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.

Earnings among people with multiple sclerosis in Sweden, by education and occupation

Background

Multiple sclerosis (MS) may affect the individual’s working life. We aimed to 1) investigate the mean levels and distributions of earnings among people with MS (PwMS) before and after MS diagnosis compared to people without an MS diagnosis, and whether such differences in earnings were associated with educational level or occupation and 2) assess the prevalence of sickness absence (SA) and disability pension (DP).

Methods

Population-based cohort study (10 years prior to 5 years after MS diagnosis) using microdata linked from nationwide Swedish registers of all individuals aged 30-54 with MS diagnosed in 2003-2006 (n = 2553) and references without MS (n = 7584) randomly selected by stratified matching (sex and age). Annual mean earnings, by educational level and type of occupation, were compared with t-tests. Tobit regressions investigated the associations of earnings with individual characteristics. Lastly, the proportions on SA and DP, stratified by educational level and type of occupation, were examined in the diagnosis year and 5 years later.

Results

Differences in earnings between PwMS and references were observed beginning one year prior to diagnosis and increased with time. PwMS had lower mean earnings for the diagnosis year (difference=SEK 28,000, p-value<0.05), and the difference had more than doubled (p-value<0.05) 5 years later. These differences remained after taking educational level and type of occupation into account. PwMS with university education and/or more qualified occupations had mean earnings most like their respective references’. PwMS had higher prevalence of SA and DP than the references, in both the diagnosis year and 5 years later.

Conclusions

Earnings of people with MS were lower than references’ already one year before diagnosis, and the gap increased thereafter. Results indicate that educational level and type of occupation are of importance for earnings. Moreover, SA and DP were more common among people with MS.

Key messages

Our results indicate that working-aged people with MS have less earnings than references already one year before diagnosis and that thereafter this gap in earnings increases with time. Education and occupation were influential in explaining the people with MS’ heterogeneous earnings, with a hierarchal ordering of who maintained similar earnings to their respective peers.

A retrospective analysis of case-load and supervision from a large anaesthetic logbook database

The recent development of electronic logbooks with secure off-device data storage provides a rich resource for research. We present the largest analysis of anaesthetic logbooks to date, with data from 494,235 cases logged by 964 anaesthetists over a 4-year period. Our analysis describes and compares the annual case-load and supervision levels of different grades of anaesthetists across the UK and Republic of Ireland. We calculated the number of cases undertaken per year by grade (median (IQR [range]) core trainees = 388 (252-512 [52-1204]); specialist trainees = 344 (228-480 [52-1144]); and consultants = 328 (204-500 [52-1316]). Overall, the proportion of cases undertaken with direct consultant supervision was 56.7% and 41.6% for core trainees and specialist trainees, respectively. The proportion of supervised cases reduced out-of-hours, for both core trainees (day 93.5%, evening 86.3%, night 78.6%) and specialist trainees (day 81.0%, evening 67.7%, night 56.4%).

Hayabusa2 arrives at the carbonaceous asteroid 162173 Ryugu-A spinning top-shaped rubble pile

The Hayabusa2 spacecraft arrived at the near-Earth carbonaceous asteroid 162173 Ryugu in 2018. We present Hayabusa2 observations of Ryugu's shape, mass, and geomorphology. Ryugu has an oblate "spinning top" shape, with a prominent circular equatorial ridge. Its bulk density, 1.19 ± 0.02 grams per cubic centimeter, indicates a high-porosity (>50%) interior. Large surface boulders suggest a rubble-pile structure. Surface slope analysis shows Ryugu's shape may have been produced from having once spun at twice the current rate. Coupled with the observed global material homogeneity, this suggests that Ryugu was reshaped by centrifugally induced deformation during a period of rapid rotation. From these remote-sensing investigations, we identified a suitable sample collection site on the equatorial ridge.

The geomorphology, color, and thermal properties of Ryugu: Implications for parent-body processes

The near-Earth carbonaceous asteroid 162173 Ryugu is thought to have been produced from a parent body that contained water ice and organic molecules. The Hayabusa2 spacecraft has obtained global multicolor images of Ryugu. Geomorphological features present include a circum-equatorial ridge, east-west dichotomy, high boulder abundances across the entire surface, and impact craters. Age estimates from the craters indicate a resurfacing age of [Formula: see text] years for the top 1-meter layer. Ryugu is among the darkest known bodies in the Solar System. The high abundance and spectral properties of boulders are consistent with moderately dehydrated materials, analogous to thermally metamorphosed meteorites found on Earth. The general uniformity in color across Ryugu's surface supports partial dehydration due to internal heating of the asteroid's parent body.

