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Terpou BA, Lapointe-Shaw L, Wang R, Martin D, Tadrous M, Bhatia S, Shuldiner J, Berthelot S, Thakkar N, McBrien K, Salahub C, Kiran T, Ivers N, Desveaux L. A shifting terrain: Understanding the perspectives of walk-in physicians on their roles amid worsening primary care access in Ontario, Canada. PLoS One 2024; 19:e0303107. [PMID: 38748707 PMCID: PMC11095764 DOI: 10.1371/journal.pone.0303107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/18/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND High-quality primary care is associated with better health outcomes and more efficient and equitable health system performance. However, the rate of primary care attachment is falling, and timely access to primary care is worsening, driving many patients to use walk-in clinics for their comprehensive primary care needs. This study sought to explore the experiences and perceived roles and responsibilities of walk-in physicians in this current climate. Methods: Qualitative interviews were conducted with nineteen physicians currently providing walk-in care in Ontario, Canada between May and December 2022. RESULTS Limited capacity for continuity and comprehensiveness of care were identified as major sources of professional tension for walk-in physicians. Divergent perspectives on their roles were anchored in how physicians viewed their professional identity. Some saw providing continuous and comprehensive care as an infringement on their professional role; others saw their professional role as more flexible and responsive to population needs. Regardless of their professional identity, participants reported feeling ill-equipped to manage the swell of unattached patients, citing a lack of time, resources, connectivity to the system, and remuneration flexibility. Conclusions: As practice demands of walk-in clinics change, an evolution in the professional roles and responsibilities of walk-in physicians follows. However, the resources, structure, and incentives of walk-in care have not evolved to reflect this, leaving physicians to set their own professional boundaries with patients. This results in increasing variations in care and confusion across the primary care sector around who is responsible for what, when, and how.
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Affiliation(s)
- Braeden A. Terpou
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Lauren Lapointe-Shaw
- Division of General Internal Medicine and Geriatrics, University Health Network and Sinai Health System, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Ruoxi Wang
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Danielle Martin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Mina Tadrous
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Sacha Bhatia
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Jennifer Shuldiner
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - Simon Berthelot
- Département de Médecine de Famille et de Médecine D’urgence, Université Laval, Laval, Quebec, Canada
| | - Niels Thakkar
- College of Nurses of Ontario, Toronto, Ontario, Canada
| | - Kerry McBrien
- Department of Family Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Christine Salahub
- Supports, Systems and Outcomes Department, University Health Network, Toronto, Ontario, Canada
| | - Tara Kiran
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Noah Ivers
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Laura Desveaux
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
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Doherty S, Agarwal P, Wang R, Meaney C, Eldridge K, Damji AN, Elman D, Fung S, Gupta KL, Walji S, Weber L, Witty M, Kiran T. Patient Experience With Resident Versus Staff Physicians: Results From a Cross-Sectional Patient Survey From Canadian Family Medicine Residencies. Fam Med 2024; 56:286-293. [PMID: 38652844 DOI: 10.22454/fammed.2024.729822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
BACKGROUND AND OBJECTIVES We compared experiences of patients who reported usually being seen by a resident with those usually seen by a staff physician. METHODS We analyzed responses to a patient experience survey distributed at 13 family medicine teaching practices affiliated with the University of Toronto between May and June 2020. We analyzed responses to seven questions pertaining to timely access, continuity, and patient-centeredness. We compared responses between two types of usual primary care clinicians and calculated odds ratios before and after adjustment for patient characteristics. RESULTS We analyzed data from 6,545 unique surveys; 18.6% reported their usual clinician was a resident physician. Resident patients were more likely to be older, born outside of Canada, report a high school education or less, and report having difficulty making ends meet. Compared to patients of staff physicians, patients of resident physicians had lower odds of being able to see their preferred primary care clinician and lower odds of getting nonurgent care in a reasonable time. They also had lower odds of reporting patient-centered care, but we found no significant differences in whether the time for an urgent appointment was about right or whether accessing care after hours was easy. CONCLUSIONS In our setting, patients who reported usually seeing resident physicians had worse continuity of care and timeliness for nonurgent care than patients who reported usually seeing staff physicians despite resident patients being older, sicker, and having a lower socioeconomic position. Postgraduate training programs need to test models to support access and continuity for resident patient panels.
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Affiliation(s)
- Sean Doherty
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Payal Agarwal
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Ri Wang
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Christopher Meaney
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kirsten Eldridge
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ali N Damji
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Credit Valley Family Health Team, Mississauga, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Debbie Elman
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Susanna Fung
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karuna L Gupta
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Health For All Family Health Team, Markham, Ontario, Canada
| | - Sakina Walji
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- St. Joseph's Health Centre Urban Family Health Team, Toronto, Ontario, Canada
| | - Linda Weber
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- St. Joseph's Health Centre Urban Family Health Team, Toronto, Ontario, Canada
| | - Melissa Witty
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Barrie and Community Family Health Team, Barrie, Ontario, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
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Shuldiner J, Green ME, Kiran T, Khan S, Frymire E, Moineddin R, Kerr M, Tadrous M, Nowak DA, Kwong JC, Hu J, Witteman HO, Hamilton B, Bogoch I, Marshall LJ, Ikura S, Bar-Ziv S, Kaplan D, Ivers N. Characteristics of primary care practices by proportion of patients unvaccinated against SARS-CoV-2: a cross-sectional cohort study. CMAJ 2024; 196:E432-E440. [PMID: 38589026 PMCID: PMC11001391 DOI: 10.1503/cmaj.230816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Variations in primary care practices may explain some differences in health outcomes during the COVID-19 pandemic. We sought to evaluate the characteristics of primary care practices by the proportion of patients unvaccinated against SARS-CoV-2. METHODS We conducted a population-based, cross-sectional cohort study using linked administrative data sets in Ontario, Canada. We calculated the percentage of patients unvaccinated against SARS-CoV-2 enrolled with each comprehensive-care family physician, ranked physicians according to the proportion of patients unvaccinated, and identified physicians in the top 10% (v. the other 90%). We compared characteristics of family physicians and their patients in these 2 groups using standardized differences. RESULTS We analyzed 9060 family physicians with 10 837 909 enrolled patients. Family physicians with the largest proportion (top 10%) of unvaccinated patients (n = 906) were more likely to be male, to have trained outside of Canada, to be older, and to work in an enhanced fee-for-service model than those in the remaining 90%. Vaccine coverage (≥ 2 doses of SARS-CoV-2 vaccine) was 74% among patients of physicians with the largest proportion of unvaccinated patients, compared with 87% in the remaining patient population. Patients in the top 10% group tended to be younger and live in areas with higher levels of ethnic diversity and immigration and lower incomes. INTERPRETATION Primary care practices with the largest proportion of patients unvaccinated against SARS-CoV-2 served marginalized communities and were less likely to use team-based care models. These findings can guide resource planning and help tailor interventions to integrate public health priorities within primary care practices.
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Affiliation(s)
- Jennifer Shuldiner
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont.
| | - Michael E Green
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Tara Kiran
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Shahriar Khan
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Eliot Frymire
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Rahim Moineddin
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Meghan Kerr
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Mina Tadrous
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Dominik Alex Nowak
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Jeffrey C Kwong
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Jia Hu
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Holly O Witteman
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Bryn Hamilton
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Isaac Bogoch
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Lydia-Joy Marshall
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Sophia Ikura
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Stacey Bar-Ziv
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - David Kaplan
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
| | - Noah Ivers
- Women's College Hospital Institute of Virtual Care and Systems Solutions (Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Departments of Family Medicine and Public Health Sciences (Green, Kerr), Queen's University, Kingston, Ont.; ICES (Green, Khan, Moineddin, Tadrous, Kwong, Ivers); Department of Family and Community Medicine (Kiran, Nowak, Kwong), University of Toronto; St. Michael's Hospital (Kiran), Unity Health Toronto; MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Centre for Health Services and Policy Research (Frymire), Queen's University, Kingston, Ont.; Leslie Dan School of Pharmacy (Tadrous), and Dalla Lana School of Public Health (Nowak), University of Toronto; Women's College Hospital Academic Family Health Team (Nowak), Women's College Hospital; Public Health Ontario (Kwong); University Health Network (Kwong), Toronto, Ont.; Department of Community Health Sciences (Hu), University of Calgary, Calgary, Alta.; VITAM Research Centre for Sustainable Health (Witteman); Department of Family and Emergency Medicine (Witteman), Université Laval, Québec, Que.; Association of Family Health Teams of Ontario (Hamilton); Department of Medicine (Bogoch), University of Toronto; Health Commons Solutions Labs Ontario (Marshall, Ikura); Ontario Health (Bar-Ziv, Kaplan); Institute of Health Policy, Management and Evaluation (Ivers), University of Toronto, Toronto, Ont
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Shahaed H, Glazier RH, Anderson M, Barbazza E, Bos VLLC, Saunes IS, Auvinen J, Daneshvarfard M, Kiran T. Soins primaires pour tous: Le Canada peut s’inspirer de pays semblables ayant un niveau élevé de continuité relationnelle entre patientèle et centres de soins primaires. CMAJ 2024; 196:E359-E368. [PMID: 38499306 PMCID: PMC10948188 DOI: 10.1503/cmaj.221824-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Affiliation(s)
- Heba Shahaed
- Faculté de médecine Temerty (Shahaed) et Département de médecine familiale et communautaire (Glazier, Kiran), Hôpital St. Michael, Université de Toronto; Centre MAP pour des solutions de santé urbaines (Glazier, Daneshvarfard, Kiran), Institut du savoir Li Ka Shing, Hôpital St. Michael; Institut de recherche en services de santé (ICES Centre) (Glazier, Kiran); Institut des politiques de la gestion et de l'évaluation de la santé (Glazier, Kiran), Université de Toronto, Toronto, Ont.; Département des politiques de la santé (Anderson), École londonienne d'économie et de sciences politiques, Londres, R.-U.; Département de santé publique et de médecine du travail (Barbazza, Bos), couverture sanitaire universelle (CSU) Amsterdam, Université d'Amsterdam, Amsterdam, Pays-Bas; Grappe de recherche sur les services de santé (Saunes), Division des services de santé, Institut norvégien de santé publique, Oslo, Norvège; Unité de recherche sur la santé des populations (Auvinen), Université d'Oulu; Centre de recherches médicales (Auvinen), Hôpital universitaire d'Oulu et Université d'Oulu, Oulu, Finlande
| | - Richard H Glazier
- Faculté de médecine Temerty (Shahaed) et Département de médecine familiale et communautaire (Glazier, Kiran), Hôpital St. Michael, Université de Toronto; Centre MAP pour des solutions de santé urbaines (Glazier, Daneshvarfard, Kiran), Institut du savoir Li Ka Shing, Hôpital St. Michael; Institut de recherche en services de santé (ICES Centre) (Glazier, Kiran); Institut des politiques de la gestion et de l'évaluation de la santé (Glazier, Kiran), Université de Toronto, Toronto, Ont.; Département des politiques de la santé (Anderson), École londonienne d'économie et de sciences politiques, Londres, R.-U.; Département de santé publique et de médecine du travail (Barbazza, Bos), couverture sanitaire universelle (CSU) Amsterdam, Université d'Amsterdam, Amsterdam, Pays-Bas; Grappe de recherche sur les services de santé (Saunes), Division des services de santé, Institut norvégien de santé publique, Oslo, Norvège; Unité de recherche sur la santé des populations (Auvinen), Université d'Oulu; Centre de recherches médicales (Auvinen), Hôpital universitaire d'Oulu et Université d'Oulu, Oulu, Finlande
| | - Michael Anderson
- Faculté de médecine Temerty (Shahaed) et Département de médecine familiale et communautaire (Glazier, Kiran), Hôpital St. Michael, Université de Toronto; Centre MAP pour des solutions de santé urbaines (Glazier, Daneshvarfard, Kiran), Institut du savoir Li Ka Shing, Hôpital St. Michael; Institut de recherche en services de santé (ICES Centre) (Glazier, Kiran); Institut des politiques de la gestion et de l'évaluation de la santé (Glazier, Kiran), Université de Toronto, Toronto, Ont.; Département des politiques de la santé (Anderson), École londonienne d'économie et de sciences politiques, Londres, R.-U.; Département de santé publique et de médecine du travail (Barbazza, Bos), couverture sanitaire universelle (CSU) Amsterdam, Université d'Amsterdam, Amsterdam, Pays-Bas; Grappe de recherche sur les services de santé (Saunes), Division des services de santé, Institut norvégien de santé publique, Oslo, Norvège; Unité de recherche sur la santé des populations (Auvinen), Université d'Oulu; Centre de recherches médicales (Auvinen), Hôpital universitaire d'Oulu et Université d'Oulu, Oulu, Finlande
| | - Erica Barbazza
- Faculté de médecine Temerty (Shahaed) et Département de médecine familiale et communautaire (Glazier, Kiran), Hôpital St. Michael, Université de Toronto; Centre MAP pour des solutions de santé urbaines (Glazier, Daneshvarfard, Kiran), Institut du savoir Li Ka Shing, Hôpital St. Michael; Institut de recherche en services de santé (ICES Centre) (Glazier, Kiran); Institut des politiques de la gestion et de l'évaluation de la santé (Glazier, Kiran), Université de Toronto, Toronto, Ont.; Département des politiques de la santé (Anderson), École londonienne d'économie et de sciences politiques, Londres, R.-U.; Département de santé publique et de médecine du travail (Barbazza, Bos), couverture sanitaire universelle (CSU) Amsterdam, Université d'Amsterdam, Amsterdam, Pays-Bas; Grappe de recherche sur les services de santé (Saunes), Division des services de santé, Institut norvégien de santé publique, Oslo, Norvège; Unité de recherche sur la santé des populations (Auvinen), Université d'Oulu; Centre de recherches médicales (Auvinen), Hôpital universitaire d'Oulu et Université d'Oulu, Oulu, Finlande
| | - Véronique L L C Bos
- Faculté de médecine Temerty (Shahaed) et Département de médecine familiale et communautaire (Glazier, Kiran), Hôpital St. Michael, Université de Toronto; Centre MAP pour des solutions de santé urbaines (Glazier, Daneshvarfard, Kiran), Institut du savoir Li Ka Shing, Hôpital St. Michael; Institut de recherche en services de santé (ICES Centre) (Glazier, Kiran); Institut des politiques de la gestion et de l'évaluation de la santé (Glazier, Kiran), Université de Toronto, Toronto, Ont.; Département des politiques de la santé (Anderson), École londonienne d'économie et de sciences politiques, Londres, R.-U.; Département de santé publique et de médecine du travail (Barbazza, Bos), couverture sanitaire universelle (CSU) Amsterdam, Université d'Amsterdam, Amsterdam, Pays-Bas; Grappe de recherche sur les services de santé (Saunes), Division des services de santé, Institut norvégien de santé publique, Oslo, Norvège; Unité de recherche sur la santé des populations (Auvinen), Université d'Oulu; Centre de recherches médicales (Auvinen), Hôpital universitaire d'Oulu et Université d'Oulu, Oulu, Finlande
| | - Ingrid S Saunes
- Faculté de médecine Temerty (Shahaed) et Département de médecine familiale et communautaire (Glazier, Kiran), Hôpital St. Michael, Université de Toronto; Centre MAP pour des solutions de santé urbaines (Glazier, Daneshvarfard, Kiran), Institut du savoir Li Ka Shing, Hôpital St. Michael; Institut de recherche en services de santé (ICES Centre) (Glazier, Kiran); Institut des politiques de la gestion et de l'évaluation de la santé (Glazier, Kiran), Université de Toronto, Toronto, Ont.; Département des politiques de la santé (Anderson), École londonienne d'économie et de sciences politiques, Londres, R.-U.; Département de santé publique et de médecine du travail (Barbazza, Bos), couverture sanitaire universelle (CSU) Amsterdam, Université d'Amsterdam, Amsterdam, Pays-Bas; Grappe de recherche sur les services de santé (Saunes), Division des services de santé, Institut norvégien de santé publique, Oslo, Norvège; Unité de recherche sur la santé des populations (Auvinen), Université d'Oulu; Centre de recherches médicales (Auvinen), Hôpital universitaire d'Oulu et Université d'Oulu, Oulu, Finlande
| | - Juha Auvinen
- Faculté de médecine Temerty (Shahaed) et Département de médecine familiale et communautaire (Glazier, Kiran), Hôpital St. Michael, Université de Toronto; Centre MAP pour des solutions de santé urbaines (Glazier, Daneshvarfard, Kiran), Institut du savoir Li Ka Shing, Hôpital St. Michael; Institut de recherche en services de santé (ICES Centre) (Glazier, Kiran); Institut des politiques de la gestion et de l'évaluation de la santé (Glazier, Kiran), Université de Toronto, Toronto, Ont.; Département des politiques de la santé (Anderson), École londonienne d'économie et de sciences politiques, Londres, R.-U.; Département de santé publique et de médecine du travail (Barbazza, Bos), couverture sanitaire universelle (CSU) Amsterdam, Université d'Amsterdam, Amsterdam, Pays-Bas; Grappe de recherche sur les services de santé (Saunes), Division des services de santé, Institut norvégien de santé publique, Oslo, Norvège; Unité de recherche sur la santé des populations (Auvinen), Université d'Oulu; Centre de recherches médicales (Auvinen), Hôpital universitaire d'Oulu et Université d'Oulu, Oulu, Finlande
| | - Maryam Daneshvarfard
- Faculté de médecine Temerty (Shahaed) et Département de médecine familiale et communautaire (Glazier, Kiran), Hôpital St. Michael, Université de Toronto; Centre MAP pour des solutions de santé urbaines (Glazier, Daneshvarfard, Kiran), Institut du savoir Li Ka Shing, Hôpital St. Michael; Institut de recherche en services de santé (ICES Centre) (Glazier, Kiran); Institut des politiques de la gestion et de l'évaluation de la santé (Glazier, Kiran), Université de Toronto, Toronto, Ont.; Département des politiques de la santé (Anderson), École londonienne d'économie et de sciences politiques, Londres, R.-U.; Département de santé publique et de médecine du travail (Barbazza, Bos), couverture sanitaire universelle (CSU) Amsterdam, Université d'Amsterdam, Amsterdam, Pays-Bas; Grappe de recherche sur les services de santé (Saunes), Division des services de santé, Institut norvégien de santé publique, Oslo, Norvège; Unité de recherche sur la santé des populations (Auvinen), Université d'Oulu; Centre de recherches médicales (Auvinen), Hôpital universitaire d'Oulu et Université d'Oulu, Oulu, Finlande
| | - Tara Kiran
- Faculté de médecine Temerty (Shahaed) et Département de médecine familiale et communautaire (Glazier, Kiran), Hôpital St. Michael, Université de Toronto; Centre MAP pour des solutions de santé urbaines (Glazier, Daneshvarfard, Kiran), Institut du savoir Li Ka Shing, Hôpital St. Michael; Institut de recherche en services de santé (ICES Centre) (Glazier, Kiran); Institut des politiques de la gestion et de l'évaluation de la santé (Glazier, Kiran), Université de Toronto, Toronto, Ont.; Département des politiques de la santé (Anderson), École londonienne d'économie et de sciences politiques, Londres, R.-U.; Département de santé publique et de médecine du travail (Barbazza, Bos), couverture sanitaire universelle (CSU) Amsterdam, Université d'Amsterdam, Amsterdam, Pays-Bas; Grappe de recherche sur les services de santé (Saunes), Division des services de santé, Institut norvégien de santé publique, Oslo, Norvège; Unité de recherche sur la santé des populations (Auvinen), Université d'Oulu; Centre de recherches médicales (Auvinen), Hôpital universitaire d'Oulu et Université d'Oulu, Oulu, Finlande.
