=0.553). In both provinces, trends in mammography use rates were sustained for up to three years after guideline release. Conclusions: We observed a decrease in screening for women aged 40-49. Additional research to explore whether shared decision making was used to optimize guideline-concordant screening for women aged 50-74 is needed.

Influence of chronic comorbidities on periodic colorectal cancer screening participation: A population-based cohort study

Guidelines recommend regular screening for colorectal cancer (CRC). We examined the effects of chronic comorbidities on periodic CRC testing. Using linked healthcare databases from Ontario, Canada, we assembled a population-based cohort of 50-74-year olds overdue for guideline-recommended CRC screening between April 1, 2004 and March 31, 2016. We implemented multivariable recurrent events models to determine the association between comorbidities and the rate of becoming up-to-date with periodic CRC tests. The cohort included 4,642,422 individuals. CRC testing rates were significantly lower in persons with renal disease on dialysis (hazard ratio, HR 0.66, 95% confidence interval, CI 0.63 to 0.68), heart failure (HR 0.75, CI 0.75 to 0.76), respiratory disease (HR 0.84, CI 0.83 to 0.84), cardiovascular disease (HR 0.85, CI 0.84 to 0.85), diabetes (HR 0.86, 95% CI 0.86 to 0.87) and mental illness (HR 0.88, CI 0.87 to 0.88). There was an inverse association between the number of medical conditions and the rate of CRC testing (5 vs. none: HR 0.30, CI 0.25 to 0.36; 4 vs. none: HR 0.48, CI 0.47 to 0.50; 3 vs. none: HR 0.59, CI 0.58 to 0.60; 2 vs. none: HR 0.72, CI 0.71 to 0.72; 1 vs. none: HR 0.85, CI 0.84 to 0.85). Having both medical and mental comorbidities was associated with lower testing rates than either type of comorbidity alone (HR 0.72, CI 0.71 to 0.72). In summary, chronic comorbidities present a barrier to periodic guideline-recommended CRC testing. Exploration of cancer prevention gaps in these populations is warranted.

How to make universal, voluntary testing for COVID-19 work? A behavioural economics perspective

Testing is widely seen as one core element of a successful strategy to curtail the COVID-19 pandemic and many countries have increased their efforts to provide testing at large scale. As most democratic governments refrain from enacting mandatory testing, a key emerging challenge is to increase voluntary participation. Using behavioural economics insights complemented with data from a novel survey in the US and a survey experiment in Luxembourg, we examine behavioural factors associated with the individual willingness to get tested (WTT). In our analysis, individual characteristics that correlate positively with WTT include age, altruism, conformism, the tendency to abide by government-imposed rules, concern about contracting COVID-19, and patience. Risk aversion, unemployment, and conservative political orientation correlate negatively with WTT. Building on and expanding these insights may prove fruitful for policy to effectively raise people's propensity to get tested.

Is the evidence on the effectiveness of pay for performance schemes in healthcare changing? Evidence from a meta-regression analysis

BACKGROUND

This study investigated if the evidence on the success of the Pay for Performance (P4P) schemes in healthcare is changing as the schemes continue to evolve by updating a previous systematic review.

METHODS

A meta-regression analysis using 116 studies evaluating P4P schemes published between January 2010 to February 2018. The effects of the research design, incentive schemes, use of incentives, and the size of the payment to revenue ratio on the proportion of statically significant effects in each study were examined.

RESULTS

There was evidence of an increase in the range of countries adopting P4P schemes and weak evidence that the proportion of studies with statistically significant effects have increased. Factors hypothesized to influence the success of schemes have not changed. Studies evaluating P4P schemes which made payments for improvement over time, were associated with a lower proportion of statistically significant effects. There was weak evidence of a positive association between the incentives' size and the proportion of statistically significant effects.

CONCLUSION

The evidence on the effectiveness of P4P schemes is evolving slowly, with little evidence that lessons are being learned concerning the design and evaluation of P4P schemes.

Physician remuneration schemes, psychiatric hospitalizations and follow-up care: Evidence from blended fee-for-service and capitation models

Psychiatric hospitalizations could be reduced if mental illnesses were detected and treated earlier in the primary care setting, leading to the World Health Organization recommendation that mental health services be integrated into primary care. The mental health services provided in primary care settings may vary based on how physicians are incentivized. Little is known about the link between physician remuneration and psychiatric hospitalizations. We contribute to this literature by studying the relationship between physician remuneration and psychiatric hospitalizations in Canada's most populous province, Ontario. Specifically, we study family physicians (FPs) who switched from blended fee-for-service (FFS) to blended capitation remuneration model, relative to those who remained in the blended FFS model, on psychiatric hospitalizations. Outcomes included psychiatric hospitalizations by enrolled patients and the proportion of hospitalized patients who had a follow-up visit with the FP within 14 days of discharge. We used longitudinal health administrative data from a cohort of practicing physicians from 2006 through 2016. Because physicians practicing in these two models are likely to be different, we employed inverse probability weighting based on estimated propensity scores to ensure that switchers and non-switchers were comparable at the baseline. Using inverse probability weighted fixed-effects regressions controlling for relevant confounders, we found that switching from blended FFS to blended capitation was associated with a 6.2% decrease in the number of psychiatric hospitalizations and a 4.7% decrease in the number of patients with a psychiatric hospitalization. No significant effect of remuneration on follow-up visits within 14 days of discharge was observed. Our results suggest that the blended capitation model is associated with fewer psychiatric hospitalizations relative to blended FFS.

Implementation of a Physician Incentive Program for 18-Month Developmental Screening in Ontario, Canada

OBJECTIVES

To evaluate factors associated with uptake of a financial incentive for developmental screening at an enhanced 18-month well-child visit (EWCV) in Ontario, Canada.

STUDY DESIGN

Population-based cohort study using linked administrative data of children (17-24 months of age) eligible for EWCV between 2009 and 2017. Logistic regression modeled associations of EWCV receipt by provider and patient characteristics.