89 Effect of embryo transfer and recipient breed on offspring performance in equine show jumping

Maternal preconceptional, gestational, and postnatal environments alter offspring phenotype in humans and animals. In particular, embryo technologies were shown in horses and other species to affect offspring growth and metabolism. Quantitative genetic calculations in a database containing genealogy and a measured trait (performance) of individuals enable geneticists to estimate the respective contribution of (A) genetic aptitude for the trait (inherited from all parents), (B) genetic maternal aptitude (additional contribution of the mother and her ancestors, acting through pregnancy, lactation, and nursing), and (C) the permanent maternal environment (similarities between the offspring of a dam that are not attributed to genetics) to the variability of this trait in this population. Additionally, fixed effects can be introduced and estimated to take into account additional factors acting on individual performance. The aim of this project was to apply this method to estimate the respective contributions of A, B, and C as well as the fixed effects of maternal parity (D), age at foaling (E), foaling interval (F), embryo transfer (G), and breed of recipient mare (for ET recipients) on the adult offspring sport performance in show jumping horses. The data came from the French Horse Database established in 1976 for genealogy and performance; calculation was done using WOMBAT® software. The performance of 207,984 horses (4.5 years per horse), born to 90,438 dams (of which 4187 were ET recipients, the others being bred by AI or natural service), were studied. Performance was expressed as follows. For each event, points were distributed depending on the horse’s rank within the event and the event’s difficulty. The logarithm of the sum of points of the year has a Gaussian distribution and is then normalised to mean=0 and standard deviation=1. The genetic maternal aptitude and permanent maternal environment showed a small but significant contribution to the variance of performance (1.4 and 1.5%, respectively) compared to a direct genetic contribution of 24.4%. Within each age class of dam, offspring of primiparous mares have a handicap (−0.04 to −0.06) compared to multiparous mares. Within multiparous mares, a foaling interval of 1 year only provided a small advantage (+0.01, nonsignificant) compared to longer intervals (>2 years). The effect of embryo transfer was strong and significant (+0.24), which could reflect the better management of the horses produced by embryo transfer because of their genetic and financial value rather than a physiologic effect. The performance of offspring born to draft and warmblood recipients (+0.27v. +0.24, nonsignificant) were not different. In conclusion, although jumping performance occurs several years after birth, maternal effects are still measurable and embryo transfer is associated with a strongly increased performance independent of genetic value, probably due to better management of these horses. No effect of recipient mare’s breed was found.

A window of opportunity for cooperativity in the T Cell Receptor

The T-cell antigen receptor (TCR) is pre-organised in oligomers, known as nanoclusters. Nanoclusters could provide a framework for inter-TCR cooperativity upon peptide antigen-major histocompatibility complex (pMHC) binding. Here we have used soluble pMHC oligomers in search for cooperativity effects along the plasma membrane plane. We find that initial binding events favour subsequent pMHC binding to additional TCRs, during a narrow temporal window. This behaviour can be explained by a 3-state model of TCR transition from Resting to Active, to a final Inhibited state. By disrupting nanoclusters and hampering the Active conformation, we show that TCR cooperativity is consistent with TCR nanoclusters adopting the Active state in a coordinated manner. Preferential binding of pMHC to the Active TCR at the immunological synapse suggests that there is a transient time frame for signal amplification in the TCR, allowing the T cells to keep track of antigen quantity and binding time.

T cells can be activated by a small, two-digit, number of antigen peptide molecules even though the receptor for antigen (TCR) is of low affinity. Here the authors present evidence that all TCRs within a nanocluster can become activated when only a subset is bound to antigen.

Direct analysis of volatile organic compounds in foods by headspace extraction atmospheric pressure chemical ionisation mass spectrometry

RATIONALE

The rapid screening of volatile organic compounds (VOCs) by direct analysis has potential applications in the areas of food and flavour science. Currently, the technique of choice for VOC analysis is gas chromatography/mass spectrometry (GC/MS). However, the long chromatographic run times and elaborate sample preparation associated with this technique have led a movement towards direct analysis techniques, such as selected ion flow tube mass spectrometry (SIFT-MS), proton transfer reaction mass spectrometry (PTR-MS) and electronic noses. The work presented here describes the design and construction of a Venturi jet-pump-based modification for a compact mass spectrometer which enables the direct introduction of volatiles for qualitative and quantitative analysis.