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Shahaed H, Glazier RH, Anderson M, Barbazza E, Bos VLLC, Saunes IS, Auvinen J, Daneshvarfard M, Kiran T. Primary care for all: lessons for Canada from peer countries with high primary care attachment. CMAJ 2023; 195:E1628-E1636. [PMID: 38049161 DOI: 10.1503/cmaj.221824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/06/2023] Open
Affiliation(s)
- Heba Shahaed
- Temerty Faculty of Medicine (Shahaed), and Department of Family and Community Medicine (Glazier, Kiran), St. Michael's Hospital, University of Toronto; MAP Centre for Urban Health Solutions (Glazier, Daneshvarfard, Kiran), Li Ka Shing Knowledge Institute, St. Michael's Hospital; ICES Central (Glazier, Kiran); Institute of Health Policy, Management and Evaluation (Glazier, Kiran), University of Toronto, Toronto, Ont.; Department of Health Policy (Anderson), London School of Economics and Political Science, London, UK; Department of Public and Occupational Health (Barbazza, Bos), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cluster for Health Services Research (Saunes), Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway; Research Unit of Population Health (Auvinen), University of Oulu; Medical Research Center (Auvinen), Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Richard H Glazier
- Temerty Faculty of Medicine (Shahaed), and Department of Family and Community Medicine (Glazier, Kiran), St. Michael's Hospital, University of Toronto; MAP Centre for Urban Health Solutions (Glazier, Daneshvarfard, Kiran), Li Ka Shing Knowledge Institute, St. Michael's Hospital; ICES Central (Glazier, Kiran); Institute of Health Policy, Management and Evaluation (Glazier, Kiran), University of Toronto, Toronto, Ont.; Department of Health Policy (Anderson), London School of Economics and Political Science, London, UK; Department of Public and Occupational Health (Barbazza, Bos), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cluster for Health Services Research (Saunes), Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway; Research Unit of Population Health (Auvinen), University of Oulu; Medical Research Center (Auvinen), Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Michael Anderson
- Temerty Faculty of Medicine (Shahaed), and Department of Family and Community Medicine (Glazier, Kiran), St. Michael's Hospital, University of Toronto; MAP Centre for Urban Health Solutions (Glazier, Daneshvarfard, Kiran), Li Ka Shing Knowledge Institute, St. Michael's Hospital; ICES Central (Glazier, Kiran); Institute of Health Policy, Management and Evaluation (Glazier, Kiran), University of Toronto, Toronto, Ont.; Department of Health Policy (Anderson), London School of Economics and Political Science, London, UK; Department of Public and Occupational Health (Barbazza, Bos), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cluster for Health Services Research (Saunes), Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway; Research Unit of Population Health (Auvinen), University of Oulu; Medical Research Center (Auvinen), Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Erica Barbazza
- Temerty Faculty of Medicine (Shahaed), and Department of Family and Community Medicine (Glazier, Kiran), St. Michael's Hospital, University of Toronto; MAP Centre for Urban Health Solutions (Glazier, Daneshvarfard, Kiran), Li Ka Shing Knowledge Institute, St. Michael's Hospital; ICES Central (Glazier, Kiran); Institute of Health Policy, Management and Evaluation (Glazier, Kiran), University of Toronto, Toronto, Ont.; Department of Health Policy (Anderson), London School of Economics and Political Science, London, UK; Department of Public and Occupational Health (Barbazza, Bos), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cluster for Health Services Research (Saunes), Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway; Research Unit of Population Health (Auvinen), University of Oulu; Medical Research Center (Auvinen), Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Véronique L L C Bos
- Temerty Faculty of Medicine (Shahaed), and Department of Family and Community Medicine (Glazier, Kiran), St. Michael's Hospital, University of Toronto; MAP Centre for Urban Health Solutions (Glazier, Daneshvarfard, Kiran), Li Ka Shing Knowledge Institute, St. Michael's Hospital; ICES Central (Glazier, Kiran); Institute of Health Policy, Management and Evaluation (Glazier, Kiran), University of Toronto, Toronto, Ont.; Department of Health Policy (Anderson), London School of Economics and Political Science, London, UK; Department of Public and Occupational Health (Barbazza, Bos), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cluster for Health Services Research (Saunes), Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway; Research Unit of Population Health (Auvinen), University of Oulu; Medical Research Center (Auvinen), Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Ingrid S Saunes
- Temerty Faculty of Medicine (Shahaed), and Department of Family and Community Medicine (Glazier, Kiran), St. Michael's Hospital, University of Toronto; MAP Centre for Urban Health Solutions (Glazier, Daneshvarfard, Kiran), Li Ka Shing Knowledge Institute, St. Michael's Hospital; ICES Central (Glazier, Kiran); Institute of Health Policy, Management and Evaluation (Glazier, Kiran), University of Toronto, Toronto, Ont.; Department of Health Policy (Anderson), London School of Economics and Political Science, London, UK; Department of Public and Occupational Health (Barbazza, Bos), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cluster for Health Services Research (Saunes), Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway; Research Unit of Population Health (Auvinen), University of Oulu; Medical Research Center (Auvinen), Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Juha Auvinen
- Temerty Faculty of Medicine (Shahaed), and Department of Family and Community Medicine (Glazier, Kiran), St. Michael's Hospital, University of Toronto; MAP Centre for Urban Health Solutions (Glazier, Daneshvarfard, Kiran), Li Ka Shing Knowledge Institute, St. Michael's Hospital; ICES Central (Glazier, Kiran); Institute of Health Policy, Management and Evaluation (Glazier, Kiran), University of Toronto, Toronto, Ont.; Department of Health Policy (Anderson), London School of Economics and Political Science, London, UK; Department of Public and Occupational Health (Barbazza, Bos), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cluster for Health Services Research (Saunes), Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway; Research Unit of Population Health (Auvinen), University of Oulu; Medical Research Center (Auvinen), Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Maryam Daneshvarfard
- Temerty Faculty of Medicine (Shahaed), and Department of Family and Community Medicine (Glazier, Kiran), St. Michael's Hospital, University of Toronto; MAP Centre for Urban Health Solutions (Glazier, Daneshvarfard, Kiran), Li Ka Shing Knowledge Institute, St. Michael's Hospital; ICES Central (Glazier, Kiran); Institute of Health Policy, Management and Evaluation (Glazier, Kiran), University of Toronto, Toronto, Ont.; Department of Health Policy (Anderson), London School of Economics and Political Science, London, UK; Department of Public and Occupational Health (Barbazza, Bos), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cluster for Health Services Research (Saunes), Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway; Research Unit of Population Health (Auvinen), University of Oulu; Medical Research Center (Auvinen), Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Tara Kiran
- Temerty Faculty of Medicine (Shahaed), and Department of Family and Community Medicine (Glazier, Kiran), St. Michael's Hospital, University of Toronto; MAP Centre for Urban Health Solutions (Glazier, Daneshvarfard, Kiran), Li Ka Shing Knowledge Institute, St. Michael's Hospital; ICES Central (Glazier, Kiran); Institute of Health Policy, Management and Evaluation (Glazier, Kiran), University of Toronto, Toronto, Ont.; Department of Health Policy (Anderson), London School of Economics and Political Science, London, UK; Department of Public and Occupational Health (Barbazza, Bos), Amsterdam UMC, University of Amsterdam, Amsterdam, the Netherlands; Cluster for Health Services Research (Saunes), Division for Health Services, Norwegian Institute of Public Health, Oslo, Norway; Research Unit of Population Health (Auvinen), University of Oulu; Medical Research Center (Auvinen), Oulu University Hospital and University of Oulu, Oulu, Finland.
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Lapointe-Shaw L, Salahub C, Austin PC, Bai L, Bhatia RS, Bird C, Glazier RH, Hedden L, Ivers NM, Martin D, Shuldiner J, Spithoff S, Tadrous M, Kiran T. Virtual Visits With Own Family Physician vs Outside Family Physician and Emergency Department Use. JAMA Netw Open 2023; 6:e2349452. [PMID: 38150254 PMCID: PMC10753397 DOI: 10.1001/jamanetworkopen.2023.49452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 11/13/2023] [Indexed: 12/28/2023] Open
Abstract
Importance Virtual visits became more common after the COVID-19 pandemic, but it is unclear in what context they are best used. Objective To investigate whether there was a difference in subsequent emergency department use between patients who had a virtual visit with their own family physician vs those who had virtual visits with an outside physician. Design, Setting, and Participants This propensity score-matched cohort study was conducted among all Ontario residents attached to a family physician as of April 1, 2021, who had a virtual family physician visit in the subsequent year (to March 31, 2022). Exposure The type of virtual family physician visit, with own or outside physician, was determined. In a secondary analysis, own physician visits were compared with visits with a physician working in direct-to-consumer telemedicine. Main Outcome and Measure The primary outcome was an emergency department visit within 7 days after the virtual visit. Results Among 5 229 240 Ontario residents with a family physician and virtual visit, 4 173 869 patients (79.8%) had a virtual encounter with their own physician (mean [SD] age, 49.3 [21.5] years; 2 420 712 females [58.0%]) and 1 055 371 patients (20.2%) had an encounter with an outside physician (mean [SD] age, 41.8 [20.9] years; 605 614 females [57.4%]). In the matched cohort of 1 885 966 patients, those who saw an outside physician were 66% more likely to visit an emergency department within 7 days than those who had a virtual visit with their own physician (30 748 of 942 983 patients [3.3%] vs 18 519 of 942 983 patients [2.0%]; risk difference, 1.3% [95% CI, 1.2%-1.3%]; relative risk, 1.66 [95% CI, 1.63-1.69]). The increase in the risk of emergency department visits was greater when comparing 30 216 patients with definite direct-to-consumer telemedicine visits with 30 216 patients with own physician visits (risk difference, 4.1% [95% CI, 3.8%-4.5%]; relative risk, 2.99 [95% CI, 2.74-3.27]). Conclusions and Relevance In this study, patients whose virtual visit was with an outside physician were more likely to visit an emergency department in the next 7 days than those whose virtual visit was with their own family physician. These findings suggest that primary care virtual visits may be best used within an existing clinical relationship.
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Affiliation(s)
- Lauren Lapointe-Shaw
- University Health Network, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Division of General Internal Medicine and Geriatrics, University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | | | - Peter C. Austin
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Li Bai
- ICES, Toronto, Ontario, Canada
| | - R. Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Cardiology, University Health Network, Toronto, Ontario, Canada
| | | | - Richard H. Glazier
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Lindsay Hedden
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Noah M. Ivers
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Danielle Martin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Jennifer Shuldiner
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
| | - Sheryl Spithoff
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Mina Tadrous
- ICES, Toronto, Ontario, Canada
- Women’s College Institute for Health System Solutions and Virtual Care, Women’s College Hospital, Toronto, Ontario, Canada
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Tara Kiran
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
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Shuldiner J, Kiran T, Agarwal P, Daneshvarfard M, Eldridge K, Kim S, Greiver M, Jokhio I, Ivers N. Developing an Audit and Feedback Dashboard for Family Physicians: User-Centered Design Process. JMIR Hum Factors 2023; 10:e47718. [PMID: 37943586 PMCID: PMC10667970 DOI: 10.2196/47718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 06/29/2023] [Accepted: 07/22/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Audit and feedback (A&F), the summary and provision of clinical performance data, is a common quality improvement strategy. Successful design and implementation of A&F-or any quality improvement strategy-should incorporate evidence-informed best practices as well as context-specific end user input. OBJECTIVE We used A&F theory and user-centered design to inform the development of a web-based primary care A&F dashboard. We describe the design process and how it influenced the design of the dashboard. METHODS Our design process included 3 phases: prototype development based on A&F theory and input from clinical improvement leaders; workshop with family physician quality improvement leaders to develop personas (ie, fictional users that represent an archetype character representative of our key users) and application of those personas to design decisions; and user-centered interviews with family physicians to learn about the physician's reactions to the revised dashboard. RESULTS The team applied A&F best practices to the dashboard prototype. Personas were used to identify target groups with challenges and behaviors as a tool for informed design decision-making. Our workshop produced 3 user personas, Dr Skeptic, Frazzled Physician, and Eager Implementer, representing common users based on the team's experience of A&F. Interviews were conducted to further validate findings from the persona workshop and found that (1) physicians were interested in how they compare with peers; however, if performance was above average, they were not motivated to improve even if gaps compared to other standards in their care remained; (2) burnout levels were high as physicians are trying to catch up on missed care during the pandemic and are therefore less motivated to act on the data; and (3) additional desired features included integration within the electronic medical record, and more up-to-date and accurate data. CONCLUSIONS We found that carefully incorporating data from user interviews helped operationalize generic best practices for A&F to achieve an acceptable dashboard that could meet the needs and goals of physicians. We demonstrate such a design process in this paper. A&F dashboards should address physicians' data skepticism, present data in a way that spurs action, and support physicians to have the time and capacity to engage in quality improvement work; the steps we followed may help those responsible for quality improvement strategy implementation achieve these aims.
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Affiliation(s)
| | - Tara Kiran
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
- MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Payal Agarwal
- Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Maryam Daneshvarfard
- MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, ON, Canada
| | - Kirsten Eldridge
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Susie Kim
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Academic Family Health Team, Women's College Hospital, Toronto, ON, Canada
| | - Michelle Greiver
- North York General Hospital Office of Research and Innovation, Toronto, ON, Canada
| | | | - Noah Ivers
- Women's College Hospital, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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Shuldiner J, Shah H, Bar-Ziv S, Mauti J, Kaplan D, Tradrous M, Green ME, Bogoch I, Nowak DA, Mehta K, Desveaux L, Marshall LJ, Ikura S, Taljaard M, Hu J, Vohra-Miller S, Presseau J, Witteman H, Lofters A, Kiran T, Ivers N. Practice Facilitation to Support Family Physicians in Encouraging COVID-19 Vaccine Uptake: A Multimethod Process Evaluation. Ann Fam Med 2023; 21:526-533. [PMID: 38012044 PMCID: PMC10681695 DOI: 10.1370/afm.3041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 06/09/2023] [Accepted: 08/01/2023] [Indexed: 11/29/2023] Open
Abstract
PURPOSE We offered a practice facilitation intervention to family physicians in Ontario, Canada, known to have large numbers of patients not yet vaccinated against coronavirus disease 2019 (COVID-19). METHODS We conducted a multimethod process evaluation embedded within a randomized controlled trial (clinical trial #NCT05099497). We collected descriptive statistics regarding engagement and qualitative interview data from family physicians and practice facilitators, as well as data from facilitator field notes. We analyzed and triangulated the data using thematic analysis and mapped barriers to and enablers for implementation to structural, organizational, physician, and patient factors. RESULTS Of the 300 approached, 90 family physicians (30%) accepted facilitation. Of these, 57% received technical support to identify unvaccinated patients, 29% used trained medical student volunteers to contact patients on their behalf, and 30% used automated calling to reach patients. Key factors affecting engagement with the intervention were staff shortages owing to COVID-19 (structural), clinic characteristics such as technical issues and gatekeeping by staff, which prevented facilitators from talking with physicians (organizational), burnout (physician), and specialized populations that required targeted resources (patient). The facilitator's ability to address technical issues and connect family physicians with medical students helped with engagement. CONCLUSIONS Strategies to help underresourced family physicians serving high-needs populations for issues of public health importance, such as vaccine promotion, must acknowledge the scarcity of physicians' time and provide new resources. To successfully engage family physicians, practice facilitators should seek to build trust and relationships over time, including with front-office staff.
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Affiliation(s)
- Jennifer Shuldiner
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada (Shuldiner, Shah, Tradrous, Desveaux, Ivers);
| | - Huda Shah
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada (Shuldiner, Shah, Tradrous, Desveaux, Ivers)
| | - Stacey Bar-Ziv
- Ontario Health, Toronto, Ontario, Canada (Bar-Ziv, Mauti, Kaplan)
| | - Joe Mauti
- Ontario Health, Toronto, Ontario, Canada (Bar-Ziv, Mauti, Kaplan)
| | - David Kaplan
- Ontario Health, Toronto, Ontario, Canada (Bar-Ziv, Mauti, Kaplan)
| | - Mina Tradrous
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada (Shuldiner, Shah, Tradrous, Desveaux, Ivers)
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada (Tradrous)
| | - Michael E Green
- Departments of Family Medicine and Public Health Sciences, Queen's University, Kingston, Ontario, Canada (Green)
| | - Isaac Bogoch
- Department of Medicine, University of Toronto, Toronto General Hospital Research Institute, Toronto, Ontario, Canada (Bogoch)
| | - Dominik Alex Nowak
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (Nowak, Kiran, Ivers)
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada (Nowak, Vohra-Miller)
| | - Kavita Mehta
- Associations of Family Health Teams of Ontario, Toronto, Ontario, Canada (Mehta)
| | - Laura Desveaux
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada (Shuldiner, Shah, Tradrous, Desveaux, Ivers)
- Institute of Better Health, Trillium Health Partners (THP), Mississauga, Ontario, Canada (Desveaux)
- Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada (Desveaux)
| | - Lydia-Joi Marshall
- Health Commons Solution Lab, Sinai Health System, Toronto, Ontario, Canada (Marshall, Ikura)
| | - Sophia Ikura
- Health Commons Solution Lab, Sinai Health System, Toronto, Ontario, Canada (Marshall, Ikura)
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada (Taljaard)
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (Taljaard, Presseau)
| | - Jia Hu
- Alberta Health Services, Edmonton, Alberta, Canada (Hu)
| | - Sabina Vohra-Miller
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada (Nowak, Vohra-Miller)
| | - Justin Presseau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (Taljaard, Presseau)
| | - Holly Witteman
- Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada (Witteman)
| | - Aisha Lofters
- Peter Gilgan Centre for Women's Cancers, Women's College Hospital, Toronto, Ontario, Canada (Lofters)
| | - Tara Kiran
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (Nowak, Kiran, Ivers)
| | - Noah Ivers
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada (Shuldiner, Shah, Tradrous, Desveaux, Ivers)
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada (Nowak, Kiran, Ivers)
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9
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Lofters AK, Wu F, Frymire E, Kiran T, Vahabi M, Green ME, Glazier RH. Cancer Screening Disparities Before and After the COVID-19 Pandemic. JAMA Netw Open 2023; 6:e2343796. [PMID: 37983033 PMCID: PMC10660460 DOI: 10.1001/jamanetworkopen.2023.43796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/08/2023] [Indexed: 11/21/2023] Open
Abstract
Importance Breast, cervical, and colorectal cancer-screening disparities existed prior to the COVID-19 pandemic, and it is unclear whether those have changed since the pandemic. Objective To assess whether changes in screening from before the pandemic to after the pandemic varied for immigrants and for people with limited income. Design, Setting, and Participants This population-based, cross-sectional study, using data from March 31, 2019, and March 31, 2022, included adults in Ontario, Canada, the country's most populous province, with more than 14 million people, almost 30% of whom are immigrants. At both dates, the screening-eligible population for each cancer type was assessed. Exposures Neighborhood income quintile, immigrant status, and primary care model type. Main Outcomes and Measures For each cancer screening type, the main outcome was whether the screening-eligible population was up to date on screening (a binary outcome) on March 31, 2019, and March 31, 2022. Up to date on screening was defined as having had a mammogram in the previous 2 years, a Papanicolaou test in the previous 3 years, and a fecal test in the previous 2 years or a flexible sigmoidoscopy or colonoscopy in the previous 10 years. Results The overall cohort on March 31, 2019, included 1 666 943 women (100%) eligible for breast screening (mean [SD] age, 59.9 [5.1] years), 3 918 225 women (100%) eligible for cervical screening (mean [SD] age, 45.5 [13.2] years), and 3 886 345 people eligible for colorectal screening (51.4% female; mean [SD] age, 61.8 [6.4] years). The proportion of people up to date on screening in Ontario decreased for breast, cervical, and colorectal cancers, with the largest decrease for breast screening (from 61.1% before the pandemic to 51.7% [difference, -9.4 percentage points]) and the smallest decrease for colorectal screening (from 65.9% to 62.0% [difference, -3.9 percentage points]). Preexisting disparities in screening for people living in low-income neighborhoods and for immigrants widened for breast screening and colorectal screening. For breast screening, compared with income quintile 5 (highest), the β estimate for income quintile 1 (lowest) was -1.16 (95% CI, -1.56 to -0.77); for immigrant vs nonimmigrant, the β estimate was -1.51 (95% CI, -1.84 to -1.18). For colorectal screening, compared with income quintile 5, the β estimate for quntile 1 was -1.29 (95% CI, 16 -1.53 to -1.06); for immigrant vs nonimmigrant, the β estimate was -1.41 (95% CI, -1.61 to -1.21). The lowest screening rates both before and after the COVID-19 pandemic were for people who had no identifiable family physician (eg, moving from 11.3% in 2019 to 9.6% in 2022 up to date for breast cancer). In addition, patients of interprofessional, team-based primary care models had significantly smaller reductions in β estimates for breast (2.14 [95% CI, 1.79 to 2.49]), cervical (1.72 [95% CI, 1.46 to 1.98]), and colorectal (2.15 [95% CI, 1.95 to 2.36]) postpandemic screening and higher uptake of screening in general compared with patients of other primary care models. Conclusions and Relevance In this cross-sectional study in Ontario that included 2 time points, widening disparities before compared with after the COVID-19 pandemic were found for breast cancer and colorectal cancer screening based on income and immigrant status, but smaller declines in disparities were found among patients of interprofessional, team-based primary care models than among their counterparts. Policy makers should investigate the value of prioritizing and investing in improving access to team-based primary care for people who are immigrants and/or with limited income.