RESULTS

Of 910 976 eligible children, 54.2% received EWCV (annually, 39.2%-61.2%). The odds of assessment were lower for socially vulnerable children, namely, those from the lowest vs highest neighborhood income quintile (aOR, 0.84; 95% CI, 0.83-0.85), those born to refugee vs nonimmigrant mothers (aOR, 0.90; 95% CI, 0.88-0.93), and to teenaged mothers (aOR, 0.70; 95% CI, 0.69-0.71)). Children were more likely to have had developmental screening if cared for by a pediatrician vs family physician (aOR, 1.28; 95% CI, 1.13-1.44), recently trained physician (aOR, 1.38; 95% CI, 1.29-1.48 for ≤5 years in practice vs ≥21 years) and less likely if the physician was male (aOR, 0.64; 95% CI, 0.61-0.66). For physicians eligible for a pay-for-performance immunization bonus, there was a positive association with screening.

CONCLUSIONS

In the context of a universal healthcare system and a specific financial incentive, uptake of the developmental assessment increased over time but remains moderate. The implementation of similar interventions or incentives needs to account for physician factors and focus on socially vulnerable children to be effective.

The Impact of Team-Based Primary Care on Guideline-Recommended Disease Screening

INTRODUCTION

Family Medicine Groups, implemented in Quebec in 2002, are interprofessional primary care teams designed to improve timely access to high-quality primary care. This study investigates whether Family Medicine Groups increased rates of guideline-recommended screenings for 3 chronic diseases: colorectal cancer (colonoscopy/sigmoidoscopy), breast cancer (mammography), and osteoporosis (bone mineral density testing).

METHODS

Using population-based administrative health data from the provincial insurer (2000-2010), the authors examined elderly and chronically ill patients who registered with a general practitioner in the first 15 months of the Family Medicine Group policy. Propensity score weighting and a difference-in-differences model estimated differential change in biennial screening rates among Family Medicine Group and non-Family Medicine Group patients over 5 years of follow-up (analysis, 2016-2018).

RESULTS

Rates of mammography, colonoscopy/sigmoidoscopy, and bone mineral density testing increased after patient registration with a general practitioner, similarly for both Family Medicine Group and non-Family Medicine Group patients. Colonoscopy/sigmoidoscopy rates increased by 9.7% and 10.4% for Family Medicine Group and non-Family Medicine Group patients, mammography rates by 5.3% and 3.4%, and bone mineral density testing by 4.2% and 7.1%. Difference-in-differences estimates showed no detectable effect of Family Medicine Groups on disease screening rates: -0.06 percentage points (95% CI= -0.32, 0.20) for colonoscopy/sigmoidoscopy, 1.01 percentage points (95% CI= -0.25, 2.27) for mammography, and -0.32 (95% CI= -0.71, -0.07) for bone mineral density testing.

CONCLUSIONS

This study found no evidence that Family Medicine Groups affected screening rates for these 3 chronic diseases. Limitations in the implementation of the Family Medicine Group policy in its early years may have contributed to this lack of impact. Interprofessional primary care teams may need to include elements other than organizational changes to increase disease prevention efforts.

Understanding those overdue for cancer screening by five years or more: A retrospective cohort study in Ontario, Canada

Populations that are more than just slightly overdue for breast, cervical and colorectal screening should likely be targeted for policy and practice interventions. We used provincial-level administrative data to describe the Ontario population who are screen-eligible for breast, cervical and colorectal cancers but overdue by at least five years. For each cancer screening type, we created three cohorts and a binary outcome: screened at least once in the previous five years or not, using March 31, 2017 as our index date. We conducted simple descriptive analyses as well as multivariable logistic regression, where age category, immigrant status, neighbourhood income quintile, region, urban/suburban/rural status, primary care model type, and healthcare utilization were included in the models. More than 20% of Ontarians eligible for each of breast, cervical and colorectal cancer screening respectively had no history of screening in the previous five years. In multivariable analyses, people were significantly more likely to have no recent screening history if they lived in lower-income neighbourhoods (e.g. adjusted odds ratio [95% confidence interval]: 0.59 [0.58-0.59] for cervical screening), were recent immigrants, did not have a primary care provider, had a provider who practiced in a traditional fee-for-service model. Despite the presence of three provincial organized screening programs, we have found that more than one-fifth of Ontarians who are eligible for each of breast, cervical and colorectal screening respectively have not been screened for five years or more. Ensuring that all Ontarians have access to high-quality primary care, may be crucial to increasing screening uptake.

Role of primary care enrolment in advanced cervical cancer diagnosis: a population-based case-control study

INTRODUCTION

The elimination of cervical cancer will only be achievable through primary and secondary prevention. The aim of this study was to determine the effect of primary care enrolment on the prevention of advanced cervical cancer.

METHODS

Using a population-based case-control study, all women (n=5548) above 18 years of age who were diagnosed with cervical cancer between January 2006 and December 2015 in Ontario, Canada were selected for the analysis. The controls were women (n=27 740) above 18 years of age and without a diagnosis of cervical cancer. Five controls were matched to each case by year of birth. Descriptive statistics were used to compare the patients and controls. Multiple imputations and logistic regression were used to estimate the correlation between enrolment with a primary care provider and diagnosis of cervical cancer.

RESULTS

A total of 44% of advanced cervical cancer patients and 56% of controls had a screening test 10 years before the index date. The odds of having had a Pap test in the 3 and 10 years before were higher when patients were enrolled with a primary care provider (OR 3.5 and 5.1, p<0.001). The correlation between screening and advanced cervical cancer (stage II-IV) incidence was modified by primary care enrolment: if the patient was enrolled with a primary care provider and had at least one screen in the previous 10 years, the OR of developing advanced cervical cancer was 0.42 (95% CI 0.40 to 0.43); if the patient was not enrolled the OR was 0.78 (95% CI 0.72 to 0.84).

DISCUSSION

Primary care enrolment is an effect modifier of cervical cancer screening on advanced cervical cancer incidence. Efforts should be made to increase the capacity of primary care providers to offer screening in order to eradicate cervical cancer.