METHODS

Volatile organic compounds were extracted from the headspace of heated vials into the atmospheric pressure chemical ionization source of a quadrupole mass spectrometer using a Venturi pump. Samples were analysed directly with no prior sample preparation. Principal component analysis (PCA) was used to differentiate between different classes of samples.

RESULTS

The interface is shown to be able to routinely detect problem analytes such as fatty acids and biogenic amines without the requirement of a derivatisation step, and is shown to be able to discriminate between four different varieties of cheese with good intra and inter-day reproducibility using an unsupervised PCA model. Quantitative analysis is demonstrated using indole standards with limits of detection and quantification of 0.395 μg/mL and 1.316 μg/mL, respectively.

CONCLUSIONS

The described methodology can routinely detect highly reactive analytes such as volatile fatty acids and diamines without the need for a derivatisation step or lengthy chromatographic separations. The capability of the system was demonstrated by discriminating between different varieties of cheese and monitoring the spoilage of meats.

Alternate Access to Care: A Cross Sectional Survey of Low Acuity Emergency Department Patients

Introduction Patients with low-acuity (Canadian Triage and Acuity Scale level IV and V) complaints use the emergency department (ED) to access care. This has often been attributed to lack of a primary care provider. However, simply being registered with a primary care provider may not prevent low acuity ED presentation. There is some evidence that a lack of timely access to primary care may contribute to low acuity ED presentations. The Wait Time Alliance, a group of Canadian physicians and their respective professional associations, has recently set a benchmark of same day access to family doctors. It is unclear if this benchmark has been achieved in all jurisdictions.  Methods We performed linked cross sectional surveys to quantify the number of people presenting to the ED for nonurgent problems who felt unable to access primary care. Primary care practices were also surveyed to assess access using the metric of time to third next available appointment.  Results In the patient survey, 381 of 580 patients consented to participate. Of the 89 patients who met eligibility criteria, 100% completed the survey. 32 (35.9%) reported that the wait to see their primary care provider was "too long". 45 (50.5%) patients did not contact their primary care provider's office prior to ED presentation. 45 of 72 physician surveys were returned; a response rate of 62.5%. Most (77%) physicians estimated their wait time for a standard appointment to be greater than 48 hours. The mean calculated time to third next available appointment in the region was 6.6 (95% CI 4.6-8.7) days. Conclusions Approximately half of low acuity patients do not attempt to access their primary care provider prior to ED presentation. The benchmark of same day access to primary care has not been achieved in many practices in our region. Further education regarding primary care access would likely be beneficial to both patients and providers.

Barriers and facilitators to successful transition from long-term residential substance abuse treatment

Although residential substance abuse treatment has been shown to improve substance use and other outcomes, relapse is common. This qualitative study explores factors that hinder and help individuals during the transition from long-term residential substance abuse treatment to the community. Semi-structured interviews were conducted with 32 individuals from residential substance abuse treatment. Based on the socio-ecological model, barriers and facilitators to transition were identified across five levels: individual, interpersonal, organizational, community, and policy. The major results indicate that primary areas of intervention needed to improve outcomes for these high-risk individuals include access to stable housing and employment, aftercare services and positive support networks; expanded discharge planning services and transitional assistance; and funding to address gaps in service delivery and to meet individuals' basic needs. This study contributes to the literature by identifying transition barriers and facilitators from the perspectives of individuals in residential treatment, and by using the socio-ecological model to understand the complexity of this transition at multiple levels. Findings identify potential targets for enhanced support post-discharge from residential treatment.

Pain as an Indicator of Bone Metastasis

Patients with breast or prostate cancer routinely referred for bone scintigraphy were evaluated for the presence of skeletal pain, as determined by a self administered questionnaire. Pain was a common finding, whether or not metastatic disease was present, and occurred in over half of patients. Although most patients with bone metastases did report bone pain, a significant fraction (21% of breast and 22% of prostate patients) were asymptomatic. A distinct minority of individual anatomic regions of metastasis were painful: pain was reported in 23 % of sites of breast metastases and 15% of metastatic prostate cancer sites. Of all sites at which pain was present, metastases were demonstrated in only about one half. These results indicate that pain is not a reliable indicator of the presence of location of metastatic bone disease.