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Affiliation(s)
- Aisha K. Lofters
- Peter Gilgan Centre for Women’s Cancers, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES Central, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Toronto, Ontario, Canada
| | | | - Eliot Frymire
- Health Services and Policy Research Institute, Queen’s University, Kingston, Ontario, Canada
- ICES Queen’s, Kingston, Ontario, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES Central, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Toronto, Ontario, Canada
| | - Mandana Vahabi
- Daphne Cockwell School of Nursing, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Michael E. Green
- Health Services and Policy Research Institute, Queen’s University, Kingston, Ontario, Canada
- ICES Queen’s, Kingston, Ontario, Canada
- Department of Family Medicine, Queen’s University, Kingston, Ontario, Canada
| | - Richard H. Glazier
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES Central, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St Michael’s Hospital, Toronto, Ontario, Canada
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10
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O’Neill B, Yusuf A, Lofters A, Huang A, Ekeleme N, Kiran T, Greiver M, Sullivan F, Kurdyak P. Breast Cancer Screening Among Females With and Without Schizophrenia. JAMA Netw Open 2023; 6:e2345530. [PMID: 38019514 PMCID: PMC10687664 DOI: 10.1001/jamanetworkopen.2023.45530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 10/19/2023] [Indexed: 11/30/2023] Open
Abstract
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.
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Affiliation(s)
- Braden O’Neill
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Abban Yusuf
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Ontario, Canada
| | - Aisha Lofters
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
- Women’s College Research Institute, Toronto, Ontario, Canada
| | | | - Ngozi Ekeleme
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Ontario, Canada
| | - Tara Kiran
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael’s Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
| | - Michelle Greiver
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada
- Department of Family and Community Medicine, North York General Hospital, Toronto, Ontario, Canada
| | - Frank Sullivan
- School of Medicine, Sir James Mackenzie Institute for Early Diagnosis, Population and Behavioural Science Division, University of St Andrews, St Andrews, Scotland
| | - Paul Kurdyak
- ICES, Toronto, Ontario, Canada
- Institute for Mental Health Policy Research and Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Giridhar M, Manjunath BC, Surendra BS, Harish KN, Prashantha SC, Kiran T, Uma B, Murthy HCA. Sustainable approach of La doped CuFe 2O 4 nanomaterial for electrochemical lead and paracetamol sensing action with multiple applications. Sci Rep 2023; 13:17821. [PMID: 37857785 PMCID: PMC10587082 DOI: 10.1038/s41598-023-45029-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 10/14/2023] [Indexed: 10/21/2023] Open
Abstract
This present research aimed to investigate the novel applications of synthesized La doped CuFe2O4 nanomaterial (LCF NMs) using renewable bio-fuel (Aegle Marmelos extract) by combustion process. The sensor applications were accomplished by modified electrode using LCF NMs with graphite powder and examined its excellent sensing action towards heavy metal (Lead content) and drug chemical (Paracetamol) substances. The thermodynamics of redox potential and super-capacitor behavior of LCF NMs were investigated through Cyclic Voltametric (CV) and Electrochemical Impedance Spectral (EIS) methods under specific conditions at scan rate of 1 to 5 mV/s. The heterogeneous photo-catalytic process of prepared NMs on Fast orange Red (FOR) dye-decolouration was investigated and noted its excellent degradation (91.7%) at 90 min using 20 ppm of dye solution and 40 mg of synthesized samples under Sun-light irradiation. Further, the antibacterial activity of synthesized NMs is investigated against various strains of gram positive (Bacillus subtillis) and gram negative bacteria (Pseudomonas aeruginosa), which confirms that the LCF NMs have higher activity towards gram positive bacteria with an average inhibition zone of 19 mm. This synthesized LCF NMs is a multi-functional material with stable and eco-friendly materials.
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Affiliation(s)
- Meenakshi Giridhar
- Department of Physics, St. Phelomena's College, University of Mysore, Mysore, India
| | - B C Manjunath
- Department of Physics, Yuvaraja's College, University of Mysore, Mysore, India.
| | - B S Surendra
- Department of Chemistry, Dayananda Sagar College of Engineering, Bangalore, 560111, India.
| | - K N Harish
- Department of Chemistry, BMS College of Engineering, Bull Temple Road, Bangalore, 560019, India
| | | | - T Kiran
- Department of Chemistry, SJB Institute of Technology, Bangalore, 560 060, India
| | - B Uma
- Department of Chemistry, Dayananda Sagar College of Engineering, Bangalore, 560111, India
| | - H C Ananda Murthy
- Department of Applied Chemistry, School of Applied Natural Science, Adama Science and Technology University, P O Box 1888, Adama, Ethiopia.
- Department of Prosthodontics, Saveetha Dental College & Hospital, Saveetha Institute of Medical and Technical Sciences (SIMATS), Saveetha University, Chennai, 600077, Tamil Nadu, India.
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12
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Rahman B, Costa AP, Gayowsky A, Rahim A, Kiran T, Ivers N, Price D, Jones A, Lapointe-Shaw L. The association between patients' timely access to their usual primary care physician and use of walk-in clinics in Ontario, Canada: a cross-sectional study. CMAJ Open 2023; 11:E847-E858. [PMID: 37751920 PMCID: PMC10521921 DOI: 10.9778/cmajo.20220231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND Challenges in timely access to one's usual primary care physician and the ongoing use of walk-in clinics have been major health policy issues in Ontario for over a decade. We sought to determine the association between patient-reported timely access to their usual primary care physician or clinic and their use of walk-in clinics. METHODS We conducted a cross-sectional study of Ontario residents who had a primary care physician by linking population-based administrative data to Ontario's Health Care Experience Survey, collected between 2013 and 2020. We described sociodemographic characteristics and health care use for users of walk-in clinics and nonusers. We measured the adjusted association between self-reported same-day or next-day access and after-hours access to usual primary care physicians or clinics and the use of walk-in clinics in the previous 12 months. RESULTS Of the 60 935 total responses from people who had a primary care physician, 16 166 (weighted 28.6%, unweighted 26.5%) reported visiting a walk-in clinic in the previous 12 months. Compared with nonusers, those who used walk-in clinics were predominantly younger, lived in large and medium-sized urban areas and reported a tight, very tight or poor financial situation. Respondents who reported poor same-day or next-day access to their primary care physician or clinic were more likely to report having attended a walk-in clinic in the previous 12 months than those with better access (adjusted odds ratio [OR] 1.23, 95% confidence interval [Cl] 1.13-1.34). Those who reported being unaware that their primary care physician offered after-hours care had a higher likelihood of going to a walk-in clinic (adjusted OR 1.14, 95% Cl 1.07-1.21). INTERPRETATION In this population-based health survey, patient-reported use of walk-in clinics was associated with a reported lack of access to same-day or next-day care and unawareness of after-hours care by respondents' usual primary care physicians. These findings could inform policies to improve access to primary care, while preserving care continuity.
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Affiliation(s)
- Bahram Rahman
- Physician and Provider Services Division (Rahman), Ministry of Health, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Rahman, Costa, Gayowsky, Rahim, Jones), McMaster University; ICES McMaster (Costa, Gayowsky, Jones); Centre for Health Economics and Policy Analysis (Costa), and Department of Medicine (Costa), McMaster University; The Research Institute of St. Joe's Hamilton (Costa), St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.; ICES Central (Kiran, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran), St. Michaels's Hospital; MAP Centre for Urban Health Solutions (Kiran), St. Michaels's Hospital; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), Women's College Hospital, Toronto, Ont.; McMaster Family Health Team (Price), Hamilton, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw), University of Toronto, Toronto, Ont.
| | - Andrew P Costa
- Physician and Provider Services Division (Rahman), Ministry of Health, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Rahman, Costa, Gayowsky, Rahim, Jones), McMaster University; ICES McMaster (Costa, Gayowsky, Jones); Centre for Health Economics and Policy Analysis (Costa), and Department of Medicine (Costa), McMaster University; The Research Institute of St. Joe's Hamilton (Costa), St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.; ICES Central (Kiran, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran), St. Michaels's Hospital; MAP Centre for Urban Health Solutions (Kiran), St. Michaels's Hospital; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), Women's College Hospital, Toronto, Ont.; McMaster Family Health Team (Price), Hamilton, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw), University of Toronto, Toronto, Ont
| | - Anastasia Gayowsky
- Physician and Provider Services Division (Rahman), Ministry of Health, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Rahman, Costa, Gayowsky, Rahim, Jones), McMaster University; ICES McMaster (Costa, Gayowsky, Jones); Centre for Health Economics and Policy Analysis (Costa), and Department of Medicine (Costa), McMaster University; The Research Institute of St. Joe's Hamilton (Costa), St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.; ICES Central (Kiran, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran), St. Michaels's Hospital; MAP Centre for Urban Health Solutions (Kiran), St. Michaels's Hospital; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), Women's College Hospital, Toronto, Ont.; McMaster Family Health Team (Price), Hamilton, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw), University of Toronto, Toronto, Ont
| | - Ahmad Rahim
- Physician and Provider Services Division (Rahman), Ministry of Health, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Rahman, Costa, Gayowsky, Rahim, Jones), McMaster University; ICES McMaster (Costa, Gayowsky, Jones); Centre for Health Economics and Policy Analysis (Costa), and Department of Medicine (Costa), McMaster University; The Research Institute of St. Joe's Hamilton (Costa), St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.; ICES Central (Kiran, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran), St. Michaels's Hospital; MAP Centre for Urban Health Solutions (Kiran), St. Michaels's Hospital; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), Women's College Hospital, Toronto, Ont.; McMaster Family Health Team (Price), Hamilton, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw), University of Toronto, Toronto, Ont
| | - Tara Kiran
- Physician and Provider Services Division (Rahman), Ministry of Health, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Rahman, Costa, Gayowsky, Rahim, Jones), McMaster University; ICES McMaster (Costa, Gayowsky, Jones); Centre for Health Economics and Policy Analysis (Costa), and Department of Medicine (Costa), McMaster University; The Research Institute of St. Joe's Hamilton (Costa), St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.; ICES Central (Kiran, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran), St. Michaels's Hospital; MAP Centre for Urban Health Solutions (Kiran), St. Michaels's Hospital; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), Women's College Hospital, Toronto, Ont.; McMaster Family Health Team (Price), Hamilton, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw), University of Toronto, Toronto, Ont
| | - Noah Ivers
- Physician and Provider Services Division (Rahman), Ministry of Health, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Rahman, Costa, Gayowsky, Rahim, Jones), McMaster University; ICES McMaster (Costa, Gayowsky, Jones); Centre for Health Economics and Policy Analysis (Costa), and Department of Medicine (Costa), McMaster University; The Research Institute of St. Joe's Hamilton (Costa), St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.; ICES Central (Kiran, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran), St. Michaels's Hospital; MAP Centre for Urban Health Solutions (Kiran), St. Michaels's Hospital; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), Women's College Hospital, Toronto, Ont.; McMaster Family Health Team (Price), Hamilton, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw), University of Toronto, Toronto, Ont
| | - David Price
- Physician and Provider Services Division (Rahman), Ministry of Health, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Rahman, Costa, Gayowsky, Rahim, Jones), McMaster University; ICES McMaster (Costa, Gayowsky, Jones); Centre for Health Economics and Policy Analysis (Costa), and Department of Medicine (Costa), McMaster University; The Research Institute of St. Joe's Hamilton (Costa), St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.; ICES Central (Kiran, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran), St. Michaels's Hospital; MAP Centre for Urban Health Solutions (Kiran), St. Michaels's Hospital; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), Women's College Hospital, Toronto, Ont.; McMaster Family Health Team (Price), Hamilton, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw), University of Toronto, Toronto, Ont
| | - Aaron Jones
- Physician and Provider Services Division (Rahman), Ministry of Health, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Rahman, Costa, Gayowsky, Rahim, Jones), McMaster University; ICES McMaster (Costa, Gayowsky, Jones); Centre for Health Economics and Policy Analysis (Costa), and Department of Medicine (Costa), McMaster University; The Research Institute of St. Joe's Hamilton (Costa), St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.; ICES Central (Kiran, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran), St. Michaels's Hospital; MAP Centre for Urban Health Solutions (Kiran), St. Michaels's Hospital; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), Women's College Hospital, Toronto, Ont.; McMaster Family Health Team (Price), Hamilton, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw), University of Toronto, Toronto, Ont
| | - Lauren Lapointe-Shaw
- Physician and Provider Services Division (Rahman), Ministry of Health, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Rahman, Costa, Gayowsky, Rahim, Jones), McMaster University; ICES McMaster (Costa, Gayowsky, Jones); Centre for Health Economics and Policy Analysis (Costa), and Department of Medicine (Costa), McMaster University; The Research Institute of St. Joe's Hamilton (Costa), St. Joseph's Healthcare Hamilton; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Schlegel Research Institute for Aging (Costa), Waterloo, Ont.; ICES Central (Kiran, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran), St. Michaels's Hospital; MAP Centre for Urban Health Solutions (Kiran), St. Michaels's Hospital; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), Women's College Hospital, Toronto, Ont.; McMaster Family Health Team (Price), Hamilton, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw), University of Toronto, Toronto, Ont
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Bayoumi I, Glazier RH, Jaakkimainen L, Premji K, Kiran T, Frymire E, Khan S, Green ME. Trends in attachment to a primary care provider in Ontario, 2008-2018: an interrupted time-series analysis. CMAJ Open 2023; 11:E809-E819. [PMID: 37669813 PMCID: PMC10482493 DOI: 10.9778/cmajo.20220167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Abstract
BACKGROUND Attachment to a regular primary care provider is associated with better health outcomes, but 15% of people in Canada lack a consistent source of ongoing primary care. We sought to evaluate trends in attachment to a primary care provider in Ontario in 2008-2018, through an equity lens and in relation to policy changes in implementation of payment reforms and team-based care. METHODS Using linked, population-level administrative data, we conducted a retrospective observational study to calculate rates of patients attached to a regular primary care provider from Apr. 1, 2008, to Mar. 31, 2019. We evaluated the association of patient characteristics and attachment in 2018 using sex-stratified, adjusted, multivariable logistic regression models and used segmented piecewise regression to evaluate changing trends before and after implementation of a policy that restricted physician entry to alternate models. RESULTS Attachment increased from 80.5% (n = 10 352 385) in 2008 to 88.9% of the population (n = 12 537 172) in 2018, but was lower among people with low comorbidity, high residential instability, material deprivation, rural residence and recent immigrants. Inequities narrowed for recent immigrants, males and people with lower incomes over the study period, but disparities persisted for these groups. Attachment grew by 1.47% annually until 2014 (p < 0.0001), but was stagnant thereafter (annual percent change of 0.13, p = 0.16). INTERPRETATION Lack of sustained progress in attachment followed reduced levels of physician entry to alternate funding models. Although disparities narrowed for many groups over the study period, persistent gaps remained for immigrants and people with lower incomes; targeted interventions and policy changes are needed to address these persistent gaps.