Fecal occult blood test screening uptake among immigrants from Muslim majority countries: A retrospective cohort study in Ontario, Canada

Background

Colorectal cancer (CRC) is the second and third highest cause of cancer deaths among Canadian men and women, respectively. Population‐based screening through fecal occult blood testing (FOBT) has been proven to be effective in reducing CRC morbidity and mortality. Although participation in Ontario's organized CRC screening program has been increasing steadily since 2008, its uptake remains low among recent immigrant populations despite the known benefits of screening. To promote participation in CRC screening, it is imperative to understand both individual and system level barriers and enablers. Although a number of immigrant and nonimmigrant factors have been associated with low participation, there is a dearth of knowledge related to the religious affiliation in CRC screening uptake. Our study is among the first to examine this issue in Ontario, one of the most ethnically diverse Canadian provinces and preferred settlement destinations for immigrants.

Methods

We conducted a population‐based retrospective cohort study using linked health care administrative databases. Our cohort included Ontario residents, age 50‐74 who were eligible for FOBT from 1 April 2013 to 31 March 2015.

Results

We found that immigrants from the Middle East and North Africa and Eastern Europe and Central Asia had the lowest rates of screening. Furthermore, being born in a Muslim‐majority country was associated with lower FOBT screening even after controlling for other confounders including world region and income (ie, overall adjusted relative risk (ARR) of screening 0.92 [95% CI 0.90‐0.93]). Moreover, being enrolled in a primary care model, having a female primary care provider and having an internationally trained physician were associated with increased screening among immigrants from Muslim‐majority countries.

Conclusions

These findings can inform future efforts to improve screening uptake like: enhancing access to primary care providers and enrollment in primary care models, targeted FOBT education for male providers and providers not in a primary care model, development of culturally sensitive and appropriate educational materials, and use of interactive approaches for communication of cancer screening information.

Effect of financial incentives on breast, cervical and colorectal cancer screening delivery rates: Results from a systematic literature review

Preventive care, such as screening, is important for reducing the risk of cancer, a leading cause of death worldwide. Indeed, some type of cancers are detected through screening programs, which in most countries run for colorectal, breast, and cervical cancers. In this context, general practitioners play a key role in increasing the participation rate in cancer screening programs. To improve cancer screening delivery rates, performance incentives have increasingly been implemented in primary care by healthcare payers and organizations in different countries. The effects of these tools are still not clear. We conducted a systematic literature review in order to answer the following research question: What is the evidence in the literature for the effects of financial incentives on the delivery rates of breast, cervical and colorectal cancer screening in general practice? We performed a literature search in Web of Science, PubMed, Cochrane Library and Google Scholar, according to the PRISMA guidelines. 18 studies were selected, classified and discussed according to the health preventive services investigated. Most of studies showed partial or no effects of financial incentives on breast and cervical cancer screening delivery rates. Few positive or partial effects were found regarding colorectal cancer screening. Ongoing monitoring of incentive programs is critical to determining the effectiveness of financial incentives and their effects on the improvement of cancer screening delivery rates.

Primary care providers' views on a future lung cancer screening program

BACKGROUND

The National Lung Screening Trial demonstrated that screening with low-dose computed tomography significantly reduces mortality from lung cancer in high-risk individuals.

OBJECTIVE

To describe the role preferences and information needs of primary care providers (PCPs) in a future organized lung cancer screening program.

METHODS

We purposively sampled PCPs from diverse health regions of Ontario and from different practice models including family health teams and community health centres. We also recruited family physicians with a leadership role in cancer screening. We used focus groups and a nominal group process to identify informational priorities. Two analysts systematically applied a coding scheme to interview transcripts.

RESULTS

Four groups were held with 34 providers and administrative staff [28 (82%) female, 21 (62%) physicians, 7 (20%) other health professionals and 6 (18%) administrative staff]. PCPs and staff were generally positive about a potential lung cancer screening program but had variable views on their involvement. Informational needs included evidence of potential benefits and harms of screening. Most providers preferred that a new program be modelled on positive features of an existing breast cancer screening program. Lung cancer screening was viewed as a new opportunity to counsel patients about smoking cessation.

CONCLUSIONS

The development of a future lung cancer screening program should consider the wide variability in the roles that PCPs preferred. An explicit link to existing smoking cessation programs was seen as essential. As providers had significant information needs, learning materials and opportunities should be developed with them.

Effect of primary health care reforms in the province of Newfoundland and Labrador: Interrupted time-series analysis

OBJECTIVE

To examine the effects of primary health care (PHC) reforms in the Canadian province of Newfoundland and Labrador on ambulatory care-sensitive (ACS) hospitalization rates and mortality.

DESIGN

Interrupted time-series analysis of administrative data.

SETTING

All communities in the province of Newfoundland and Labrador were divided into 3 groups: rural reform (n = 69 143), rural nonreform (n = 228 914), and urban nonreform (n = 197 012). No urban communities introduced PHC reforms.

PARTICIPANTS

All residents of the province who held a valid health card and did not change their address during the 2001-2009 study period were included. Individuals were assigned to 1 of the 3 study groups based on community of residence.

MAIN OUTCOME MEASURES

Hospitalization rates for ACS conditions, hospitalization rates for control conditions, and ACS-related mortality were compared using interrupted time-series models.

RESULTS

Results are reported as rate ratio or odds ratio (OR) (95% CI). In rural reform and rural nonreform communities, there was a decreasing trend in ACS hospitalization rates that preceded reforms (rate ratio of 0.97 [0.94-1.00]) and rate ratio of 0.98 [0.96-1.00], respectively) but no change following reforms. There were no significant changes in the urban group. In all 3 groups, there was a significant increasing trend in ACS-related mortality before reforms (OR of 1.09 [1.02-1.15], OR of 1.10 [1.06-1.13], and OR of 1.09 [1.05-1.14] for rural reform, rural nonreform, and urban communities, respectively), which was reversed after the introduction of reforms (P < .01).

CONCLUSION

Primary health care reforms in Newfoundland and Labrador had no observed effect on ACS hospitalization rates, but a potential effect might have been masked by a decreasing trend that preceded the introduction of reforms. The increase in mortality rates that was reversed after the introduction of reforms cannot be attributed to the reforms because it occurred in all studied populations including those that did not introduce reforms.

Integrating clinical medicine and population health: where to from here?