Education. Undergraduate research experiences: impacts and opportunities

Most undergraduates give high ratings to research experiences. Studies report that these experiences improve participation and persistence, often by strengthening students' views of themselves as scientists. Yet, the evidence for these claims is weak. More than half the 60 studies reviewed rely on self-report surveys or interviews. Rather than introducing new images of science, research experiences may reinforce flawed images especially of research practices and conceptual understanding. The most convincing studies show benefits for mentoring and for communicating the nature of science, but the ideas that students learn are often isolated or fragmented rather than integrated and coherent. Rigorous research is needed to identify ways to design research experiences so that they promote integrated understanding. These studies need powerful and generalizable assessments that can document student progress, help distinguish effective and ineffective aspects of the experiences, and illustrate how students interpret the research experiences they encounter. To create research experiences that meet the needs of interested students and make effective use of scarce resources, we encourage systematic, iterative studies with multiple indicators of success.

Emergency department use: is frequent use associated with a lack of primary care provider?

OBJECTIVE

To determine if having a primary care provider is an important factor in frequency of emergency department (ED) use.

DESIGN

Analysis of a central computerized health network database.

SETTING

Three EDs in southern New Brunswick.

PARTICIPANTS

All ED visits during 1 calendar year to an urban regional hospital (URH), an urban urgent care centre (UCC), and a rural community hospital (RCH) were captured.

MAIN OUTCOME MEASURES

Patients with and without listed primary care providers were compared in terms of number of visits to the ED. A logistic regression analysis was used to determine factors predictive of frequent attendance.

RESULTS

In total, 48 505, 41 004, and 27 900 visits were made to the URH, UCC, and RCH, respectively, in 2009. The proportion of patients with listed primary care providers was 36.6% for the URH, 37.1% for the UCC, and 89.4% for the RCH. Among ED patients at all sites, frequent attenders (4 or more visits to an ED in 1 year) were significantly more likely (59.6% vs 45.1%, P < .001) to have listed primary care providers. Other factors that predicted frequent use included attendance at a rural ED, female sex, and older age.

CONCLUSION

This study characterizes attendance rates for 3 EDs in southern New Brunswick. Our findings highlight interesting differences between urban and rural ED populations, and suggest that frequent use of the ED might not be related to lack of a listed primary care provider.

Autism spectrum disorder diagnostic assessments: improvements since publication of the National Autism Plan for Children

OBJECTIVES

To assess in the context of a publically funded healthcare system, change in UK autism spectrum disorder (ASD) clinical diagnostic practice following the recommendations of the National Autism Plan for Children (NAP-C 2003).

METHODS

In 2007, a questionnaire based on standards from the NAP-C was sent to UK child development teams (CDTs); results were compared with 2001 data from the National Initiative for Autism Screening and Assessment.

MAIN FINDINGS

Responses were received from 149 of 243 UK CDTs (61%). Most teams used standardised autism diagnostic assessments. There was greater access to members of the multidisciplinary team than in 2001. Only one-third of teams had a defined timescale for completion of assessment; of those teams, about half met the recommended NAP-C target.

CONCLUSIONS

Since 2001, there has been an improvement in diagnostic services for children with ASD, however, inequalities remain. Providers should continue to improve services in order to deliver timely and comprehensive assessments for children with ASD.

Multiple N-methylation of MT-II backbone amide bonds leads to melanocortin receptor subtype hMC1R selectivity: pharmacological and conformational studies

Multiple N-methylation is a novel technology to improve bioavailability of peptides and increase receptor subtype selectivity. This technique has been applied here to the superpotent but nonselective cyclic peptide MT-II. A library of all possible 31 backbone N-methylated derivatives has been synthesized and tested for binding and activation at melanocortin receptor subtypes 1, 3, 4, and 5. It turned out that selectivity is improved with every introduced N-methyl group, resulting in several N-methylated selective and potent agonists for the hMC1R. The most potent of these derivatives is N-methylated on four out of five amide bonds in the cyclic structure. Its solution structure indicates a strongly preferred backbone conformation that resembles other alpha-MSH analogs but possesses much less flexibility and in addition distinct differences in the spatial arrangement of individual amino acid side chains.