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Affiliation(s)
- Imaan Bayoumi
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont.
| | - Richard H Glazier
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Liisa Jaakkimainen
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Kamila Premji
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Tara Kiran
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Eliot Frymire
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Shahriar Khan
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
| | - Michael E Green
- Department of Family Medicine (Bayoumi), Queen's University; ICES Queen's (Bayoumi, Frymire, Khan, Green), Kingston, Ont.; ICES Central (Glazier, Jaakkimainen, Premji, Kiran); Department of Family and Community Medicine (Glazier, Kiran), University of Toronto, Toronto, Ont.; Health Services and Policy Research Institute (Frymire, Khan, Green), Queen's University, Kingston, Ont
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Pinto AD, Eissa A, Kiran T, Mashford-Pringle A, Needham A, Dhalla I. Enjeux relatifs à la collecte des données sur la race et l’identité autochtone lors du renouvellement de la carte santé au Canada. CMAJ 2023; 195:E1062-E1064. [PMID: 37580079 PMCID: PMC10426351 DOI: 10.1503/cmaj.221587-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/16/2023] Open
Affiliation(s)
- Andrew D Pinto
- Laboratoire Upstream (Pinto, Eissa), Centre MAP pour des solutions de santé urbaine, Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Pinto, Eissa, Mashford-Pringle, Dhalla), École Dalla Lana de santé publique et Département de médecine familiale et communautaire (Pinto, Eissa, Kiran), Faculté de médecine, Université de Toronto; Département de médecine familiale et communautaire (Pinto, Kiran), Hôpital St Michael, Réseau universitaire de santé de Toronto, Toronto, Ont.; Équipe de santé familiale de Barrie (Eissa), Unité d'enseignement en médecine familiale de Barrie, Centre de santé régional Royal Victoria, Barrie, Ont.; ICES Central (Kiran, Dhalla); Centre MAP pour des solutions en santé urbaine (Kiran), Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut Waakebiness-Bryce pour la santé autochtone (Mashford-Pringle), École Dalla Lana de santé publique, Université de Toronto; Direction de la lutte antiraciste, de l'équité et de la responsabilité sociale (Needham, Dhalla) et Département de médecine (Dhalla), Hôpital St Michael, Réseau universitaire de santé de Toronto; Département de médecine (Dhalla), Faculté de médecine, Université de Toronto, Toronto, Ont.
| | - Azza Eissa
- Laboratoire Upstream (Pinto, Eissa), Centre MAP pour des solutions de santé urbaine, Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Pinto, Eissa, Mashford-Pringle, Dhalla), École Dalla Lana de santé publique et Département de médecine familiale et communautaire (Pinto, Eissa, Kiran), Faculté de médecine, Université de Toronto; Département de médecine familiale et communautaire (Pinto, Kiran), Hôpital St Michael, Réseau universitaire de santé de Toronto, Toronto, Ont.; Équipe de santé familiale de Barrie (Eissa), Unité d'enseignement en médecine familiale de Barrie, Centre de santé régional Royal Victoria, Barrie, Ont.; ICES Central (Kiran, Dhalla); Centre MAP pour des solutions en santé urbaine (Kiran), Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut Waakebiness-Bryce pour la santé autochtone (Mashford-Pringle), École Dalla Lana de santé publique, Université de Toronto; Direction de la lutte antiraciste, de l'équité et de la responsabilité sociale (Needham, Dhalla) et Département de médecine (Dhalla), Hôpital St Michael, Réseau universitaire de santé de Toronto; Département de médecine (Dhalla), Faculté de médecine, Université de Toronto, Toronto, Ont
| | - Tara Kiran
- Laboratoire Upstream (Pinto, Eissa), Centre MAP pour des solutions de santé urbaine, Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Pinto, Eissa, Mashford-Pringle, Dhalla), École Dalla Lana de santé publique et Département de médecine familiale et communautaire (Pinto, Eissa, Kiran), Faculté de médecine, Université de Toronto; Département de médecine familiale et communautaire (Pinto, Kiran), Hôpital St Michael, Réseau universitaire de santé de Toronto, Toronto, Ont.; Équipe de santé familiale de Barrie (Eissa), Unité d'enseignement en médecine familiale de Barrie, Centre de santé régional Royal Victoria, Barrie, Ont.; ICES Central (Kiran, Dhalla); Centre MAP pour des solutions en santé urbaine (Kiran), Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut Waakebiness-Bryce pour la santé autochtone (Mashford-Pringle), École Dalla Lana de santé publique, Université de Toronto; Direction de la lutte antiraciste, de l'équité et de la responsabilité sociale (Needham, Dhalla) et Département de médecine (Dhalla), Hôpital St Michael, Réseau universitaire de santé de Toronto; Département de médecine (Dhalla), Faculté de médecine, Université de Toronto, Toronto, Ont
| | - Angela Mashford-Pringle
- Laboratoire Upstream (Pinto, Eissa), Centre MAP pour des solutions de santé urbaine, Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Pinto, Eissa, Mashford-Pringle, Dhalla), École Dalla Lana de santé publique et Département de médecine familiale et communautaire (Pinto, Eissa, Kiran), Faculté de médecine, Université de Toronto; Département de médecine familiale et communautaire (Pinto, Kiran), Hôpital St Michael, Réseau universitaire de santé de Toronto, Toronto, Ont.; Équipe de santé familiale de Barrie (Eissa), Unité d'enseignement en médecine familiale de Barrie, Centre de santé régional Royal Victoria, Barrie, Ont.; ICES Central (Kiran, Dhalla); Centre MAP pour des solutions en santé urbaine (Kiran), Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut Waakebiness-Bryce pour la santé autochtone (Mashford-Pringle), École Dalla Lana de santé publique, Université de Toronto; Direction de la lutte antiraciste, de l'équité et de la responsabilité sociale (Needham, Dhalla) et Département de médecine (Dhalla), Hôpital St Michael, Réseau universitaire de santé de Toronto; Département de médecine (Dhalla), Faculté de médecine, Université de Toronto, Toronto, Ont
| | - Allison Needham
- Laboratoire Upstream (Pinto, Eissa), Centre MAP pour des solutions de santé urbaine, Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Pinto, Eissa, Mashford-Pringle, Dhalla), École Dalla Lana de santé publique et Département de médecine familiale et communautaire (Pinto, Eissa, Kiran), Faculté de médecine, Université de Toronto; Département de médecine familiale et communautaire (Pinto, Kiran), Hôpital St Michael, Réseau universitaire de santé de Toronto, Toronto, Ont.; Équipe de santé familiale de Barrie (Eissa), Unité d'enseignement en médecine familiale de Barrie, Centre de santé régional Royal Victoria, Barrie, Ont.; ICES Central (Kiran, Dhalla); Centre MAP pour des solutions en santé urbaine (Kiran), Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut Waakebiness-Bryce pour la santé autochtone (Mashford-Pringle), École Dalla Lana de santé publique, Université de Toronto; Direction de la lutte antiraciste, de l'équité et de la responsabilité sociale (Needham, Dhalla) et Département de médecine (Dhalla), Hôpital St Michael, Réseau universitaire de santé de Toronto; Département de médecine (Dhalla), Faculté de médecine, Université de Toronto, Toronto, Ont
| | - Irfan Dhalla
- Laboratoire Upstream (Pinto, Eissa), Centre MAP pour des solutions de santé urbaine, Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut des politiques, de la gestion et de l'évaluation de la santé (Pinto, Eissa, Mashford-Pringle, Dhalla), École Dalla Lana de santé publique et Département de médecine familiale et communautaire (Pinto, Eissa, Kiran), Faculté de médecine, Université de Toronto; Département de médecine familiale et communautaire (Pinto, Kiran), Hôpital St Michael, Réseau universitaire de santé de Toronto, Toronto, Ont.; Équipe de santé familiale de Barrie (Eissa), Unité d'enseignement en médecine familiale de Barrie, Centre de santé régional Royal Victoria, Barrie, Ont.; ICES Central (Kiran, Dhalla); Centre MAP pour des solutions en santé urbaine (Kiran), Institut du savoir Li Ka Shing, Réseau universitaire de santé de Toronto; Institut Waakebiness-Bryce pour la santé autochtone (Mashford-Pringle), École Dalla Lana de santé publique, Université de Toronto; Direction de la lutte antiraciste, de l'équité et de la responsabilité sociale (Needham, Dhalla) et Département de médecine (Dhalla), Hôpital St Michael, Réseau universitaire de santé de Toronto; Département de médecine (Dhalla), Faculté de médecine, Université de Toronto, Toronto, Ont
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Stewart A, Craig-Neil A, Hodwitz K, Wang R, Cheng D, Arbess G, Jeon C, Juando-Prats C, Kiran T. Increasing Treatment Rates for Hepatitis C in Primary Care. J Am Board Fam Med 2023; 36:591-602. [PMID: 37468214 DOI: 10.3122/jabfm.2022.220427r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 03/06/2023] [Accepted: 03/13/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Despite antiviral agents that can cure the disease, many individuals with Hepatitis C Virus (HCV) remain untreated. Primary care clinicians can play an important role in HCV treatment but often feel they do not have the requisite skills. METHODS We implemented a population-based improvement intervention over 10 months to support treatment of HCV in a primary care setting. The intervention included a decision-support tool, education for clinicians, enhanced interprofessional team supports, mentorship, and proactive patient outreach. We used process and outcome measures to understand the impact on the proportion of patients who initiated treatment and achieved Sustained Virologic Response (SVR). We used physician focus groups and pharmacist interviews to understand the context and mechanisms influencing the impact of the intervention. RESULTS Between December 2018 and June 2020, the percentage of HCV RNA positive patients who started treatment rose from 66.0% (354/536) to 75.5% (401/531) with 92.5% (371/401) of those starting treatment achieving SVR. Qualitative findings highlighted that the intervention helped raise awareness and confidence among physicians for treating HCV in primary care. A collaborative team environment, education, mentorship, and a decision-support tool integrated into the electronic record were all enablers of success although patient psychosocial complexity remained a barrier to engagement in treatment. CONCLUSION A multifaceted primary care improvement initiative increased clinician confidence and was associated with an increase in the proportion of HCV RNA positive patients who initiated curative treatment.
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Affiliation(s)
- Ann Stewart
- From the Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK)
| | - Amy Craig-Neil
- From the Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK)
| | - Kathryn Hodwitz
- From the Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK)
| | - Rick Wang
- From the Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK)
| | - Doret Cheng
- From the Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK)
| | - Gordon Arbess
- From the Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK)
| | - Caroline Jeon
- From the Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK)
| | - Clara Juando-Prats
- From the Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK)
| | - Tara Kiran
- From the Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada (AS, DC, GA, CJ, TK); Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, ON, Canada (AS, GA, CJ, TK); MAP Centre for Urban Health Solutions, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (AC, RW, TK); Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada (KH, CJ); Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada (CJ); Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada (TK)
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Pinto AD, Eissa A, Kiran T, Mashford-Pringle A, Needham A, Dhalla I. Considerations for collecting data on race and Indigenous identity during health card renewal across Canadian jurisdictions. CMAJ 2023; 195:E880-E882. [PMID: 37364910 DOI: 10.1503/cmaj.221587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023] Open
Affiliation(s)
- Andrew D Pinto
- Upstream Lab (Pinto, Eissa), MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto; Institute for Health Policy, Management and Evaluation (Pinto, Eissa, Mashford-Pringle, Dhalla), Dalla Lana School of Public Health, and Department of Family and Community Medicine (Pinto, Eissa, Kiran), Faculty of Medicine, University of Toronto; Department of Family and Community Medicine (Pinto, Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Barrie Family Health Team (Eissa), Barrie Family Medicine Teaching Unit, Royal Victoria Regional Health Centre, Barrie, Ont.; ICES Central (Kiran, Dhalla); MAP Centre for Urban Health Solutions (Kiran), Li Ka Shing Knowledge Institute, Unity Health Toronto; Waakebiness-Bryce Institute for Indigenous Health (Mashford-Pringle), Dalla Lana School of Public Health, University of Toronto; Anti-Racism, Equity and Social Accountability Office (Needham, Dhalla), and Department of Medicine (Dhalla), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Dhalla), Faculty of Medicine, University of Toronto, Toronto, Ont.
| | - Azza Eissa
- Upstream Lab (Pinto, Eissa), MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto; Institute for Health Policy, Management and Evaluation (Pinto, Eissa, Mashford-Pringle, Dhalla), Dalla Lana School of Public Health, and Department of Family and Community Medicine (Pinto, Eissa, Kiran), Faculty of Medicine, University of Toronto; Department of Family and Community Medicine (Pinto, Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Barrie Family Health Team (Eissa), Barrie Family Medicine Teaching Unit, Royal Victoria Regional Health Centre, Barrie, Ont.; ICES Central (Kiran, Dhalla); MAP Centre for Urban Health Solutions (Kiran), Li Ka Shing Knowledge Institute, Unity Health Toronto; Waakebiness-Bryce Institute for Indigenous Health (Mashford-Pringle), Dalla Lana School of Public Health, University of Toronto; Anti-Racism, Equity and Social Accountability Office (Needham, Dhalla), and Department of Medicine (Dhalla), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Dhalla), Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Tara Kiran
- Upstream Lab (Pinto, Eissa), MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto; Institute for Health Policy, Management and Evaluation (Pinto, Eissa, Mashford-Pringle, Dhalla), Dalla Lana School of Public Health, and Department of Family and Community Medicine (Pinto, Eissa, Kiran), Faculty of Medicine, University of Toronto; Department of Family and Community Medicine (Pinto, Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Barrie Family Health Team (Eissa), Barrie Family Medicine Teaching Unit, Royal Victoria Regional Health Centre, Barrie, Ont.; ICES Central (Kiran, Dhalla); MAP Centre for Urban Health Solutions (Kiran), Li Ka Shing Knowledge Institute, Unity Health Toronto; Waakebiness-Bryce Institute for Indigenous Health (Mashford-Pringle), Dalla Lana School of Public Health, University of Toronto; Anti-Racism, Equity and Social Accountability Office (Needham, Dhalla), and Department of Medicine (Dhalla), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Dhalla), Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Angela Mashford-Pringle
- Upstream Lab (Pinto, Eissa), MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto; Institute for Health Policy, Management and Evaluation (Pinto, Eissa, Mashford-Pringle, Dhalla), Dalla Lana School of Public Health, and Department of Family and Community Medicine (Pinto, Eissa, Kiran), Faculty of Medicine, University of Toronto; Department of Family and Community Medicine (Pinto, Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Barrie Family Health Team (Eissa), Barrie Family Medicine Teaching Unit, Royal Victoria Regional Health Centre, Barrie, Ont.; ICES Central (Kiran, Dhalla); MAP Centre for Urban Health Solutions (Kiran), Li Ka Shing Knowledge Institute, Unity Health Toronto; Waakebiness-Bryce Institute for Indigenous Health (Mashford-Pringle), Dalla Lana School of Public Health, University of Toronto; Anti-Racism, Equity and Social Accountability Office (Needham, Dhalla), and Department of Medicine (Dhalla), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Dhalla), Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Allison Needham
- Upstream Lab (Pinto, Eissa), MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto; Institute for Health Policy, Management and Evaluation (Pinto, Eissa, Mashford-Pringle, Dhalla), Dalla Lana School of Public Health, and Department of Family and Community Medicine (Pinto, Eissa, Kiran), Faculty of Medicine, University of Toronto; Department of Family and Community Medicine (Pinto, Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Barrie Family Health Team (Eissa), Barrie Family Medicine Teaching Unit, Royal Victoria Regional Health Centre, Barrie, Ont.; ICES Central (Kiran, Dhalla); MAP Centre for Urban Health Solutions (Kiran), Li Ka Shing Knowledge Institute, Unity Health Toronto; Waakebiness-Bryce Institute for Indigenous Health (Mashford-Pringle), Dalla Lana School of Public Health, University of Toronto; Anti-Racism, Equity and Social Accountability Office (Needham, Dhalla), and Department of Medicine (Dhalla), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Dhalla), Faculty of Medicine, University of Toronto, Toronto, Ont
| | - Irfan Dhalla
- Upstream Lab (Pinto, Eissa), MAP/Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto; Institute for Health Policy, Management and Evaluation (Pinto, Eissa, Mashford-Pringle, Dhalla), Dalla Lana School of Public Health, and Department of Family and Community Medicine (Pinto, Eissa, Kiran), Faculty of Medicine, University of Toronto; Department of Family and Community Medicine (Pinto, Kiran), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.; Barrie Family Health Team (Eissa), Barrie Family Medicine Teaching Unit, Royal Victoria Regional Health Centre, Barrie, Ont.; ICES Central (Kiran, Dhalla); MAP Centre for Urban Health Solutions (Kiran), Li Ka Shing Knowledge Institute, Unity Health Toronto; Waakebiness-Bryce Institute for Indigenous Health (Mashford-Pringle), Dalla Lana School of Public Health, University of Toronto; Anti-Racism, Equity and Social Accountability Office (Needham, Dhalla), and Department of Medicine (Dhalla), St. Michael's Hospital, Unity Health Toronto; Department of Medicine (Dhalla), Faculty of Medicine, University of Toronto, Toronto, Ont
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Husain MO, Khoso AB, Kiran T, Chaudhry N, Husain MI, Asif M, Ansari M, Rajput AH, Dawood S, Naqvi HA, Nizami AT, Tareen Z, Rumi J, Sherzad S, Khan HA, Bhatia MR, Siddiqui KMS, Zadeh Z, Mehmood N, Talib U, de Oliveira C, Naeem F, Wang W, Voineskos A, Husain N, Foussias G, Chaudhry IB. Culturally adapted psychosocial interventions (CaPSI) for early psychosis in a low-resource setting: study protocol for a large multi-center RCT. BMC Psychiatry 2023; 23:444. [PMID: 37328751 PMCID: PMC10276384 DOI: 10.1186/s12888-023-04904-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Psychosis treatment guidelines recommend cognitive behaviour therapy (CBT) and family intervention (FI), for all patients with first episode psychosis (FEP), though guidance borrows heavily from literature in adults from high income countries. To our knowledge, there are few randomized controlled trials (RCTs) examining the comparative effect of these commonly endorsed psychosocial interventions in individuals with early psychosis from high-income countries and no such trials from low and middle-income countries (LMICs). The present study aims to confirm the clinical-efficacy and cost-effectiveness of delivering culturally adapted CBT (CaCBT) and culturally adapted FI (CulFI) to individuals with FEP in Pakistan. METHOD A multi-centre, three-arm RCT of CaCBT, CulFI, and treatment as usual (TAU) for individuals with FEP (n = 390), recruited from major centres across Pakistan. Reducing overall symptoms of FEP will be the primary outcome. Additional aims will include improving patient and carer outcomes and estimating the economic impact of delivering culturally appropriate psychosocial interventions in low-resource settings. This trial will assess the clinical-efficacy and cost-effectiveness of CaCBT and CulFI compared with TAU in improving patient (positive and negative symptoms of psychosis, general psychopathology, depressive symptoms, quality of life, cognition, general functioning, and insight) and carer related outcomes (carer experience, wellbeing, illness attitudes and symptoms of depression and anxiety). CONCLUSIONS A successful trial may inform the rapid scale up of these interventions not only in Pakistan but other low-resource settings, to improve clinical outcomes, social and occupational functioning, and quality of life in South Asian and other minority groups with FEP. TRIAL REGISTRATION NCT05814913.
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Affiliation(s)
- M O Husain
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 1025 Queen St West, Toronto, ON, Canada.