Efforts to contain healthcare costs have led a renewed clinician interest in addressing population-level outcomes, with some proposing that the integration of population health into clinical practice represents a novel concept entitled "clinical population medicine" (CPM). This commentary offers an examination of the function and utility of CPM. In reviewing relevant literature, we note several inconsistencies in CPM's purported mandate, which ranges from simply incorporating the social determinants of health into clinical practice to broad involvement in community health planning. The latter of these seems to overlap, and potentially conflict, with the work of public health practitioners, and cited examples of activities used to define "CPM" seem to apply a label to established clinician activities around the determinants of health that would be captured more simply as research, evaluation, or advocacy undertaken by clinicians in other areas of practice. Our analysis suggests that CPM may have value in encouraging clinicians to incorporate community determinants and contextual considerations into their practices, but must take care to remain complementary and distinct from public health practice.

Impact of timing of methadone initiation on perinatal outcomes following delivery among pregnant women on methadone maintenance therapy in Ontario

BACKGROUND AND AIMS

Methadone maintenance therapy (MMT) is associated with improved outcomes for children exposed to maternal opioid dependence in utero. We examined Ontario's population of pregnant women on MMT and determined the impact of timing of MMT initiation on perinatal outcomes.

DESIGN

Cohort study.

SETTING

Ontario, Canada.

PARTICIPANTS

Women eligible for public drug benefits and on MMT during pregnancy between 2005 and 2015.

MEASUREMENTS

We stratified women based on their timing of MMT initiation: (1) stabilized prior to conception, (2) newly initiated prior to conception, (3) initiation in trimester 1, (4) initiation in trimester 2 or (5) initiation in trimester 3. The primary outcomes in the multivariable logistic regression analysis were key perinatal health indicators: small for gestational age, preterm birth, congenital anomalies, severe maternal morbidity, caesarean section and induced labor. Secondary outcomes were specific to maternal opioid dependence: neonatal abstinence syndrome (NAS), admission to a neonatal intensive care unit (NICU), NAS treatment, removal from mother's custody at hospital discharge and neonatal death.

FINDINGS

Among 1842 women on MMT during pregnancy, 87.6% (n = 1614) initiated MMT before conception. Almost a quarter of their infants (22.2%; n = 408) were born small for gestational age, 17.5% (n = 323) were preterm and 5.9% (n = 109) were born with a congenital anomaly. The odds of primary outcomes occurring did not differ based on timing of methadone initiation; however, infants of mothers who initiated methadone during pregnancy had up to a fourfold increase in the odds of social services removal at the hospital [adjusted odds ratio (aOR) range = 3.70-4.19] compared with those whose mothers were stabilized on MMT prior to conception.

CONCLUSIONS

Later initiation of methadone maintenance therapy among pregnant women in Ontario, Canada has not been found to be clearly related to most key perinatal adverse health outcomes.

Cancer screening rates among transgender adults: Cross-sectional analysis of primary care data

OBJECTIVE

To compare rates of cervical, breast, and colorectal cancer screening between patients who are transgender and those who are cisgender (ie, nontransgender).

DESIGN

Cross-sectional study.

SETTING

A multisite academic family health team in Toronto, Ont, serving more than 45 000 enrolled patients.

PARTICIPANTS

All patients enrolled in the family health team who were eligible for cervical, breast, or colorectal cancer screening. Patients were identified as transgender using an automated search of the practice electronic medical record followed by manual audit.

MAIN OUTCOME MEASURES

Screening rates for cervical, breast, and colorectal cancer calculated using data from the electronic medical record and provincial cancer screening registry. Screening rates among the transgender and cisgender populations were compared using ² tests, and logistic regression modeling was used to understand differences in screening after adjustment for age, neighbourhood income quintile, and number of primary care visits.

RESULTS

A total of 120 transgender patients were identified as eligible for cancer screening. More than 85% of transgender patients eligible for breast cancer screening were assigned male at birth. Transgender patients were less likely than cisgender patients (n = 20 514) were to be screened for cervical (56% vs 72%, P = .001; adjusted odds ratio [OR] of 0.39; 95% CI 0.25 to 0.62), breast (33% vs 65%, P < .001; adjusted OR = 0.27; 95% CI 0.12 to 0.59), and colorectal cancer (55% vs 70%, P = .046; adjusted OR = 0.50; 95% CI 0.26 to 0.99).

CONCLUSION

In this setting, transgender patients were less likely to receive recommended cancer screening compared with the cisgender population. Future research and quality improvement activities should aim to understand and address potential patient, provider, and system factors.

Uncertainty about the effort-performance relationship in threshold-based payment schemes

Incentive schemes often feature a threshold beyond which providers receive no additional payment for performance. We investigate whether providers' uncertainty about the relationship between effort and measured performance leads to financially unrewarded performance in such schemes. Using data from the British Quality and Outcomes Framework, we proxy general practitioners' uncertainty about the effort-performance relationship by their experience with the scheme and their span of control. We find evidence that providers respond to uncertainty by exerting financially unrewarded performance, suggesting that uncertainty may be a mechanism by which payers can extract unrewarded performance.

Designing Emails Aimed at Increasing Family Physicians' Use of a Web-Based Audit and Feedback Tool to Improve Cancer Screening Rates: Cocreation Process

BACKGROUND

Providing clinical performance data to health professionals, a process known as audit and feedback, can play an important role in health system improvement. However, audit and feedback tools can only be effective if the targeted health professionals access and actively review their data. Email is used by Cancer Care Ontario, a provincial cancer agency, to promote access to a Web-based audit and feedback tool called the Screening Activity Report (SAR); however, current emails that lack behavior change content have been ineffective at encouraging log-in to the SAR.

OBJECTIVE

The objective of our study was to describe the process and experience of developing email content that incorporates user input and behavior change techniques (BCTs) to promote the use of the SAR among Ontario primary care providers.

METHODS

Our interdisciplinary research team first identified BCTs shown to be effective in other settings that could be adapted to promote use of the SAR. We then developed draft BCT-informed email content. Next, we conducted cocreation workshops with physicians who had logged in to the SAR more than once over the past year. Participants provided reactions to researcher-developed BCT-informed content and helped to develop an email that they believed would prompt their colleagues to use the SAR. Content from cocreation workshops was brought to focus groups with physicians who had not used the SAR in the past year. We analyzed notes from the cocreation workshops and focus groups to inform decisions about content. Finally, 8 emails were created to test BCT-informed content in a 2×2×2 factorial randomized experiment.

