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

Primary care quality for older adults: Practice-based quality measures derived from a RAND/UCLA appropriateness method study

We established consensus on practice-based metrics that characterize quality of care for older primary care patients and can be examined using secondary health administrative data. We conducted a two-round RAND/UCLA Appropriateness Method (RAM) study and recruited 10 Canadian clinicians and researchers with expertise relevant to the primary care of elderly patients. Informed by a literature review, the first RAM round evaluated the appropriateness and importance of candidate quality measures in an online questionnaire. Technical definitions were developed for each endorsed indicator to specify how the indicator could be operationalized using health administrative data. In a virtual synchronous meeting, the expert panel offered feedback on the technical specifications for the endorsed indicators. Panelists then completed a second (final) questionnaire to rate each indicator and corresponding technical definition on the same criteria (appropriateness and importance). We used statistical integration to combine technical expert panelists' judgements and content analysis of open-ended survey responses. Our literature search and internal screening resulted in 61 practice-based quality indicators for rating. We developed technical definitions for indicators endorsed in the first questionnaire (n = 55). Following the virtual synchronous meeting and second questionnaire, we achieved consensus on 12 practice-based quality measures across four Priority Topics in Care of the Elderly. The endorsed indicators provide a framework to characterize practice- and population-level encounters of family physicians delivering care to older patients and will offer insights into the outcomes of their care provision. This study presented a case of soliciting expert feedback to develop measurable practice-based quality indicators that can be examined using administrative data to understand quality of care within population-based data holdings. Future work will refine and operationalize the technical definitions established through this process to examine primary care provision for older adults in a particular context (Ontario, Canada).

Understanding and addressing changing administrative workload in primary care in Canada: protocol for a mixed-method study

INTRODUCTION

Many Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care.

METHODS AND ANALYSIS

In this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events.

ETHICS AND DISSEMINATION

We received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences.

What can publicly funded schools teach us about how to fix the family doctor shortage?

Recent estimates suggest that up to 22% of Canadians over 18 do not have regular access to a family doctor or nurse practitioner. This lack of access is often characterized as a "family doctor shortage" and has been making headlines for decades. However, we have more family doctors than ever before, and in fact, the lack of primary care access is less about a shortage of physicians and more a need to develop a modern infrastructure and new way of funding and organizing care. Real change will require a paradigm shift from doctor- to clinic-organized care. The example of how schools are organized for public education may hold answers about how to make that paradigm shift and with investment in infrastructure see improvements in access to care across the country.

Starting out rural: a qualitative study of the experiences of family physician graduates transitioning to practice in rural Ontario

BACKGROUND

New family medicine graduates are a promising group to recruit to underserved rural areas. This study aimed to understand the experiences of this group as they transitioned to practice in rural Ontario.

METHODS

We used a hermeneutic phenomenology approach. Purposive sampling was used to recruit participants who graduated from a Canadian family medicine residency program and worked in a rural community in Ontario (Rurality Index for Ontario score ≥ 40) for at least 1 year within the past 5 years. Participants completed an online demographic survey followed by a virtual semistructured interview (May-August 2022). Interviews were video recorded and transcribed. Two researchers reviewed transcripts for codes, and then codes were reviewed in an iterative process to create themes. Transcripts, codes and themes were reviewed by an independent researcher, and final themes were shared with participants to ensure reliability.

RESULTS

We included 18 family physicians in the study. We identified 8 themes and 18 subthemes. The themes identified as important to the experience of new graduates were as follows: choosing rural practice, preparedness for practice, navigating work-life balance, navigating transition to practice, challenges during transition to practice, successes during transition to practice, locuming and emergency medicine as part of rural generalist practice.

INTERPRETATION

Most physicians interviewed felt prepared for rural practice and enjoyed their work; however, they faced unique challenges associated with being an early-career physician in rural practice. This study identifies opportunities for improvements, which can guide medical educators, rural communities and their recruiters, new graduates and policy-makers.

Productivity Decline or Administrative Avalanche? Examining Factors That Shape Changing Workloads in Primary Care

Background

In Canada, family physicians (FPs) per capita have increased but so have access challenges. We explored changes in population characteristics, service delivery and FP practice that may help understand these trends.

Methods

We used linked administrative data in British Columbia to describe changes in patient ages and comorbidities, hospitalizations and receipt of services that may require FP coordination, review and/or follow-up: prescriptions dispensed, laboratory tests, diagnostic imaging (radiology and ultrasound), specialist visits and emergency department visits. We estimate the number of FPs delivering community-based comprehensive care and report changes in service volume per community-based FP visit.

Results

Between 1999/2000 and 2017/2018, people experienced fewer days in hospital, but the number of treated comorbidities, day surgeries and other services requiring FP coordination increased over and above the expected levels attributed to population aging. While the total number of FPs per capita have increased, numbers in community-based care have not and visits per physician have fallen. Increases in services that may involve FP coordination per community-based FP visit ranged from 32.2% for diagnostic radiology to 122.1% for lab tests.

Conclusion

Findings suggest substantially increased coordination workload per FP visit. Ongoing impacts of population aging and changing service delivery on primary care workload require further examination.