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada.
| | - A B Khoso
- Pakistan Institute of Living and Learning, Karachi, Pakistan
| | - T Kiran
- Pakistan Institute of Living and Learning, Karachi, Pakistan
| | - N Chaudhry
- Pakistan Institute of Living and Learning, Karachi, Pakistan
| | - M I Husain
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 1025 Queen St West, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - M Asif
- Pakistan Institute of Living and Learning, Karachi, Pakistan
| | - M Ansari
- Department of Psychiatry, Liaquat University of Medical and Health Sciences, Hyderabad, Pakistan
| | - A H Rajput
- Department of Psychiatry, Liaquat University of Medical and Health Sciences, Hyderabad, Pakistan
| | - S Dawood
- Centre for Clinical Psychology, University of the Punjab, Lahore, Pakistan
| | - H A Naqvi
- Department of Psychiatry, Dow University Health Sciences, Karachi, Pakistan
| | - A T Nizami
- Institute of Psychiatry, Benazir Bhutto Hospital, Rawalpindi, Pakistan
| | - Z Tareen
- Department of Psychiatry, Balochistan Institute of Psychiatry & Behavioural Sciences, Quetta, Pakistan
| | - J Rumi
- Department of Psychiatry, Balochistan Institute of Psychiatry & Behavioural Sciences, Quetta, Pakistan
| | - S Sherzad
- Department of Psychiatry, Balochistan Institute of Psychiatry & Behavioural Sciences, Quetta, Pakistan
| | - H A Khan
- Department of Psychiatry, Balochistan Institute of Psychiatry & Behavioural Sciences, Quetta, Pakistan
| | - M R Bhatia
- Department of Psychiatry, Peoples University of Medical and Health Sciences, Shaheed Benazirabad, Pakistan
| | | | - Z Zadeh
- Pakistan Institute of Living and Learning, Karachi, Pakistan
| | - N Mehmood
- Institute for Mental Health, Karwan-E-Hayat, Karachi, Pakistan
| | - U Talib
- Institute for Mental Health, Karwan-E-Hayat, Karachi, Pakistan
| | - C de Oliveira
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 1025 Queen St West, Toronto, ON, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - F Naeem
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 1025 Queen St West, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - W Wang
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 1025 Queen St West, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - A Voineskos
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 1025 Queen St West, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - N Husain
- Mersey Care NHS Foundation Trust, Prescott, UK
- Division of Psychology and Mental Health, University of Manchester, Manchester, UK
| | - G Foussias
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, 1025 Queen St West, Toronto, ON, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - I B Chaudhry
- Pakistan Institute of Living and Learning, Karachi, Pakistan
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Psychiatry, Ziauddin University, Karachi, Pakistan
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Lofters A, Salahub C, Austin PC, Bai L, Berthelot S, Bhatia RS, Desveaux L, Ivers NM, Kiran T, Maclure M, Martin D, McBrien KA, McCracken R, Paterson JM, Rahman B, Shuldiner J, Tadrous M, Thakkar N, Lapointe-Shaw L. Up-to-date on cancer screening among Ontario patients seen by walk-in clinic physicians: A retrospective cohort study. Prev Med 2023; 172:107537. [PMID: 37156431 DOI: 10.1016/j.ypmed.2023.107537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 05/03/2023] [Accepted: 05/05/2023] [Indexed: 05/10/2023]
Abstract
Walk-in clinics are typically viewed as high-volume locations for managing acute issues but also may serve as a location for primary care, including cancer screening, for patients without a family physician. In this population-based cohort study, we compared breast, cervical and colorectal cancer screening up-to-date status for people living in the Canadian province of Ontario who were formally enrolled to a family physician versus those not enrolled but who had at least one encounter with a walk-in clinic physician in the previous year. Using provincial administrative databases, we created two mutually exclusive groups: i) those who were formally enrolled to a family physician, ii) those who were not enrolled but had at least one visit with a walk-in clinic physician from April 1, 2019 to March 31, 2020. We compared up to date status for three cancer screenings as of April 1, 2020 among screen-eligible people. We found that people who were not enrolled and had seen a walk-in clinic physician in the previous year consistently were less likely to be up to date on cancer screening than Ontarians who were formally enrolled with a family physician (46.1% vs. 67.4% for breast, 45.8% vs. 67.4% for cervical, 49.5% vs. 73.1% for colorectal). They were also more likely to be foreign-born and to live in structurally marginalized neighbourhoods. New methods are needed to enable screening for people who are reliant on walk-in clinics and to address the urgent need in Ontario for more primary care providers who deliver comprehensive, longitudinal care.
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Affiliation(s)
- Aisha Lofters
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Peter Gilgan Centre for Women's Cancers, Women's College Hospital, Toronto, Ontario, Canada.
| | | | - Peter C Austin
- ICES, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | | | - Simon Berthelot
- Département de médecine familiale et de médecine d'urgence, Université Laval, Québec, Canada
| | - R Sacha Bhatia
- Department of Cardiology, University Health Network, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Laura Desveaux
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Institute for Better Health at Ontario Trillium Health Partners, Mississauga, Ontario, Canada
| | - Noah M Ivers
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; ICES, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada; Department of Family Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; ICES, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Danielle Martin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Kerry A McBrien
- Departments of Family Medicine and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rita McCracken
- Department of Family Practice, The University of British Columbia, Vancouver, British Columbia, Canada; Department of Family Medicine, Providence Health Care, Vancouver, British Columbia, Canada
| | - J Michael Paterson
- ICES, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Bahram Rahman
- Primary Health Care Branch, Ministry of Health, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Ontario, Canada
| | - Jennifer Shuldiner
- Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada
| | - Mina Tadrous
- University Health Network, Toronto, Ontario, Canada; ICES, Ontario, Canada; Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Niels Thakkar
- College of Nurses of Ontario, Toronto, Ontario, Canada
| | - Lauren Lapointe-Shaw
- University Health Network, Toronto, Ontario, Canada; ICES, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada; Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, Ontario, Canada; Division of General Internal Medicine and Geriatrics, University Health Network and Sinai Health System, Toronto, Ontario, Canada
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Kiran T, Rozmovits L, O'Brien P. Factors influencing family physician engagement in practice-based quality improvement: Qualitative study. Can Fam Physician 2023; 69:e113-e119. [PMID: 37173000 PMCID: PMC10177636 DOI: 10.46747/cfp.6905e113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
OBJECTIVE To explore the experiences of family physicians leading quality improvement (QI) efforts and to better understand facilitators and barriers related to advancing QI in family practice. DESIGN Qualitative descriptive study. SETTING The Department of Family and Community Medicine at the University of Toronto in Ontario. The department launched a quality and innovation program in 2011 with the dual goals of teaching QI skills to learners and supporting faculty in leading QI efforts in practice. PARTICIPANTS Family physician faculty who held QI leadership roles at any of the department's 14 teaching units between 2011 and 2018. METHODS Fifteen semistructured telephone interviews were conducted over 3 months in 2018. Analysis was informed by a qualitative descriptive approach. Consistency of responses across the interviews was suggestive of thematic saturation. MAIN FINDINGS Substantial variation was found in the level of engagement with QI in practice settings despite the common training, forms of support, and curriculum the department provided. Four factors influenced the uptake of QI. First, committed leadership across the organization was fundamental to developing an effective QI culture. Second, external drivers such as mandatory QI plans sometimes motivated engagement in QI but sometimes were barriers, particularly when internal priorities conflicted with external demands. Third, at many practices, QI was widely perceived as extra work rather than as a way to enable better patient care. Finally, physicians described lack of time and resources as a challenge, particularly in community practices, and advocated for practice facilitation as a mechanism to support QI efforts. CONCLUSION Advancing QI in primary care practice will require committed leaders, a clear understanding among physicians of the potential benefits of QI, alignment of external demands with internal drivers for improvement, and dedicated time for QI work along with support such as practice facilitation.
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Affiliation(s)
- Tara Kiran
- Vice-Chair of Quality and Innovation in the Department of Family and Community Medicine (DFCM) at the University of Toronto (U of T) in Ontario; Associate Professor in the Faculty of Medicine and the Institute of Health Policy, Management and Evaluation at U of T; Scientist in the MAP Centre for Urban Health Solutions at St Michael's Hospital in Toronto; and a staff physician in the DFCM at St Michael's Hospital.
| | - Linda Rozmovits
- Senior Qualitative Researcher with Health Experiences Research Canada in Montréal, Que
| | - Patricia O'Brien
- Manager of the Quality and Innovation Program at the time of writing and is now Manager of Education Development in the DFCM at U of T
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Breton M, Gaboury I, Martin E, Green ME, Kiran T, Laberge M, Kaczorowski J, Ivers N, Deville-Stoetzel N, Bordeleau F, Beaulieu C, Descoteaux S. Impact of externally facilitated continuous quality improvement cohorts on Advanced Access to support primary healthcare teams: protocol for a quasi-randomized cluster trial. BMC Prim Care 2023; 24:97. [PMID: 37038126 PMCID: PMC10088119 DOI: 10.1186/s12875-023-02048-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 03/29/2023] [Indexed: 04/12/2023]
Abstract
BACKGROUND Improving access to primary health care is among top priorities for many countries. Advanced Access (AA) is one of the most recommended models to improve timely access to care. Over the past 15 years, the AA model has been implemented in Canada, but the implementation of AA varies substantially among providers and clinics. Continuous quality improvement (CQI) approaches can be used to promote organizational change like AA implementation. While CQI fosters the adoption of evidence-based practices, knowledge gaps remain, about the mechanisms by which QI happens and the sustainability of the results. The general aim of the study is to analyse the implementation and effects of CQI cohorts on AA for primary care clinics. Specific objectives are: 1) Analyse the process of implementing CQI cohorts to support PHC clinics in their improvement of AA. 2) Document and compare structural organisational changes and processes of care with respect to AA within study groups (intervention and control). 3) Assess the effectiveness of CQI cohorts on AA outcomes. 4) Appreciate the sustainability of the intervention for AA processes, organisational changes and outcomes. METHODS Cluster-controlled trial allowing for a comprehensive and rigorous evaluation of the proposed intervention 48 multidisciplinary primary care clinics will be recruited to participate. 24 Clinics from the intervention regions will receive the CQI intervention for 18 months including three activities carried out iteratively until the clinic's improvement objectives are achieved: 1) reflective sessions and problem priorisation; 2) plan-do-study-act cycles; and 3) group mentoring. Clinics located in the control regions will receive an audit-feedback report on access. Complementary qualitative and quantitative data reflecting the quintuple aim will be collected over a period of 36 months. RESULTS This research will contribute to filling the gap in the generalizability of CQI interventions and accelerate the spread of effective AA improvement strategies while strengthening local QI culture within clinics. This research will have a direct impact on patients' experiences of care. CONCLUSION This mixed-method approach offers a unique opportunity to contribute to the scientific literature on large-scale CQI cohorts to improve AA in primary care teams and to better understand the processes of CQI. TRIAL REGISTRATION Clinical Trials: NCT05715151.
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Affiliation(s)
- Mylaine Breton
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada.
| | - Isabelle Gaboury
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Elisabeth Martin
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | | | - Tara Kiran
- University of Toronto, Toronto, ON, Canada
| | | | | | - Noah Ivers
- University of Toronto, Toronto, ON, Canada
| | - Nadia Deville-Stoetzel
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Francois Bordeleau
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Christine Beaulieu
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
| | - Sarah Descoteaux
- Université de Sherbrooke, Campus Longueuil, 150 Place Charles-LeMoyne, Office 200, Longueuil, QC, J4K 0A8, Canada
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21
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Kiran T, Green ME, Strauss R, Wu CF, Daneshvarfard M, Kopp A, Lapointe-Shaw L, Latifovic L, Frymire E, Glazier RH. Virtual Care and Emergency Department Use During the COVID-19 Pandemic Among Patients of Family Physicians in Ontario, Canada. JAMA Netw Open 2023; 6:e239602. [PMID: 37115549 PMCID: PMC10148195 DOI: 10.1001/jamanetworkopen.2023.9602] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
Abstract
Importance The COVID-19 pandemic has played a role in increased use of virtual care in primary care. However, few studies have examined the association between virtual primary care visits and other health care use. Objective To evaluate the association between the percentage of virtual visits in primary care and the rate of emergency department (ED) visits. Design, Setting, and Participants This cross-sectional study used routinely collected administrative data and was conducted in Ontario, Canada. The sample comprised family physicians with at least 1 primary care visit claim between February 1 and October 31, 2021, and permanent Ontario residents who were alive as of March 31, 2021. All residents were assigned to physicians according to enrollment and billing data. Exposure Family physicians' virtual visit rate was the exposure. Physicians were stratified by the percentage of total visits that they delivered virtually (via telephone or video) during the study period (0% [100% in person], >0%-20%, >20%-40%, >40%-60%, >60%-80%, >80% to <100%, or 100%). Main Outcomes and Measures Population-level ED visit rate was calculated for each stratum of virtual care use. Multivariable regression models were used to understand the relative rate of patient ED use after adjusting for rurality of practice, patient characteristics, and 2019 ED visit rates. Results Data were analyzed for a total of 13 820 family physicians (7114 males [51.5%]; mean [SD] age, 50 [13.1] years) with 12 951 063 patients (6 714 150 females [51.8%]; mean [SD] age, 42.6 [22.9] years) who were attached to these physicians. Most physicians provided between 40% and 80% of care virtually. A higher percentage of the physicians who provided more than 80% of care virtually were 65 years or older, female individuals, and practiced in big cities. Patient comorbidity and morbidity were similar across strata of virtual care use. The mean (SD) number of ED visits was highest among patients whose physicians provided only in-person care (470.3 [1918.8] per 1000 patients) and was lowest among patients of physicians who provided more than 80% to less than 100% of care virtually (242.0 [800.3] per 1000 patients). After adjustment for patient characteristics, patients of physicians with more than 20% of visits delivered virtually had lower rates of ED visits compared with patients of physicians who provided more than 0% to 20% of care virtually (eg, >80% to <100% vs >0%-20% virtual visits in big cities: relative rate, 0.77%; 95% CI, 0.74%-0.81%). This pattern was unchanged across all rurality of practice strata and after adjustment for 2019 ED visit rates. In urban areas, there was a gradient whereby patients of physicians providing the highest level of virtual care had the lowest ED visit rates. Conclusions and Relevance Findings of this study show that patients of physicians who provided a higher percentage of virtual care did not have higher ED visit rates compared with patients of physicians who provided the lowest levels of virtual care. The findings refute the hypothesis that family physicians providing more care virtually during the pandemic resulted in higher ED use.
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Affiliation(s)
- Tara Kiran
- Department of Family and Community Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- ICES Central, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael E Green
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
- Health Services and Policy Research Institute, Queen's University, Kingston, Ontario, Canada
- ICES Queen's, Kingston, Ontario, Canada
| | | | | | - Maryam Daneshvarfard
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Lauren Lapointe-Shaw
- ICES Central, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto and University Health Network, Toronto, Ontario, Canada
| | - Lidija Latifovic
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Eliot Frymire
- Health Services and Policy Research Institute, Queen's University, Kingston, Ontario, Canada
- ICES Queen's, Kingston, Ontario, Canada
| | - Richard H Glazier
- Department of Family and Community Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- ICES Central, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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22
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O'Neill B, Yusuf A, Kurdyak P, Kiran T, Sullivan F, Chen T, Kalia S, Eisen D, Anderson E, Selby P, Campbell D. Diabetes care among individuals with and without schizophrenia in three Canadian provinces: A retrospective cohort study. Gen Hosp Psychiatry 2023; 82:19-25. [PMID: 36898192 DOI: 10.1016/j.genhosppsych.2023.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/12/2023]
Abstract
OBJECTIVE Diabetes is present in approximately 10% of people living with schizophrenia and substantially contributes to early mortality, but some aspects of diabetes care among those with schizophrenia have been inadequately investigated to date. We assessed diabetes care and comorbidity management among people with and without schizophrenia. METHODS We conducted a cohort study with data obtained from primary care electronic medical records stored in the Diabetes Action Canada (DAC) National Repository from Alberta, Ontario, and Quebec, Canada. The population studied included patients with diabetes, with and without schizophrenia, who had at least 3 primary care visits in a 2 year period between July 2017 and June 2019. Outcomes included glycemia; diabetes complication screening and monitoring; antihyperglycemic and cardioprotective medication prescription; health service use. RESULTS We identified 69,512 patients with diabetes; 911 (1.3%) of whom also had schizophrenia. Prevalence of high HbA1C (>8.5%) (9083/68601; 13.2% vs. 137/911; 15.0%) and high blood pressure (>130/80 mmHg) (4248/68601; 6.2% vs. 73/911; 8.0%) was similar between the two groups. Half (50.0%) of patients with schizophrenia (n = 455) had 11 or more primary care visits in the past year, compared with 27.8% of people without schizophrenia. (p < 0.0001). Patients with schizophrenia had lower odds of ever having blood pressure recorded (OR = 0.81, 95% CI 0.71-0.94) and fewer of those with chronic kidney disease (CKD) were prescribed renin-angiotensin aldosterone system inhibitors, compared to patients without schizophrenia (10.3% vs 15.8%, p = 0.0005). CONCLUSIONS Patients with diabetes and schizophrenia achieved similar blood glucose and blood pressure levels to those without schizophrenia, and had more primary care visits. However, they had fewer blood pressure readings and lower prescription of recommended medications among those who also had CKD. These results are both encouraging and represent opportunities for improvement in care.
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Affiliation(s)
- Braden O'Neill
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada; St. Michael's Hospital Academic Family Health Team, Toronto ON, Canada; Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Canada.
| | - Abban Yusuf
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
| | - Paul Kurdyak
- ICES, Toronto, ON, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Tara Kiran
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada; St. Michael's Hospital Academic Family Health Team, Toronto ON, Canada; Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | - Frank Sullivan
- School of Medicine, University of St. Andrews, St. Andrews, UK
| | - Tao Chen
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Canada
| | - Sumeet Kalia
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Canada; Research and Innovation, North York General Hospital, Toronto, ON, Canada
| | - David Eisen
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Canada; Research and Innovation, North York General Hospital, Toronto, ON, Canada
| | | | - Peter Selby
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Canada; Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - David Campbell
- Departments of Medicine, Community Health Sciences & Cardiac Sciences, University of Calgary, Calgary, AB, Canada
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23
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Lapointe-Shaw L, Kiran T, Salahub C, Austin PC, Berthelot S, Desveaux L, Lofters A, Maclure M, Martin D, McBrien KA, McCracken RK, Rahman B, Schultz SE, Shuldiner J, Tadrous M, Bird C, Paterson JM, Bhatia RS, Thakkar NA, Na Y, Ivers NM. Walk-in clinic patient characteristics and utilization patterns in Ontario, Canada: a cross-sectional study. CMAJ Open 2023; 11:E345-E356. [PMID: 37171909 PMCID: PMC10139081 DOI: 10.9778/cmajo.20220095] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
BACKGROUND Walk-in clinics are common in North America and are designed to provide acute episodic care without an appointment. We sought to describe a sample of walk-in clinic patients in Ontario, Canada, which is a setting with high levels of primary care attachment. METHODS We performed a cross-sectional study using health administrative data from 2019. We compared the sociodemographic characteristics and health care utilization patterns of patients attending 1 of 72 walk-in clinics with those of the general Ontario population. We examined the subset of patients who were enrolled with a family physician and compared walk-in clinic visits to family physician visits. RESULTS Our study found that 562 781 patients made 1 148 151 visits to the included walk-in clinics. Most (70%) patients who attended a walk-in clinic had an enrolling family physician. Walk-in clinic patients were younger (mean age 36 yr v. 41 yr, standardized mean difference [SMD] 0.24), yet had greater health care utilization (moderate and high use group 74% v. 65%, SMD 0.20) than the general Ontario population. Among enrolled Ontarians, walk-in patients had more comorbidities (moderate and high count 50% v. 45%, SMD 0.10), lived farther from their enrolling physician (median 8 km v. 6 km, SMD 0.21) and saw their enrolling physician less in the previous year (any visit 67% v. 80%, SMD 0.30). Walk-in encounters happened more often after hours (16% v. 9%, SMD 0.20) and on weekends (18% v. 5%, SMD 0.45). Walk-in clinics were more often within 3 km of patients' homes than enrolling physicians' offices (0 to < 3 km: 32% v. 22%, SMD 0.21). INTERPRETATION Our findings suggest that proximity of walk-in clinics and after-hours access may be contributing to walk-in clinic use among patients enrolled with a family physician. These findings have implications for policy development to improve the integration of walk-in clinics and longitudinal primary care.