RESULTS

We identified 3 key tensions during the development of the email that required us to balance user input with scientific evidence, organizational policies, and our scientific objectives, which are as follows: conflict between user preference and scientific evidence, privacy constraints around personalizing unencrypted emails with performance data, and using cocreation methods in a study with the objective of developing an email that featured BCT-informed content.

CONCLUSIONS

Teams tasked with developing content to promote health professional engagement with audit and feedback or other quality improvement tools might consider cocreation processes for developing communications that are informed by both users and BCTs. Teams should be cautious about making decisions solely based on user reactions because what users seem to prefer is not always the same as what works. Furthermore, implementing user recommendations may not always be feasible. Teams may face challenges when using cocreation methods to develop a product with the simultaneous goal of having clearly defined variables to test in later studies. The expected role of users, evidence, and the implementation context all warrant consideration to determine whether and how cocreation methods could help to achieve design and scientific objectives.

Cancer screening inequities in a time of primary care reform: a population-based longitudinal study in Ontario, Canada

BACKGROUND

Primary care has been reformed in recent years in Ontario, Canada, with a move away from traditional fee-for-service to enhanced fee-for-service and capitation-based models. It is unclear how new models have affected disparities in cancer screening. We evaluated whether Ontario's enhanced fee-for-service model was associated with a change in the gaps in cancer screening for people living with low income and people who are foreign-born.

METHODS

We conducted a population-based longitudinal analysis from 2002 to 2013 of Ontario family physicians who transitioned from traditional fee-for-service to enhanced fee-for-service. The binary outcomes of interest were adherence to cervical, breast and colorectal cancer screening recommendations. Outcomes were analyzed using mixed-effects logistic regression. Analyses produced annual odds ratios comparing the odds of being up-to-date for screening among patients in enhanced fee-for-service versus patients in traditional fee-for-service for each social stratum separately. We calculated the ratios of stratum-specific odds ratios to assess whether the transition from traditional to enhanced fee-for-service was associated with a change in screening gaps between immigrants and long-term residents, and between people in the lowest and highest neighbourhood income quintiles.

RESULTS

Throughout the study period, cancer screening was consistently lower among immigrants and among people in the lowest income quintile. Transition to enhanced fee-for-service was generally associated with increased screening uptake for all, however for most years, ratios of ratios were significantly less than 1 for all three cancer screening types, indicating that there was a widening of the screening gap between immigrants and long-term residents and between people living in the lowest vs. highest income quintile associated with transitions.

CONCLUSION

The transition to enhanced fee-for-service in Ontario was generally associated with a widening of screening inequities for foreign-born and low-income patients.

Cervical cancer screening uptake among HIV-positive women in Ontario, Canada: A population-based retrospective cohort study

Cervical cancer caused by oncogenic types of the human papillomavirus (HPV) is of concern among HIV-positive women due to impairment of immune responses required to control HPV infection. Our objectives were to describe patterns of cervical cancer screening using Pap cytology testing among HIV-positive women in Ontario, Canada from 2008 to 2013 and to identify factors associated with adequate screening. We conducted a retrospective, population-based cohort study among screen-eligible HIV-positive women using provincial administrative health data. We estimated annual proportions tested and reported these with 95% confidence intervals (CI). Next, using person-years as the unit of analysis, we identified factors associated with annual Pap testing using log-binomial regression. A total of 2271 women were followed over 10,697 person-years. In 2008, 34.0% (95%CI 31.1-37.0%) had a Pap test. By 2013, the proportion of HIV-positive women tested was 25.9% (95%CI 23.6-28.2%). Women who were most likely to undergo testing were younger, were immigrants from countries with generalized HIV epidemics, lived in the highest income neighbourhoods, had a female primary care physician, had two or more encounters per year with an infectious disease or internal medicine specialist, and had greater comorbidity. Nearly three in four HIV-positive women were under-screened despite all having universal insurance for medically-necessary services. Annual Pap testing decreased following the 2011-2013 release of new guidelines for a lengthened screen interval for average risk women and a billing disincentive. Clinic-based intervention such as physician alerts or reminders may be needed to improve screening coverage among HIV-positive women.

Payment incentives for community-based psychiatric care in Ontario, Canada

BACKGROUND

In September 2011, the government of Ontario implemented payment incentives to encourage the delivery of community-based psychiatric care to patients after discharge from a psychiatric hospital admission and to those with a recent suicide attempt. We evaluated whether these incentives affected supply of psychiatric services and access to care.

METHODS

We used administrative data to capture monthly observations for all psychiatrists who practised in Ontario between September 2009 and August 2014. We conducted interrupted time-series analyses of psychiatrist-level and patient-level data to evaluate whether the incentives affected the quantity of eligible outpatient services delivered and the likelihood of receiving follow-up care.

RESULTS

Among 1921 psychiatrists evaluated, implementation of the incentive payments was not associated with increased provision of follow-up visits after discharge from a psychiatric hospital admission (mean change in visits per month per psychiatrist 0.0099, 95% confidence interval [CI] -0.0989 to 0.1206; change in trend 0.0032, 95% CI -0.0035 to 0.0095) or after a suicide attempt (mean change -0.0910, 95% CI -0.1885 to 0.0026; change in trend 0.0102, 95% CI 0.0045 to 0.0159). There was also no change in the probability that patients received follow-up care after discharge (change in level -0.0079, 95% CI -0.0223 to 0.0061; change in trend 0.0007, 95% CI -0.0003 to 0.0016) or after a suicide attempt (change in level 0.0074, 95% CI -0.0094 to 0.0366; change in trend 0.0006, 95% CI -0.0007 to 0.0022).

INTERPRETATION

Our results suggest that implementation of the incentives did not increase access to follow-up care for patients after discharge from a psychiatric hospital admission or after a suicide attempt, and the incentives had no effect on supply of psychiatric services. Further research to guide design and implementation of more effective incentives is warranted.

Breast cancer screening utilization among women from Muslim majority countries in Ontario, Canada

Breast cancer screening disparities continue to prevail with immigrant women being at the forefront of the under screened population. There is a paucity of knowledge about the role of religious affiliation or cultural orientation on immigrant women's cancer screening uptake. This study examined differences in uptake of breast cancer screening among women from Muslim and non- Muslim majority countries in Ontario, Canada. A cohort of 1,851,834 screening-eligible women living in Ontario during April 1, 2013 to March 31, 2015 was created using linked health and social administrative databases. The study found that being born in a Muslim majority country was associated with lower breast cancer screening uptake after adjusting for region of origin, neighbourhood income, and primary care-related factors. However, screening uptake in Muslim majority countries varied by world region with the greatest differences found in Sub-Saharan Africa and South Asia. Screening uptake was lower for women who had no primary care provider, were in a traditional fee-for service model of primary care, had a male physician, had an internationally trained physician, resided in a low income neighbourhood, and entered Canada under the family class of immigration. Religion may play a role in screening uptake, however, the variation in rates by regions of origin, immigration class, and access to primary care providers alludes to confluence of socio-demographic, cultural beliefs and practices, immigration trajectories and system level factors. Facilitating access for immigrant women to regular primary care providers, particularly female providers and enrollment in primary care models could enhance screening uptake.

Effect of incentive payments on chronic disease management and health services use in British Columbia, Canada: Interrupted time series analysis

We studied the effects of incentive payments to primary care physicians for the care of patients with diabetes, hypertension, and Chronic Obstructive Pulmonary Disease (COPD) in British Columbia, Canada. We used linked administrative health data to examine monthly primary care visits, continuity of care, laboratory testing, pharmaceutical dispensing, hospitalizations, and total h ealth care spending. We examined periods two years before and two years after each incentive was introduced, and used segmented regression to assess whether there were changes in level or trend of outcome measures across all eligible patients following incentive introduction, relative to pre-intervention periods. We observed no increases in primary care visits or continuity of care after incentives were introduced. Rates of ACR testing and antihypertensive dispensing increased among patients with hypertension, but none of the other modest increases in laboratory testing or prescriptions dispensed reached statistical significance. Rates of hospitalizations for stroke and heart failure among patients with hypertension fell relative to pre-intervention patterns, while hospitalizations for COPD increased. Total hospitalizations and hospitalizations via the emergency department did not change. Health care spending increased for patients with hypertension. This large-scale incentive scheme for primary care physicians showed some positive effects for patients with hypertension, but we observe no similar changes in patient management, reductions in hospitalizations, or changes in spending for patients with diabetes and COPD.

BETTER HEALTH: Durham -- protocol for a cluster randomized trial of BETTER in community and public health settings

BACKGROUND

The Building on Existing Tools to Improve Chronic Disease Prevention and Screening (BETTER) cluster randomized trial in primary care settings demonstrated a 30% improvement in adherence to evidence-based Chronic Disease Prevention and Screening (CDPS) activities. CDPS activities included healthy activities, lifestyle modifications, and screening tests. We present a protocol for the adaptation of BETTER to a public health setting, and testing the adaptation in a cluster randomized trial (BETTER HEALTH: Durham) among low income neighbourhoods in Durham Region, Ontario (Canada).

METHODS

The BETTER intervention consists of a personalized prevention visit between a participant and a prevention practitioner, which is focused on the participant's eligible CDPS activities, and uses Brief Action Planning, to empower the participant to set achievable short-term goals.

BETTER HEALTH

Durham aims to establish that the BETTER intervention can be adapted and proven effective among 40-64 year old residents of low income areas when provided in the community by public health nurses trained as prevention practitioners. Focus groups and key informant interviews among stakeholders and eligible residents of low income areas will inform the adaptation, along with feedback from the trial's Community Advisory Committee. We have created a sampling frame of 16 clusters composed of census dissemination areas in the lowest urban quintile of median household income, and will sample 10 clusters to be randomly allocated to immediate intervention or six month wait list control. Accounting for the clustered design effect, the trial will have 80% power to detect an absolute 30% difference in the primary outcome, a composite score of completed eligible CDPS actions six months after enrollment. The prevention practitioner will attempt to link participants without a primary care provider (PCP) to a local PCP. The implementation of BETTER HEALTH: Durham will be evaluated by focus groups and key informant interviews.

DISCUSSION

The effectiveness of BETTER HEALTH: Durham will be tested for delivery in low income neighbourhoods by a public health department.

TRIAL REGISTRATION

NCT03052959, registered February 10, 2017.

Temporal trends in the association between socioeconomic status and cancer survival in Ontario: a population-based retrospective study

BACKGROUND

Cancer survival is known to be associated with socioeconomic status. The income gap between the richer and poorer segments of the population has widened over the last 20 years in Canada. The purpose of this study was to investigate temporal trends in disparities in cancer-specific survival related to socioeconomic status in Ontario.

METHODS

There were 920 334 cancer cases between 1993 and 2009 in the Ontario Cancer Registry. We linked median household income from the Canadian census to the registry. We calculated 5-year cancer-specific survival rates for all cancers combined and for specific cancer sites by socioeconomic status quintile and year of diagnosis, and modelled time to death using Cox regression.

RESULTS

Between 1993 and 2009, for all cancers combined, the hazard of death decreased by 3.1% (hazard ratio [HR] 0.969 [95% confidence interval (CI) 0.967-0.971]) per year in the richest quintile and by 1.2% (HR 0.988 [95% CI 0.987-0.990]) per year in the poorest quintile. The corresponding values for breast cancer were 4.3% (HR 0.957 [95% CI 0.951-0.964]) and 2.0% (HR 0.980 [95% CI 0.975-0.986]); for lung cancer, 1.4% (HR 0.986 [95% CI 0.982-0.990]) and 0.3% (HR 0.997 [95% CI 0.995-1.000]); for colorectal cancer, 3.7% (HR 0.963 [95% CI 0.958-0.968]) and 1.8% (HR 0.982 [95% CI 0.978-0.985]); and for head and neck cancer, 3.1% (HR 0.969 [95% CI 0.958-0.979]) and 1.0% (HR 0.990 [95% CI 0.983-0.996]).

INTERPRETATION

Between 1993 and 2009, cancer-specific survival in Ontario improved more among patients from affluent communities than among those from poorer communities. This phenomenon cannot be explained by increased disparity in income.