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Affiliation(s)
- Lauren Lapointe-Shaw
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont.
| | - Tara Kiran
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Christine Salahub
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Peter C Austin
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Simon Berthelot
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Laura Desveaux
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Aisha Lofters
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Malcolm Maclure
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Danielle Martin
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Kerry A McBrien
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Rita K McCracken
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Bahram Rahman
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Susan E Schultz
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Jennifer Shuldiner
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Mina Tadrous
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Cherryl Bird
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - J Michael Paterson
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - R Sacha Bhatia
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Niels A Thakkar
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Yingbo Na
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
| | - Noah M Ivers
- ICES (Lapointe-Shaw, Kiran, Austin, Schultz, Tadrous, Paterson, Bhatia, Na, Ivers), Toronto, Ont.; Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Austin, Desveaux, Martin, Paterson, Bhatia, Ivers), University of Toronto, Toronto, Ont.; Division of General Internal Medicine and Geriatrics (Lapointe-Shaw), University Health Network and Sinai Health System, Toronto, Ont.; Department of Medicine (Lapointe-Shaw, Bhatia), University of Toronto, Toronto, Ont.; Women's College Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Martin, Shuldiner, Tadrous, Ivers), Women's College Hospital, Toronto, Ont.; Toronto General Hospital Research Institute, University Health Network (Lapointe-Shaw, Salahub), Toronto, Ont.; Peter Munk Cardiac Centre, University Health Network (Bhatia), Toronto, Ont.; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Département de médecine familiale et de médecine d'urgence (Berthelot), Université Laval, Quebec City, Qué.; Institute for Better Health, Trillium Health Partners (Desveaux), Mississauga, Ont.; Department of Family and Community Medicine (Lofters, Martin, Ivers, Kiran), University of Toronto, Toronto, Ont.; Peter Gilgan Centre for Women's Cancers (Lofters), Women's College Hospital, Toronto, Ont.; Department of Anesthesiology, Pharmacology and Therapeutics (Maclure), University of British Columbia, Vancouver, BC; Department of Family Medicine (Martin, Ivers), Women's College Hospital, Toronto, Ont.; Temerty Faculty of Medicine (Martin), University of Toronto, Toronto, Ont.; Departments of Family Medicine and Community Health Sciences (McBrien), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Family Practice (McCracken), University of British Columbia, Vancouver, BC; Department of Family Medicine (McCracken), Providence Health Care, Vancouver, BC; Primary Health Care Branch (Rahman), Ministry of Health, Toronto, Ont.; patient partner (Bird), Toronto, Ont.; Department of Family Medicine (Paterson), McMaster University, Hamilton, Ont.; College of Nurses of Ontario (Thakkar), Toronto, Ont.; Women's College Hospital Research Institute (Na), Women's College Hospital, Toronto, Ont
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24
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Salahub C, Kiran T, Na Y, Sinha SK, Stall NM, Ivers NM, Costa AP, Jones A, Lapointe-Shaw L. Characteristics and practice patterns of family physicians who provide home visits in Ontario, Canada: a cross-sectional study. CMAJ Open 2023; 11:E282-E290. [PMID: 36944429 PMCID: PMC10035667 DOI: 10.9778/cmajo.20220124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
BACKGROUND Physician home visits are essential for populations who cannot easily access office-based primary care. The objective of this study was to describe the characteristics, practice patterns and physician-level patient characteristics of Ontario physicians who provide home visits. METHODS This was a retrospective cross-sectional study, based on health administrative data, of Ontario physicians who provided home visits and their patients, between Jan. 1, 2019, and Dec. 31, 2019. We selected family physicians who had at least 1 home visit in 2019. Physician demographic characteristics, practice patterns and aggregated patient characteristics were compared between high-volume home visit physicians (the top 5%) and low-volume home visit physicians (bottom 95%). RESULTS A total of 6572 family physicians had at least 1 home visit in 2019. The top 5% of home visit physicians (n = 330) performed 58.6% of all home visits (n = 227 321 out of 387 139). Compared with low-volume home visit physicians (n = 6242), the top 5% were more likely to be male and practise in large urban areas, and rarely saw patients who were enrolled to them (median 4% v. 87.5%, standardized mean difference 1.12). High-volume physicians' home visit patients were younger, had greater levels of health care resource utilization, resided in lower-income and large urban neighbourhoods, and were less likely to have a medical home. INTERPRETATION A small subset of home visit physicians provided a large proportion of home visits in Ontario. These home visits may be addressing a gap in access to primary care for certain patients, but could be contributing to lower continuity of care.
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Affiliation(s)
- Christine Salahub
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Tara Kiran
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Yingbo Na
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Samir K Sinha
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Nathan M Stall
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Noah M Ivers
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Andrew P Costa
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Aaron Jones
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont
| | - Lauren Lapointe-Shaw
- Support, Systems, and Outcomes Department (Salahub, Lapointe-Shaw), Toronto General Hospital Research Institute, University Health Network; ICES Central (Kiran, Na, Ivers, Lapointe-Shaw); Institute of Health Policy, Management and Evaluation (Kiran, Sinha, Stall, Ivers, Lapointe-Shaw), and Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Kiran), St Michael's Hospital; Division of General Internal Medicine and Geriatrics (Sinha, Stall, Lapointe-Shaw), University Health Network and Sinai Health System; Department of Medicine (Sinha, Stall, Lapointe-Shaw), University of Toronto; Women's College Institute for Health System Solutions and Virtual Care (Ivers, Lapointe-Shaw), and Department of Family Medicine (Ivers), Women's College Hospital, Toronto, Ont.; ICES McMaster (Costa, Jones); Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.
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25
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Kiran T. Garder la porte d’entrée ouverte : assurer l’accès aux soins primaires à toute la population canadienne. CMAJ 2023; 195:E251-E253. [PMID: 36781196 PMCID: PMC9928439 DOI: 10.1503/cmaj.221563-f] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/15/2023] Open
Affiliation(s)
- Tara Kiran
- Département de médecine familiale et communautaire, Hôpital St. Michael, Réseau hospitalier Unity Health Toronto; Département de médecine familiale et communautaire, Université de Toronto; Centre MAP pour des solutions de santé urbaine, Institut du savoir Li Ka Shing, Hôpital St. Michael; Institut de recherche en services de santé ICES Central; Institut des politiques, de la gestion et de l'évaluation de la santé, Université de Toronto, Toronto, Ont.
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26
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Gupta M, Bansal A, Chakrapani V, Jaiswal N, Kiran T. The effectiveness of prenatal and postnatal home visits by paramedical professionals and women's group meetings in improving maternal and child health outcomes in low and middle-income countries: a systematic review and meta-analysis. Public Health 2023; 215:106-117. [PMID: 36682079 DOI: 10.1016/j.puhe.2022.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 11/22/2022] [Accepted: 11/29/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To assess the effectiveness of prenatal and postnatal home visits (HVs) and women group meetings (WGMs) by paramedical professionals to improve maternal and child health outcomes in low- and middle-income countries (LMICs). STUDY DESIGN Systematic review and meta-analysis. METHODS We conducted a systematic review of trials published till December 2020, as per registered protocol in The International Prospective Register of Systematic Reviews (PROSPERO) (CRD42018091968). Outcomes were neonatal mortality rate (NMR), maternal mortality ratio (MMR), the incidence of low birth weight, and still birth rate (SBR). The Cochrane Pregnancy and Childbirth Group's Trials Register, Cochrane Central Register of Controlled Trials, PubMed, and Excerpta Medica Database (EMBASE) were searched. Pooled results were estimated using random-effects meta-analysis in RevMan version 5.2. RESULTS Twenty-five trials met the inclusion criteria. HVs were the key intervention in 12, WGMs in 11, and both interventions in 2 trials. The pooled estimates have shown that NMR was significantly reduced by HVs (OR 0.77, confidence interval [CI]: 0.67-0.90, P = 0.0007, I2 = 77%) and WGMs (OR 0.76, CI: 0.65-0.90, P = 0.001, I2 = 71%). SBR was significantly reduced by HVs (OR 0.77, CI: 0.70-0.85; P < 0.001, I2 = 0%). Subgroup analysis of studies in which more than 10% of pregnant women participated in the WGMs showed significant reduction in NMR (OR 0.67, CI 0.58-0.77, P = 0.00001, I2 = 31%) and MMR (OR 0.55, CI 0.36-0.84, P = 0.005, I2 = 27%). Two studies reported improvement in birth weight by HVs. CONCLUSIONS HVs and WGMs (with >10% pregnant women) by paramedical professionals are effective strategies in reducing the NMR and MMR in LMICs. HVs were also effective in reducing SBR.
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Affiliation(s)
- M Gupta
- Postgraduate Institute of Medical Education and Research, Chandigarh, India.
| | - A Bansal
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - V Chakrapani
- Centre for Sexuality and Health Research and Policy (C-SHaRP), Chennai, India
| | - N Jaiswal
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - T Kiran
- Postgraduate Institute of Medical Education and Research, Chandigarh, India
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27
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Desveaux L, Nguyen MD, Ivers NM, Devotta K, Upshaw T, Ramji N, Weyman K, Kiran T. Snakes and ladders: A qualitative study understanding the active ingredients of social interaction around the use of audit and feedback. Transl Behav Med 2023; 13:316-326. [PMID: 36694357 PMCID: PMC10182419 DOI: 10.1093/tbm/ibac114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023] Open
Abstract
Explore characteristics of the facilitator, group, and interaction that influence whether a group discussion about data leads to the identification of a clearly specified action plan. Peer-facilitated group discussions among primary care physicians were carried out and recorded. A follow-up focus group was conducted with peer facilitators to explore which aspects of the discussion promoted action planning. Qualitative data was analyzed using an inductive-deductive thematic analysis approach using the conceptual model developed by Cooke et al. Group discussions were coded case-specifically and then analyzed to identify which themes influenced action planning as it relates to performance improvement. Physicians were more likely to interact with practice-level data and explore actions for performance improvement when the group facilitator focused the discussion on action planning. Only one of the three sites (Site C) converged on an action plan following the peer-facilitated group discussion. At Site A, physicians shared skepticism of the data, were defensive about performance, and explained performance as a product of factors beyond their control. Site B identified several potential actions but had trouble focusing on a single indicator or deciding between physician- and group-level actions. None of the groups discussed variation in physician-level performance indicators, or how physician actions might contribute to the reported outcomes. Peer facilitators can support data interpretation and practice change; however their success depends on their personal beliefs about the data and their ability to identify and leverage change cues that arise in conversation. Further research is needed to understand how to create a psychologically safe environment that welcomes open discussion of physician variation.
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Affiliation(s)
- Laura Desveaux
- Institute for Better Health, Trillium Health Partners, 100 Queensway West, Mississauga, OntarioCanada.,Women's College Hospital Institute for Health Systems Solutions and Virtual Care, 76 Grenville Ave Toronto, Toronto, Ontario, Canada.,Institute for Health Policy, Management & Evaluation, University of Toronto, 155 College St, Toronto, Ontario, Canada
| | - Marlena Dang Nguyen
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, 76 Grenville Ave Toronto, Toronto, Ontario, Canada
| | - Noah Michael Ivers
- Women's College Hospital Institute for Health Systems Solutions and Virtual Care, 76 Grenville Ave Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Canada
| | - Kimberly Devotta
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, Canada
| | - Tara Upshaw
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College St, Toronto, Canada
| | - Noor Ramji
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, Canada
| | - Karen Weyman
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, Canada
| | - Tara Kiran
- Institute for Health Policy, Management & Evaluation, University of Toronto, 155 College St, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, Canada.,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute of St. Michael's Hospital, 30 Bond Street, Toronto, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, Canada
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28
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Kukafka R, Salahub C, Bird C, Bhatia RS, Desveaux L, Glazier RH, Hedden L, Ivers NM, Martin D, Na Y, Spithoff S, Tadrous M, Kiran T. Characteristics and Health Care Use of Patients Attending Virtual Walk-in Clinics in Ontario, Canada: Cross-sectional Analysis. J Med Internet Res 2023; 25:e40267. [PMID: 36633894 PMCID: PMC9880810 DOI: 10.2196/40267] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 10/31/2022] [Accepted: 12/01/2022] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Funding changes in response to the COVID-19 pandemic supported the growth of direct-to-consumer virtual walk-in clinics in several countries. Little is known about patients who attend virtual walk-in clinics or how these clinics contribute to care continuity and subsequent health care use. OBJECTIVE The objective of the present study was to describe the characteristics and measure the health care use of patients who attended virtual walk-in clinics compared to the general population and a subset that received any virtual family physician visit. METHODS This was a retrospective, cross-sectional study in Ontario, Canada. Patients who had received a family physician visit at 1 of 13 selected virtual walk-in clinics from April 1 to December 31, 2020, were compared to Ontario residents who had any virtual family physician visit. The main outcome was postvisit health care use. RESULTS Virtual walk-in patients (n=132,168) had fewer comorbidities and lower previous health care use than Ontarians with any virtual family physician visit. Virtual walk-in patients were also less likely to have a subsequent in-person visit with the same physician (309/132,168, 0.2% vs 704,759/6,412,304, 11%; standardized mean difference [SMD] 0.48), more likely to have a subsequent virtual visit (40,030/132,168, 30.3% vs 1,403,778/6,412,304, 21.9%; SMD 0.19), and twice as likely to have an emergency department visit within 30 days (11,003/132,168, 8.3% vs 262,509/6,412,304, 4.1%; SMD 0.18), an effect that persisted after adjustment and across urban/rural resident groups. CONCLUSIONS Compared to Ontarians attending any family physician virtual visit, virtual walk-in patients were less likely to have a subsequent in-person physician visit and were more likely to visit the emergency department. These findings will inform policy makers aiming to ensure the integration of virtual visits with longitudinal primary care.
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Affiliation(s)
| | - Christine Salahub
- Support, Systems, and Outcomes Department, University Health Network, Toronto, ON, Canada
| | | | - R Sacha Bhatia
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Peter Munk Cardiac Centre, University Health Network, Toronto, ON, Canada
| | - Laura Desveaux
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,Institute for Better Health, Ontario Trillium Health Partners, Mississauga, ON, Canada
| | - Richard H Glazier
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Department of Family and Community Medicine and MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Lindsay Hedden
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
| | - Noah M Ivers
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Family Medicine, Women's College Hospital, Toronto, ON, Canada
| | - Danielle Martin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Family Medicine, Women's College Hospital, Toronto, ON, Canada
| | | | - Sheryl Spithoff
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,Department of Family Medicine, Women's College Hospital, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada
| | - Mina Tadrous
- Women's College Institute for Health System Solutions and Virtual Care, Women's College Hospital, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Women's College Research Institute, Women's College Hospital, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Tara Kiran
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,ICES, Toronto, ON, Canada.,Department of Family and Community Medicine and MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
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Affiliation(s)
- Tara Kiran
- Department of Family and Community Medicine, St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine, University of Toronto; MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital; ICES Central; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont.
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Shah N, Latifovic L, Meaney C, Moineddin R, Derocher MB, Alhaj M, Kiran T. Association Between Clinic-Reported Third Next Available Appointment and Patient-Reported Access to Primary Care. JAMA Netw Open 2022; 5:e2246397. [PMID: 36512361 PMCID: PMC9856348 DOI: 10.1001/jamanetworkopen.2022.46397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
This cross-sectional study examines the association of the third next available appointment with patient-reported measures of access in primary care settings.
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Affiliation(s)
- Nishwa Shah
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Lidija Latifovic
- MAP Centre for Urban Health Solutions in the Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Meaney
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Mary Beth Derocher
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Mohammad Alhaj
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions in the Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada
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Kiran T, Wang R, Handford C, Laraya N, Eissa A, Pariser P, Brown R, Pedersen C. Family physician practice patterns during COVID-19 and future intentions: Cross-sectional survey in Ontario, Canada. Can Fam Physician 2022; 68:836-846. [PMID: 36376032 PMCID: PMC9833162 DOI: 10.46747/cfp.6811836] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To determine the extent to which family physicians closed their doors altogether or for in-person visits during the pandemic, their future practice intentions, and related factors. DESIGN Cross-sectional survey. SETTING Six geographic areas in Toronto, Ont, aligned with Ontario Health Team regions. PARTICIPANTS Family doctors practising office-based, comprehensive family medicine. MAIN OUTCOME MEASURES Practice operations in January 2021, use of virtual care, and future plans. RESULTS Of the 1016 (85.7%) individuals who responded to the survey, 99.7% (1001 of 1004) indicated their practices were open in January 2021, with 94.8% (928 of 979) seeing patients in person and 30.8% (264 of 856) providing in-person care to patients reporting COVID-19 symptoms. Respondents estimated spending 58.2% of clinical care time on telephone visits, 5.8% on video appointments, and 7.5% on e-mail or secure messaging. Among respondents, 17.5% (77 of 439) were planning to close their existing practices in the next 5 years. There were higher proportions of physicians who worked alone in clinics among those who did not see patients in person (27.6% no vs 12.4% yes, P<.05), among those who did not see symptomatic patients (15.6% no vs 6.5% yes, P<.001), and among those who planned to close their practices in the next 5 years (28.9% yes vs 13.9% no, P<.01). CONCLUSION Most family physicians in Toronto were open to in-person care in January 2021, but almost one-fifth were considering closing their practices in the next 5 years. Policy makers need to prepare for a growing family physician shortage and better understand factors that support recruitment and retention.
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Affiliation(s)
- Tara Kiran
- Vice-Chair of Quality and Innovation in the Department of Family and Community Medicine (DFCM) at the University of Toronto in Ontario, Associate Professor in the Faculty of Medicine and the Institute of Health Policy, Management and Evaluation at the University of Toronto, Scientist in the MAP Centre for Urban Health Solutions at St Michael’s Hospital in Toronto and a staff physician in the DFCM at St Michael’s Hospital.,Correspondence Dr Tara Kiran; e-mail
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Kiran T, Green ME, Wu CF, Kopp A, Latifovic L, Frymire E, Moineddin R, Glazier RH. Family Physicians Stopping Practice During the COVID-19 Pandemic in Ontario, Canada. Ann Fam Med 2022; 20:460-463. [PMID: 36228068 PMCID: PMC9512549 DOI: 10.1370/afm.2865] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 03/12/2022] [Accepted: 05/04/2022] [Indexed: 11/09/2022] Open
Abstract
We conducted 2 analyses using administrative data to understand whether more family physicians in Ontario, Canada stopped working during the COVID-19 pandemic compared with previous years. First, we found 3.1% of physicians working in 2019 (n = 385/12,247) reported no billings in the first 6 months of the pandemic; compared with other family physicians, a higher portion were aged 75 years or older (13.0% vs 3.4%, P <0.001), had fee-for-service reimbursement (37.7% vs 24.9%, P <0.001), and had a panel size under 500 patients (40.0% vs 25.8%, P <0.001). Second, a fitted regression line found the absolute increase in the percentage of family physicians stopping work was 0.03% per year from 2010 to 2019 (P = 0.042) but 1.2% between 2019 to 2020 (P <0.001). More research is needed to understand the impact of physicians stopping work on primary care attachment and access to care.
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Affiliation(s)
- Tara Kiran
- Department of Family and Community Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada .,MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, Ontario, Canada.,ICES Central, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Michael E Green
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada.,Health Services and Policy Research Institute, Queens University, Kingston, Ontario, Canada.,ICES Queens, Kingston, Ontario, Canada
| | | | | | - Lidija Latifovic
- MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Eliot Frymire
- Health Services and Policy Research Institute, Queens University, Kingston, Ontario, Canada.,ICES Queens, Kingston, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,ICES Central, Toronto, Ontario, Canada
| | - Richard H Glazier
- Department of Family and Community Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.,MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, Ontario, Canada.,ICES Central, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
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Spithoff S, Mogic L, Hum S, Moineddin R, Meaney C, Kiran T. Examining Access to Primary Care for People With Opioid Use Disorder in Ontario, Canada: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2233659. [PMID: 36178686 PMCID: PMC9526081 DOI: 10.1001/jamanetworkopen.2022.33659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE People with opioid use disorder are less likely than others to have a primary care physician. OBJECTIVE To determine if family physicians are less likely to accept people with opioid use disorder as new patients than people with diabetes. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial used an audit design to survey new patient intake at randomly selected family physicians in Ontario, Canada. Eligible physicians were independent practitioners allowed to prescribe opioids who were located in an office within 50 km of a population center greater than 20 000 people. A patient actor made unannounced telephone calls to family physicians asking for a new patient appointment. The data were analyzed in September 2021. INTERVENTION In the first randomly assigned scenario, the patient actor played a role of patient with diabetes in treatment with an endocrinologist. In the second scenario, the patient actor played a role of a patient with opioid use disorder undergoing methadone treatment with an addiction physician. MAIN OUTCOMES AND MEASURES Total offers of a new patient appointment; a secondary analysis compared the proportions of patients offered an appointment stratified by gender, population, model of care, and years in practice. RESULTS Of a total 383 family physicians included in analysis, a greater proportion offered a new patient appointment to a patient with diabetes (21 of 185 physicians [11.4%]) than with opioid use disorder (8 of 198 physicians [4.0%]) (absolute difference, 7.4%; 95% CI, 2.0 to 12.6; P = .007). Physicians with more than 20 years in practice were almost 13 times less likely to offer an appointment to a patient with opioid use disorder compared with diabetes (1 of 108 physicians [0.9%] vs 10 of 84 physicians [11.9%]; absolute difference, 11.0; 95% CI, 3.8 to 18.1; P = .001). Women were almost 5 times less likely (3 of 111 physicians [2.7%] vs 14 of 114 physicians [12.3%]; absolute difference, 9.6%; 95% CI, 2.4 to 16.3; P = .007) to offer an appointment to a patient with opioid use disorder than with diabetes. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, family physicians were less likely to offer a new patient appointment to a patient with opioid use disorder compared with a patient with diabetes. Potential health system solutions to this disparity include strengthening policies for accepting new patients, improved compensation, and clinician anti-oppression training. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05484609.
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Affiliation(s)
- Sheryl Spithoff
- Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Women’s College Hospital Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Lana Mogic
- Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Susan Hum
- Department of Family and Community Medicine, Women’s College Hospital, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Christopher Meaney
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, Toronto, Ontario, Canada
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Frymire E, Gozdyra P, Green M, Bayoumi I, Glazier R, Jaakkimainen L, Khan S, Kiran T, Premji K. Mapping where patients access primary care providers. Int J Popul Data Sci 2022. [DOI: 10.23889/ijpds.v7i3.2068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2022] Open
Abstract
ObjectivesTo gain an understanding of the attribution of patients to newly introduced Ontario Health Teams (OHT). OHTs are responsible for organizing and delivering health local care based on established connections between patients, their primary care providers, and hospitals. Furthermore, we aim to identify areas with poor geographic access to care.
ApproachWe used GIS analyses and maps to depict the attribution of patients to OHTs based on their uptake of primary care and hospital referral patterns. Residents of a specific local area can be attributed to different OHTs based on their prevailing health seeking choices. This leads to a creation of non-unique OHT ‘capture zones’, which may pose challenges in primary health care planning and delivery.
The range of spatial analyses and maps used in this study helps to overcome some of these limitations and provides healthcare administrators with important geographic layer of information not available through other data summary methods.
ResultsThe distribution of patients and patterns of the primary care seeking vary greatly between urban, rural and remote areas. Many of the rural and remote OHTs have their patients clustered in areas surrounding the main hospital. These areas can be quite large geographically but their extents are still unique from other OHTs. OHTs in urban areas show substantial overlaps of their patient base. The urban patients are in most cases highly clustered around the main hospital location for hospitals providing primary and secondary care. The distribution of patients attributed to OHTs with hospitals providing tertiary care is quite spread out throughout the region or even the province.
All these unique patterns reflect complex ways of primary care seeking behavior and referral patterns for hospital care.
ConclusionThese attribution maps and data tables are an essential resource for planners and decisions makers in identifying priorities within the regional provision of primary care. This knowledge is essential to a better understanding of health care needs of local populations, and to implementing improvements in health care access.
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Frymire E, Green M, Glazier R, Khan S, Premji K, Bayoumi I, Jaakkimainen L, Kiran T, Gozdyra P. Using Primary care data metrics to inform policy and practice: Human Health Resource implications. Int J Popul Data Sci 2022. [PMCID: PMC9644980 DOI: 10.23889/ijpds.v7i3.2051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Jenkinson JIR, Sniderman R, Gogosis E, Liu M, Nisenbaum R, Pedersen C, Spandier O, Tibebu T, Dyer A, Crichlow F, Richard L, Orkin A, Thulien N, Kiran T, Kayseas J, Hwang SW. Exploring COVID-19 vaccine uptake, confidence and hesitancy among people experiencing homelessness in Toronto, Canada: protocol for the Ku-gaa-gii pimitizi-win qualitative study. BMJ Open 2022; 12:e064225. [PMID: 35977770 PMCID: PMC9388714 DOI: 10.1136/bmjopen-2022-064225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION People experiencing homelessness are at high risk for COVID-19 and poor outcomes if infected. Vaccination offers protection against serious illness, and people experiencing homelessness have been prioritised in the vaccine roll-out in Toronto, Canada. Yet, current COVID-19 vaccination rates among people experiencing homelessness are lower than the general population. This study aims to characterise reasons for COVID-19 vaccine uptake and hesitancy among people experiencing homelessness, to identify strategies to overcome hesitancy and provide public health decision-makers with information to improve vaccine confidence and uptake in this priority population. METHODS AND ANALYSIS The Ku-gaa-gii pimitizi-win qualitative study (formerly the COVENANT study) will recruit up to 40 participants in Toronto who are identified as experiencing homelessness at the time of recruitment. Semistructured interviews with participants will explore general experiences during the COVID-19 pandemic (eg, loss of housing, social connectedness), perceptions of the COVID-19 vaccine, factors shaping vaccine uptake and strategies for supporting enablers, addressing challenges and building vaccine confidence. ETHICS AND DISSEMINATION Approval for this study was granted by Unity Health Toronto Research Ethics Board. Findings will be communicated to groups organising vaccination efforts in shelters, community groups and the City of Toronto to construct more targeted interventions that address reasons for vaccine hesitancy among people experiencing homelessness. Key outputs will include a community report, academic publications, presentations at conferences and a Town Hall that will bring together people with lived expertise of homelessness, shelter staff, leading scholars, community experts and public health partners.
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Affiliation(s)
- Jesse I R Jenkinson
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Ruby Sniderman
- Centre de recherche du Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Evie Gogosis
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Michael Liu
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Harvard Medical School, Boston, Massachusetts, USA
| | - Rosane Nisenbaum
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Cheryl Pedersen
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Olivia Spandier
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Tadios Tibebu
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Allison Dyer
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Frank Crichlow
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- South Riverdale Community Health Centre, Toronto, Ontario, Canada
| | - Lucie Richard
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
| | - Aaron Orkin
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Inner City Health Associates, Toronto, Ontario, Canada
| | - Naomi Thulien
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tara Kiran
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Jolen Kayseas
- Department of Languages, Literature and Culture, Toronto Metropolitan University, Toronto, Ontario, Canada
| | - Stephen W Hwang
- MAP Centre for Urban Health Solutions, Unity Health Toronto, Toronto, Ontario, Canada
- Division of General Internal Medicine, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Hodwitz K, Parsons J, Juando-Pratts C, Rosenthal E, Craig-Neil A, Hwang SW, Lockwood J, Das P, Kiran T. Challenges faced by people experiencing homelessness and their providers during the COVID-19 pandemic: a qualitative study. CMAJ Open 2022; 10:E685-E691. [PMID: 35853663 PMCID: PMC9312992 DOI: 10.9778/cmajo.20210334] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND People experiencing homelessness are vulnerable to SARS-CoV-2 infection and its consequences. We aimed to understand the perspectives of people experiencing homelessness, and of the health care and shelter workers who cared for them, during the COVID-19 pandemic. METHODS We conducted an interpretivist qualitative study in Toronto, Canada, from December 2020 to June 2021. Participants were people experiencing homelessness who received SARS-CoV-2 testing, health care workers and homeless shelter staff. We recruited participants via email, telephone or recruitment flyers. Using individual interviews conducted via telephone or video call, we explored the experiences of people who were homeless during the pandemic, their interaction with shelter and health care settings, and related system challenges. We analyzed the data using reflexive thematic analysis. RESULTS Among 26 participants were 11 men experiencing homelessness (aged 28-68 yr), 9 health care workers (aged 33-59 yr), 4 health care leaders (aged 37-60 yr) and 2 shelter managers (aged 47-57 yr). We generated 3 main themes: navigating the unknown, wherein participants grappled with evolving public health guidelines that did not adequately account for homeless individuals; confronting placelessness, as people experiencing homelessness often had nowhere to go owing to public closures and lack of isolation options; and struggling with powerlessness, since people experiencing homelessness lacked agency in their placelessness, and health care and shelter workers lacked control in the care they could provide. INTERPRETATION Reduced shelter capacity, public closures and lack of isolation options during the COVID-19 pandemic exacerbated the displacement of people experiencing homelessness and led to moral distress among providers. Planning for future pandemics must account for the unique needs of those experiencing homelessness.
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Affiliation(s)
- Kathryn Hodwitz
- Applied Health Research Centre (Hodwitz, Parsons, Juando-Pratts), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Parsons, Kiran), University of Toronto; Department of Physical Therapy and Rehabilitation Sciences Institute (Parsons), University of Toronto; Dalla Lana School of Public Health (Juando-Pratts), University of Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), Faculty of Medicine, University of Toronto; MAP Centre for Urban Health Solutions (Craig-Neil, Hwang, Kiran), St. Michael's Hospital, Unity Health Toronto; Division of General Internal Medicine (Hwang), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Emergency Medicine (Lockwood), Faculty of Medicine, University of Toronto; Department of Emergency Medicine (Lockwood), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Janet Parsons
- Applied Health Research Centre (Hodwitz, Parsons, Juando-Pratts), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Parsons, Kiran), University of Toronto; Department of Physical Therapy and Rehabilitation Sciences Institute (Parsons), University of Toronto; Dalla Lana School of Public Health (Juando-Pratts), University of Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), Faculty of Medicine, University of Toronto; MAP Centre for Urban Health Solutions (Craig-Neil, Hwang, Kiran), St. Michael's Hospital, Unity Health Toronto; Division of General Internal Medicine (Hwang), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Emergency Medicine (Lockwood), Faculty of Medicine, University of Toronto; Department of Emergency Medicine (Lockwood), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Clara Juando-Pratts
- Applied Health Research Centre (Hodwitz, Parsons, Juando-Pratts), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Parsons, Kiran), University of Toronto; Department of Physical Therapy and Rehabilitation Sciences Institute (Parsons), University of Toronto; Dalla Lana School of Public Health (Juando-Pratts), University of Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), Faculty of Medicine, University of Toronto; MAP Centre for Urban Health Solutions (Craig-Neil, Hwang, Kiran), St. Michael's Hospital, Unity Health Toronto; Division of General Internal Medicine (Hwang), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Emergency Medicine (Lockwood), Faculty of Medicine, University of Toronto; Department of Emergency Medicine (Lockwood), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Esther Rosenthal
- Applied Health Research Centre (Hodwitz, Parsons, Juando-Pratts), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Parsons, Kiran), University of Toronto; Department of Physical Therapy and Rehabilitation Sciences Institute (Parsons), University of Toronto; Dalla Lana School of Public Health (Juando-Pratts), University of Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), Faculty of Medicine, University of Toronto; MAP Centre for Urban Health Solutions (Craig-Neil, Hwang, Kiran), St. Michael's Hospital, Unity Health Toronto; Division of General Internal Medicine (Hwang), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Emergency Medicine (Lockwood), Faculty of Medicine, University of Toronto; Department of Emergency Medicine (Lockwood), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Amy Craig-Neil
- Applied Health Research Centre (Hodwitz, Parsons, Juando-Pratts), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Parsons, Kiran), University of Toronto; Department of Physical Therapy and Rehabilitation Sciences Institute (Parsons), University of Toronto; Dalla Lana School of Public Health (Juando-Pratts), University of Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), Faculty of Medicine, University of Toronto; MAP Centre for Urban Health Solutions (Craig-Neil, Hwang, Kiran), St. Michael's Hospital, Unity Health Toronto; Division of General Internal Medicine (Hwang), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Emergency Medicine (Lockwood), Faculty of Medicine, University of Toronto; Department of Emergency Medicine (Lockwood), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Stephen W Hwang
- Applied Health Research Centre (Hodwitz, Parsons, Juando-Pratts), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Parsons, Kiran), University of Toronto; Department of Physical Therapy and Rehabilitation Sciences Institute (Parsons), University of Toronto; Dalla Lana School of Public Health (Juando-Pratts), University of Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), Faculty of Medicine, University of Toronto; MAP Centre for Urban Health Solutions (Craig-Neil, Hwang, Kiran), St. Michael's Hospital, Unity Health Toronto; Division of General Internal Medicine (Hwang), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Emergency Medicine (Lockwood), Faculty of Medicine, University of Toronto; Department of Emergency Medicine (Lockwood), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Joel Lockwood
- Applied Health Research Centre (Hodwitz, Parsons, Juando-Pratts), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Parsons, Kiran), University of Toronto; Department of Physical Therapy and Rehabilitation Sciences Institute (Parsons), University of Toronto; Dalla Lana School of Public Health (Juando-Pratts), University of Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), Faculty of Medicine, University of Toronto; MAP Centre for Urban Health Solutions (Craig-Neil, Hwang, Kiran), St. Michael's Hospital, Unity Health Toronto; Division of General Internal Medicine (Hwang), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Emergency Medicine (Lockwood), Faculty of Medicine, University of Toronto; Department of Emergency Medicine (Lockwood), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Paul Das
- Applied Health Research Centre (Hodwitz, Parsons, Juando-Pratts), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Parsons, Kiran), University of Toronto; Department of Physical Therapy and Rehabilitation Sciences Institute (Parsons), University of Toronto; Dalla Lana School of Public Health (Juando-Pratts), University of Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), Faculty of Medicine, University of Toronto; MAP Centre for Urban Health Solutions (Craig-Neil, Hwang, Kiran), St. Michael's Hospital, Unity Health Toronto; Division of General Internal Medicine (Hwang), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Emergency Medicine (Lockwood), Faculty of Medicine, University of Toronto; Department of Emergency Medicine (Lockwood), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont
| | - Tara Kiran
- Applied Health Research Centre (Hodwitz, Parsons, Juando-Pratts), Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto; Institute of Health Policy, Management and Evaluation (Parsons, Kiran), University of Toronto; Department of Physical Therapy and Rehabilitation Sciences Institute (Parsons), University of Toronto; Dalla Lana School of Public Health (Juando-Pratts), University of Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), St. Michael's Hospital, Unity Health Toronto; Department of Family and Community Medicine (Rosenthal, Das, Kiran), Faculty of Medicine, University of Toronto; MAP Centre for Urban Health Solutions (Craig-Neil, Hwang, Kiran), St. Michael's Hospital, Unity Health Toronto; Division of General Internal Medicine (Hwang), Department of Medicine, Faculty of Medicine, University of Toronto; Division of Emergency Medicine (Lockwood), Faculty of Medicine, University of Toronto; Department of Emergency Medicine (Lockwood), St. Michael's Hospital, Unity Health Toronto, Toronto, Ont.
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Lapointe-Shaw L, Kiran T, Costa AP, Na Y, Sinha SK, Nelson KE, Stall NM, Ivers NM, Jones A. Physician home visits in Ontario: a cross-sectional analysis of patient characteristics and postvisit use of health care services. CMAJ Open 2022; 10:E732-E745. [PMID: 35944922 PMCID: PMC9377547 DOI: 10.9778/cmajo.20210307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND It is unknown how much of current physician home visit volume is driven by low-complexity or low-continuity visits. Our objectives were to measure physician home visit volumes and costs in Ontario from 2005/06 to 2018/19, and to compare patient characteristics and postvisit use of health care services across home visit types. METHODS This was a retrospective cross-sectional study using health administrative data. We examined annual physician home visit volumes and costs from 2005/06 to 2018/19 in Ontario, and characteristics and postvisit use of health care services of residents who received at least 1 home visit from any physician in 2014/15 to 2018/19. We categorized home visits as palliative, provided to a patient who also received home care services or "other," and compared characteristics and outcomes between groups. RESULTS A total of 4 418 334 physician home visits were performed between 2005/06 and 2018/19. More than half (2 256 667 [51.1%]) were classified as "other" and accounted for 39.1% ($22 million) of total annual physician billing costs. From 2014/15 to 2018/19, of the 413 057 home visit patients, 240 933 (58.3%) were adults aged 65 or more, and 323 283 (78.3%) lived in large urban areas. Compared to the palliative care and home care groups, the "other" group was younger, had fewer comorbidities, and had lower rates of emergency department visits and hospital admissions in the 30 days after the visit. INTERPRETATION About half of physician home visits in 2014/15 to 2018/19 were to patients who were receiving neither palliative care nor home care, a group that was younger and healthier, and had low use of health care services after the visit. There is an opportunity to refine policy tools to target patients most likely to benefit from physician home visits.