Effect of Physician Notification Regarding Nonadherence to Colorectal Cancer Screening on Patient Participation in Fecal Immunochemical Test Cancer Screening: A Randomized Clinical Trial

IMPORTANCE

Increasing participation in fecal screening tests is a major challenge in countries that have implemented colorectal cancer (CRC) screening programs.

OBJECTIVE

To determine whether providing general practitioners (GPs) a list of patients who are nonadherent to CRC screening enhances patient participation in fecal immunochemical testing (FIT).

DESIGN, SETTING, AND PARTICIPANTS

A 3-group, cluster-randomized study was conducted from July 14, 2015, to July 14, 2016, on the west coast of France, with GPs in 801 practices participating and involving adult patients (50-74 years) who were at average risk of CRC and not up-to-date with CRC screening. The final follow-up date was July 14, 2016.

INTERVENTIONS

General practitioners were randomly assigned to 1 of 3 groups: 496 received a list of patients who had not undergone CRC screening (patient-specific reminders group, 10 476 patients), 495 received a letter describing region-specific CRC screening adherence rates (generic reminders group, 10 606 patients), and 455 did not receive any reminders (usual care group, 10 147 patients).

MAIN OUTCOMES AND MEASURES

The primary end point was patient participation in CRC screening 1 year after the intervention.

RESULTS

Among 1482 randomized GPs (mean age, 53.4 years; 576 women [38.9%]), 1446 participated; of the 33 044 patients of these GPs (mean age, 59.7 years; 17 949 women [54.3%]), follow-up at 1 year was available for 31 229 (94.5%). At 1 year, 24.8% (95% CI, 23.4%-26.2%) of patients in the specific reminders group, 21.7% (95% CI, 20.5%-22.8%) in the generic reminders group, and 20.6% (95% CI, 19.3%-21.8%) in the usual care group participated in the FIT screening. The between-group differences were 3.1% (95% CI, 1.3%-5.0%) for the patient-specific reminders group vs the generic reminders group, 4.2% (95% CI, 2.3%-6.2%) for the patient-specific reminders group vs the usual care group, and 1.1% (95% CI, -0.6% to 2.8%) for generic reminders group vs the usual care group.

CONCLUSIONS AND RELEVANCE

Providing French GPs caring for adults at average risk of CRC with a list of their patients who were not up-to-date with their CRC screening resulted in a small but significant increase in patient participation in FIT screening at 1 year compared with patients who received usual care. Providing GPs with generic reminders about regional rates of CRC screening did not increase screening rates compared with usual care.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02515344.

Patterns of physician prescribing for opioid maintenance treatment in Ontario, Canada in 2014

BACKGROUND

Despite concerns surrounding high patient volumes in methadone clinics, little is known about the practice patterns of opioid maintenance therapy (OMT) providers in Ontario. We examined the distribution of these services and how physician characteristics differ based on prescribing volume.

METHODS

We conducted a cross-sectional study among prescribers of methadone or buprenorphine to Ontario public drug beneficiaries in 2014 by stratifying physicians into low- (lower 50%), moderate- (51-89%) and high-volume (top 10%) prescribers. We summarized the distribution of OMT prescription days dispensed and urine drug screens (UDS) ordered using Lorenz curves and examined physician characteristics using descriptive statistics.

RESULTS

We identified 893 OMT prescribers in 2014. Physicians were mostly male (67.5%; N=603), and middle-aged (median was 50). High-volume methadone providers (N=57) prescribed approximately 56% (N=4,115,322) of the total days of methadone (Gini coefficient=0.76, 95% CI 0.74-0.79) while high-volume buprenorphine providers (N=64) prescribed 61% (N=589,463) of the total days of buprenorphine (Gini coefficient=0.78, 95% CI 0.75-0.80). On average, each high-volume methadone prescriber treated 435 OMT patients and billed 43 UDS per patient, while each high-volume buprenorphine prescriber treated 64 OMT patients and billed 22 UDS per patient. Daily OMT patient volume was on average 74 for high-volume methadone prescribers and 6 for high-volume buprenorphine prescribers.

CONCLUSIONS

OMT services are highly concentrated among a small portion of OMT providers who carry high daily patient volumes. Future research should examine the quality of primary care received by their patients to better elucidate the possible consequences of this highly unequal distribution of services.

Impact assessment of a pay-for-performance program on breast cancer screening in France using micro data

BACKGROUND

A voluntary-based pay-for-performance (P4P) program (the CAPI) aimed at general practitioners (GPs) was implemented in France in 2009. The program targeted prevention practices, including breast cancer screening, by offering a maximal amount of €245 for achieving a target screening rate among eligible women enrolled with the GP.

OBJECTIVE

Our objective was to evaluate the impact of the French P4P program (CAPI) on the early detection of breast cancer among women between 50 and 74 years old.

METHODS

Based on an administrative database of 50,752 women aged 50-74 years followed between 2007 and 2011, we estimated a difference-in-difference model of breast cancer screening uptake as a function of visit to a CAPI signatory referral GP, while controlling for both supply-side and demand-side determinants (e.g., sociodemographics, health and healthcare use).

RESULTS

Breast cancer screening rates have not changed significantly since the P4P program implementation. Overall, visiting a CAPI signatory referral GP at least once in the pre-CAPI period increased the probability of undergoing breast cancer screening by 1.38 % [95 % CI (0.41-2.35 %)], but the effect was not significantly different following the implementation of the contract.

CONCLUSION

The French P4P program had a nonsignificant impact on breast cancer screening uptake. This result may reflect the fact that the low-powered incentives implemented in France through the CAPI might not provide sufficient leverage to generate better practices, thus inviting regulators to seek additional tools beyond P4P in the field of prevention and screening.

Measuring and improving cervical, breast, and colorectal cancer screening rates in a multi-site urban practice in Toronto, Canada

Our Family Health Team is located in Toronto, Canada and provides care to over 35 000 patients. Like many practices in Canada, we took an opportunistic approach to cervical, breast, and colorectal cancer screening. We wanted to shift to a proactive, population-based approach but were unable to systematically identify patients overdue for screening or calculate baseline screening rates. Our initiative had two goals: (1) to develop a method for systematically identifying patients eligible for screening and whether they were overdue and (2) to increase screening rates for cervical, breast, and colorectal cancer. Using external government data in combination with our practice's electronic medical record, we developed a process to identify patients eligible and overdue for cancer screening. After generating baseline data, we implemented an evidence-based, multifaceted intervention to improve cancer screening rates. We sent a personalized reminder letter to overdue patients, provided physicians with practice-level audit and feedback, and improved our electronic reminder function by updating charts with accurate data on the Fecal Occult Blood Test (FOBT). Following our initial intervention, we sought to maintain and further improve our screening rates by experimenting with alternative recall methods and collecting patient feedback. Screening rates significantly improved for all three cancers. Between March 2014 and December 2016, the cervical cancer screening rate increased from 60% to 71% (p<0.05), the breast cancer screening rate increased from 56% to 65% (p<0.05), and the overall colorectal screening rate increased from 59% to 70% (p<0.05). The increase in colorectal screening rates was largely due to an increase in FOBT screening from 18% to 25%, while colonoscopy screening remained relatively unchanged, shifting from 45% to 46%. We also found that patients living in low income neighbourhoods were less likely to be screened. Following our intervention, this equity gap narrowed modestly for breast and colorectal cancer but did not change for cervical cancer screening. Our future improvement efforts will be focused on reducing the gap in screening between patients living in low-income and high-income neighbourhoods while maintaining overall gains.

Participation and retention in the breast cancer screening program in New Brunswick Canada

New Brunswick (NB) Canada uses its breast cancer screening service program to assess the extent to which eligible NB women are complying with mammography guidelines. While many studies have investigated factors associated with participation in periodic breast cancer screening in Canada and elsewhere, most work has relied on self-reported surveys or smaller scale primary data collection. Using a longitudinal administrative dataset for NB over the period 1996-2011 of 255,789 eligible women aged 45-69, this study examined demographic, socioeconomic and geographic factors associated with initial participation in regular screening at age 50 and ongoing retention in the program. Logistic regression was used to examine correlates of initial screening, while rescreening participation was estimated using survival analysis accounting for rescreening episodes. Initial screening participation was lower for women born outside of NB, many women living farther away from screening centers, women in rural areas, and higher for married women. In contrast, retention was higher for rural women and women recently arrived in NB. For both participation and retention, regional disparities across health zone persisted after controlling for observable personal and locational factors. The analysis highlights important characteristics to be targeted to increase screening but also that how health zones operate their screening programs exerts a very significant effect on the use of screening services by eligible women. This offers lessons for the design and evaluation of any cancer screening program.

Do Primary Care Provider Strategies Improve Patient Participation in Colorectal Cancer Screening?

OBJECTIVES

Screening rates for colorectal cancer (CRC) remain suboptimal. The impact of provider strategies to enhance screening participation in the population is uncertain. The objective of this study was to determine the effect of provider strategies to increase screening in a single-payer system.

METHODS

A population-based survey was conducted in primary care providers (PCPs) linked to patients using administrative data in Ontario, Canada. Patients were due for CRC screening from April 2012 to March 2013. Patients were followed up until 31 March 2014. We determined time to become up-to-date with CRC screening. Cox proportional hazards models examined the association between PCP strategies and uptake of screening, adjusted for physician and patient factors.

RESULTS

A total of 717 PCPs and their 147,834 rostered patients due for CRC screening were included. Most physicians employed strategies to enhance screening participation, including electronic medical record use, reminders, generation of lists, audit and feedback reports, or designating staff responsible for screening. No single strategy was strongly associated with screening. For those >1 year overdue, a systematic approach to generate lists of patients overdue for screening was weakly associated with screening uptake (hazard ratio (HR)=1.14, 95% CI: 1.03-1.26, P=0.04 >5 years overdue vs. <1 year overdue). The use of multiple PCP strategies was associated with screening participation (HR=1.27, 95% CI: 1.16-1.39, P<0.0001 for PCPs using 4-5 vs. 0-1 strategies). Practice-based strategies were self-reported.

CONCLUSIONS

In practice, while individual PCP strategies have little effect, the use of multiple strategies to enhance screening appears to improve CRC screening uptake in patients.

Using self-reported data on the social determinants of health in primary care to identify cancer screening disparities: opportunities and challenges

Background

Data on the social determinants of health can help primary care practices target improvement efforts, yet relevant data are rarely available. Our family practice located in Toronto, Ontario routinely collects patient-level sociodemographic data via a pilot-tested survey developed by a multi-organizational steering committee. We sought to use these data to assess the relationship between the social determinants and colorectal, cervical and breast cancer screening, and to describe the opportunities and challenges of using data on social determinants from a self-administered patient survey.

Methods

Patients of the family practice eligible for at least one of the three cancer screening types, based on age and screening guidelines as of June 30, 2015 and who had answered at least one question on a socio-demographic survey were included in the study. We linked self-reported data from the sociodemographic survey conducted in the waiting room with patients’ electronic medical record data and cancer screening records. We created an individual-level income variable (low-income cut-off) that defined a poverty threshold and took household size into account. The sociodemographic characteristics of patients who were overdue for screening were compared to those who were up-to-date for screening for each cancer type using chi-squared tests.

Results

We analysed data for 5766 patients for whom we had survey data. Survey participants had significantly higher screening rates (72.9, 78.7, 74.4% for colorectal, cervical and breast cancer screening respectively) than the 13, 036 patients for whom we did not have survey data (59.2, 65.3, 58.9% respectively). Foreign-born patients were significantly more likely to be up-to-date on colorectal screening than their Canadian-born peers but showed no significant differences in breast or cervical cancer screening. We found a significant association between the low-income cut-off variable and cancer screening; neighbourhood income quintile was not significantly associated with cancer screening. Housing status was also significantly associated with colorectal, cervical and breast cancer screening. There was a large amount of missing data for the low-income cut-off variable, approximately 25% across the three cohorts.

Conclusion

While we were able to show that neighbourhood income might under-estimate income-related disparities in screening, individual-level income was also the most challenging variable to collect. Future work in this area should target the income disparity in cancer screening and simultaneously explore how best to collect measures of poverty.

Electronic supplementary material

The online version of this article (doi:10.1186/s12875-017-0599-z) contains supplementary material, which is available to authorized users.