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Affiliation(s)
- Lauren Lapointe-Shaw
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont.
| | - Tara Kiran
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Andrew P Costa
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Yingbo Na
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Samir K Sinha
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Katherine E Nelson
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Nathan M Stall
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Noah M Ivers
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
| | - Aaron Jones
- Division of General Internal Medicine and Geriatrics (Lapointe-Shaw, Sinha, Stall), University Health Network and Sinai Health System; Department of Medicine (Lapointe-Shaw, Sinha, Stall), University of Toronto; Women's College Hospital Institute for Health System Solutions and Virtual Care (Lapointe-Shaw, Ivers), Women's College Hospital; ICES (Lapointe-Shaw, Kiran, Costa, Na, Nelson, Ivers, Jones); Institute of Health Policy, Management and Evaluation (Lapointe-Shaw, Kiran, Sinha, Stall, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran, Sinha, Ivers), University of Toronto; Department of Family and Community Medicine (Kiran) and MAP Centre for Urban Health Solutions (Kiran), St. Michael's Hospital, Toronto, Ont.; Department of Health Research Methods, Evidence, and Impact (Costa, Jones), McMaster University; Centre for Integrated Care (Costa), St. Joseph's Health System, Hamilton, Ont.; Department of Paediatrics (Nelson), The Hospital for Sick Children; Department of Family and Community Medicine (Ivers), Women's College Hospital, Toronto, Ont
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Agarwal P, Wang R, Meaney C, Walji S, Damji A, Gill N, Yip G, Elman D, Florindo T, Fung S, Witty M, Pham TN, Ramji N, Kiran T. Sociodemographic differences in patient experience with primary care during COVID-19: results from a cross-sectional survey in Ontario, Canada. BMJ Open 2022; 12:e056868. [PMID: 35534055 PMCID: PMC9086266 DOI: 10.1136/bmjopen-2021-056868] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE We sought to understand patients' care-seeking behaviours early in the pandemic, their use and views of different virtual care modalities, and whether these differed by sociodemographic factors. METHODS We conducted a multisite cross-sectional patient experience survey at 13 academic primary care teaching practices between May and June 2020. An anonymised link to an electronic survey was sent to a subset of patients with a valid email address on file; sampling was based on birth month. For each question, the proportion of respondents who selected each response was calculated, followed by a comparison by sociodemographic characteristics using χ2 tests. RESULTS In total, 7532 participants responded to the survey. Most received care from their primary care clinic during the pandemic (67.7%, 5068/7482), the majority via phone (82.5%, 4195/5086). Among those who received care, 30.53% (1509/4943) stated that they delayed seeking care because of the pandemic. Most participants reported a high degree of comfort with phone (92.4%, 3824/4139), video (95.2%, 238/250) and email or messaging (91.3%, 794/870). However, those reporting difficulty making ends meet, poor or fair health and arriving in Canada in the last 10 years reported lower levels of comfort with virtual care and fewer wanted their practice to continue offering virtual options after the pandemic. CONCLUSIONS Our study suggests that newcomers, people living with a lower income and those reporting poor or fair health have a stronger preference and comfort for in-person primary care. Further research should explore potential barriers to virtual care and how these could be addressed.
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Affiliation(s)
- Payal Agarwal
- Women's College Hospital Institute for Health System Solutions and Virtual Care, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ri Wang
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Christopher Meaney
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sakina Walji
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Mount Sinai Academic Family Health Team, Toronto, Ontario, Canada
| | - Ali Damji
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Credit Valley Family Health Team, Mississauga, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
| | - Navsheer Gill
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Southlake Regional Health Centre, Newmarket, Ontario, Canada
| | - Gina Yip
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Oak Valley Health Markham Stouffville Hospital, Markham, Ontario, Canada
| | - Debbie Elman
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Tiffany Florindo
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, North York General Hospital, Toronto, Ontario, Canada
| | - Susanna Fung
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, Scarborough Health Network, Scarborough, Ontario, Canada
| | - Melissa Witty
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Barrie and Community Family Health Team, Barrie, Ontario, Canada
| | - Thuy-Nga Pham
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- South East Toronto Family Health Team, Toronto, Ontario, Canada
| | - Noor Ramji
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Institue of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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40
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Shakory S, Eissa A, Kiran T, Pinto AD. Best Practices for COVID-19 Mass Vaccination Clinics. Ann Fam Med 2022; 20:149-156. [PMID: 35346931 PMCID: PMC8959732 DOI: 10.1370/afm.2773] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 08/13/2021] [Accepted: 09/08/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE The coronavirus disease 2019 (COVID-19) pandemic is an unprecedented global public health crisis. Mass vaccination is the safest and fastest pandemic exit strategy. Mass vaccination clinics are a particularly important tool in quickly achieving herd immunity. Primary care physicians have played a crucial role in organizing and running vaccination clinics. In this special report, we synthesize existing guidelines and peer-reviewed studies to provide physicians with practical guidance on planning and implementing COVID-19 mass vaccination clinics. METHODS PubMed, Ovid MEDLINE and Embase were used to search for relevant literature using search terms that included COVID-19, mass vaccination, and best practice. We also identified and analyzed national and international guidelines. RESULTS Forty-six relevant articles, reports, and guidelines were identified and synthesized. Articles included mass vaccination clinic guidelines and studies before and during the COVID-19 pandemic. Key considerations for COVID-19 mass vaccination clinics include leadership and role designation, site selection, clinic layout and workflow, day-to-day operations, infection prevention, and communication strategies. CONCLUSIONS Planning and implementing a successful COVID-19 mass vaccination clinic requires several key considerations. Primary care plays an important role in organizing clinics and ensuring populations made vulnerable by social and economic policies are being reached. Ongoing data collection is required to evaluate and continuously improve COVID-19 mass vaccination efforts. As the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine rollout occurs in various countries, research will be required to identify the main factors for success to inform future pandemic responses.VISUAL ABSTRACT.
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Affiliation(s)
- Shima Shakory
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Azza Eissa
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Upstream Lab, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada.,Upstream Lab, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Andrew D Pinto
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada .,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada.,Upstream Lab, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada.,Upstream Lab, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
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Kiran T, Craig-Neil A, Das P, Lockwood J, Wang R, Nathanielsz N, Rosenthal E, Hwang S. Association of Homelessness with COVID-19 Positivity among Individuals Visiting a Testing Centre: A Cross-Sectional Study. Healthc Policy 2022; 17:34-41. [PMID: 35319442 PMCID: PMC8935920 DOI: 10.12927/hcpol.2022.26730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Among those visiting a testing centre in Toronto, ON, between March and April 2020, people experiencing homelessness (n = 214) were more likely to test positive for COVID-19 compared with those not experiencing homelessness (n = 1,836) even after adjustment for age, sex and medical co-morbidity (15.4% vs. 6.7%, p < 0.001; odds ratio [OR] 2.41, 95% confidence interval [CI: 1.51, 3.76], p < 0.001).
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Abramovich A, Pang N, Kunasekaran S, Moss A, Kiran T, Pinto AD. Examining COVID-19 vaccine uptake and attitudes among 2SLGBTQ+ youth experiencing homelessness. BMC Public Health 2022; 22:122. [PMID: 35042491 PMCID: PMC8764500 DOI: 10.1186/s12889-022-12537-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 01/06/2022] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES The COVID-19 pandemic has disproportionately impacted 2SLGBTQ+ youth experiencing homelessness. Little is known about vaccine attitudes and uptake among this population. To address this, the objectives of this study were to explore this group's COVID-19 vaccine attitudes, and facilitators and barriers impacting vaccine uptake. METHODS 2SLGBTQ+ youth experiencing homelessness in the Greater Toronto Area were recruited to participate in online surveys assessing demographic characteristics, mental health, health service use, and COVID-19 vaccine attitudes. Descriptive statistics and statistical tests were used to analyze survey data to explore variables associated with vaccine confidence. Additionally, a select group of youth and frontline workers from youth serving organizations were invited to participate in online one-on-one interviews. An iterative thematic content approach was used to analyze interview data. Quantitative and qualitative data were merged for interpretation by use of a convergent parallel analytical design. RESULTS Ninety-two youth completed surveys and 32 youth and 15 key informants participated in one-on-one interviews. Quantitative and qualitative data showed that the majority of 2SLGBTQ+ youth experiencing homelessness were confident in the COVID-19 vaccine; however, numerous youth were non-vaccine confident due to mistrust in the healthcare system, lack of targeted vaccine-related public health information, concerns about safety and side effects, and accessibility issues. Solutions to increase vaccine confidence were provided, including fostering trust, targeted public health messaging, and addressing accessibility needs. CONCLUSION Our study highlights the need for the vaccine strategy and rollouts to prioritize 2SLGBTQ+ youth experiencing homelessness and to address the pervasive health disparities that have been exacerbated by the pandemic.
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Affiliation(s)
- Alex Abramovich
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Ursula Franklin Street, Toronto, ON, M5S 2S1, Canada.
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
| | - Nelson Pang
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Ursula Franklin Street, Toronto, ON, M5S 2S1, Canada
| | - Sharumathy Kunasekaran
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Ursula Franklin Street, Toronto, ON, M5S 2S1, Canada
| | - Amanda Moss
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, 33 Ursula Franklin Street, Toronto, ON, M5S 2S1, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Andrew D Pinto
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, Ontario, Canada
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Lofters AK, Baker NA, Corrado AM, Schuler A, Rau A, Baxter NN, Leung FH, Weyman K, Kiran T. Care in the Community: Opportunities to improve cancer screening uptake for people living with low income. Prev Med Rep 2022; 24:101622. [PMID: 34976677 PMCID: PMC8684029 DOI: 10.1016/j.pmedr.2021.101622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Revised: 08/11/2021] [Accepted: 10/23/2021] [Indexed: 11/16/2022] Open
Abstract
Despite organized provincial cancer screening programs, people living with low income consistently have lower rates of screening in Ontario, Canada than their more socioeconomically advantaged peers. We previously published results of a two-phase, exploratory qualitative study involving both interviews and focus groups whose objective was to integrate knowledge of people living with low income on how to improve primary care strategies aimed at increasing cancer screening uptake. In the current paper, we report previously unpublished findings from that study that identify how taking a community outreach approach in primary care may lead to increased cancer screening uptake among people living with low income. Participants told us that they saw value in a community outreach approach to cancer screening. They recommended specific actionable approaches, in particular, mobile community-based screening and community information sessions, and recommended taking an ethno-specific lens depending on the communities being targeted. Participants expressed a desire for primary care providers to go out into the community to learn more about the whole patient, such as could be achieved with home visits, but they simultaneously believed that this may be challenging in urban settings and in the context of perceived physician shortages. Models of primary care that provide support to an entire local community and provide some of their services directly in that community may have a meaningful impact on cancer screening for socially marginalized groups.
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Affiliation(s)
- Aisha K Lofters
- Peter Gilgan Centre for Women's Cancers, Women's College Hospital, Toronto, ON M5S 2B1, Canada.,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, ON M5G 1V7, Canada.,ICES, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.,Dalla Lana School of Public Health, 155 College Street, Health Science Building 6th floor, Toronto, ON M5T 3M7, Canada.,Ontario Health (Cancer Care Ontario), 620 University Avenue, Toronto, ON M5G 2L7, Canada
| | - Natalie Alex Baker
- Dalla Lana School of Public Health, 155 College Street, Health Science Building 6th floor, Toronto, ON M5T 3M7, Canada.,Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Ann Marie Corrado
- Peter Gilgan Centre for Women's Cancers, Women's College Hospital, Toronto, ON M5S 2B1, Canada
| | - Andree Schuler
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Allison Rau
- Applied Health Research Centre, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Nancy N Baxter
- Melbourne School of Population and Global Health, University of Melbourne, Australia.,Department of Surgery, University of Toronto, Toronto, ON M5B 1W8, Canada.,Institute of Health Policy, Management and Evaluation, 155 College Street, Health Science Building 6th floor, Toronto, ON M5T 3M6, Canada
| | - Fok-Han Leung
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, ON M5G 1V7, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Karen Weyman
- Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, ON M5G 1V7, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada
| | - Tara Kiran
- MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Department of Family and Community Medicine, University of Toronto, 500 University Avenue, Toronto, ON M5G 1V7, Canada.,ICES, 2075 Bayview Avenue, Toronto, ON M4N 3M5, Canada.,Department of Family and Community Medicine, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.,Institute of Health Policy, Management and Evaluation, 155 College Street, Health Science Building 6th floor, Toronto, ON M5T 3M6, Canada
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Kiran T, Moineddin R, Kopp A, Glazier RH. Impact of Team-Based Care on Emergency Department Use. Ann Fam Med 2022; 20:24-31. [PMID: 35074764 PMCID: PMC8786428 DOI: 10.1370/afm.2728] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We sought to assess the impact of team-based care on emergency department (ED) use in the context of physicians transitioning from fee-for-service payment to capitation payment in Ontario, Canada. METHODS We conducted an interrupted time series analysis to assess annual ED visit rates before and after transition from an enhanced fee-for-service model to either a team capitation model or a nonteam capitation model. We included Ontario residents aged 19 years and older who had at least 3 years of outcome data both pretransition and post-transition (N = 2,524,124). We adjusted for age, sex, income quintile, immigration status, comorbidity, and morbidity, and we stratified by rurality. A sensitivity analysis compared outcomes for team vs nonteam patients matched on year of transition, age, sex, rurality, and health region. RESULTS We compared 387,607 team and 1,399,103 nonteam patients in big cities, 213,394 team and 380,009 nonteam patients in small towns, and 65,289 team and 78,722 nonteam patients in rural areas. In big cities, after adjustment, the ED visit rate increased by 2.4% (95% CI, 2.2% to 2.6%) per year for team patients and 5.2% (95% CI, 5.1% to 5.3%) per year for nonteam patients in the years after transition (P <.001). Similarly, there was a slower increase in ED visits for team relative to nonteam patients in small towns (0.9% [95% CI, 0.7% to 1.1%] vs 2.9% [95% CI, 2.8% to 3.1%], P <.001) and rural areas (‒0.5% [95% CI, -0.8% to 0.2%] vs 1.3% [95% CI, 1.0% to 1.6%], P <.001). Results were much the same in the matched analysis. CONCLUSIONS Adoption of team-based primary care may reduce ED use. Further research is needed to understand optimal team composition and roles.
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Affiliation(s)
- Tara Kiran
- Department of Family and Community Medicine and the MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | | | - Richard H Glazier
- Department of Family and Community Medicine and the MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Merali Z, Malhotra AK, Balas M, Lorello GR, Flexman A, Kiran T, Witiw CD. Gender-based differences in physician payments within the fee-for-service system in Ontario: a retrospective, cross-sectional study. CMAJ 2021; 193:E1584-E1591. [PMID: 34663601 PMCID: PMC8547248 DOI: 10.1503/cmaj.210437] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 01/23/2023] Open
Abstract
Background: Differences in physician income by gender have been described in numerous jurisdictions, but few studies have looked at a Canadian cohort with adjustment for confounders. In this study, we aimed to understand differences in fee-for-service payments to men and women physicians in Ontario. Methods: We conducted a cross-sectional analysis of all Ontario physicians who submitted claims to the Ontario Health Insurance Plan (OHIP) in 2017. For each physician, we gathered demographic information from the College of Physicians and Surgeons of Ontario registry. We compared differences in physician claims between men and women in the entire cohort and within each specialty using multivariable linear regressions, controlling for length of practice, specialty and practice location. Results: We identified a cohort of 30 167 physicians who submitted claims to OHIP in 2017, including 17 992 men and 12 175 women. When controlling for confounding variables in a linear mixed-effects regression model, annual physician claims were $93 930 (95% confidence interval $88 434 to $99 431) higher for men than for women. Women claimed 74% as much as men when adjusting for covariates. This discrepancy was present in nearly all specialty categories. Men claimed more than women throughout their careers, with the greatest gap 10–15 years into practice. Interpretation: We found a gender gap in fee-for-service claims in Ontario, with women claiming less than men overall and in nearly every specialty. Further work is required to understand the root causes of the gender pay gap.
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Affiliation(s)
- Zamir Merali
- Division of Neurosurgery (Merali, Malhotra, Balas), Department of Surgery, and Department of Anesthesiology and Pain Medicine (Lorello), University of Toronto; Department of Anesthesia and Pain Medicine (Lorello), Toronto Western Hospital - University Health Network, Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Flexman), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Kiran), St. Michael's Hospital, University of Toronto; Institute of Health Policy, Management and Evaluation (Kiran, Witiw), University of Toronto; Division of Neurosurgery (Witiw), Department of Surgery, University of Toronto, St Michael's Hospital, Toronto, Ont
| | - Armaan K Malhotra
- Division of Neurosurgery (Merali, Malhotra, Balas), Department of Surgery, and Department of Anesthesiology and Pain Medicine (Lorello), University of Toronto; Department of Anesthesia and Pain Medicine (Lorello), Toronto Western Hospital - University Health Network, Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Flexman), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Kiran), St. Michael's Hospital, University of Toronto; Institute of Health Policy, Management and Evaluation (Kiran, Witiw), University of Toronto; Division of Neurosurgery (Witiw), Department of Surgery, University of Toronto, St Michael's Hospital, Toronto, Ont
| | - Michael Balas
- Division of Neurosurgery (Merali, Malhotra, Balas), Department of Surgery, and Department of Anesthesiology and Pain Medicine (Lorello), University of Toronto; Department of Anesthesia and Pain Medicine (Lorello), Toronto Western Hospital - University Health Network, Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Flexman), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Kiran), St. Michael's Hospital, University of Toronto; Institute of Health Policy, Management and Evaluation (Kiran, Witiw), University of Toronto; Division of Neurosurgery (Witiw), Department of Surgery, University of Toronto, St Michael's Hospital, Toronto, Ont
| | - Gianni R Lorello
- Division of Neurosurgery (Merali, Malhotra, Balas), Department of Surgery, and Department of Anesthesiology and Pain Medicine (Lorello), University of Toronto; Department of Anesthesia and Pain Medicine (Lorello), Toronto Western Hospital - University Health Network, Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Flexman), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Kiran), St. Michael's Hospital, University of Toronto; Institute of Health Policy, Management and Evaluation (Kiran, Witiw), University of Toronto; Division of Neurosurgery (Witiw), Department of Surgery, University of Toronto, St Michael's Hospital, Toronto, Ont
| | - Alana Flexman
- Division of Neurosurgery (Merali, Malhotra, Balas), Department of Surgery, and Department of Anesthesiology and Pain Medicine (Lorello), University of Toronto; Department of Anesthesia and Pain Medicine (Lorello), Toronto Western Hospital - University Health Network, Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Flexman), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Kiran), St. Michael's Hospital, University of Toronto; Institute of Health Policy, Management and Evaluation (Kiran, Witiw), University of Toronto; Division of Neurosurgery (Witiw), Department of Surgery, University of Toronto, St Michael's Hospital, Toronto, Ont
| | - Tara Kiran
- Division of Neurosurgery (Merali, Malhotra, Balas), Department of Surgery, and Department of Anesthesiology and Pain Medicine (Lorello), University of Toronto; Department of Anesthesia and Pain Medicine (Lorello), Toronto Western Hospital - University Health Network, Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Flexman), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Kiran), St. Michael's Hospital, University of Toronto; Institute of Health Policy, Management and Evaluation (Kiran, Witiw), University of Toronto; Division of Neurosurgery (Witiw), Department of Surgery, University of Toronto, St Michael's Hospital, Toronto, Ont
| | - Christopher D Witiw
- Division of Neurosurgery (Merali, Malhotra, Balas), Department of Surgery, and Department of Anesthesiology and Pain Medicine (Lorello), University of Toronto; Department of Anesthesia and Pain Medicine (Lorello), Toronto Western Hospital - University Health Network, Toronto, Ont.; Department of Anesthesiology, Pharmacology, and Therapeutics (Flexman), University of British Columbia, Vancouver, BC; Department of Family and Community Medicine (Kiran), St. Michael's Hospital, University of Toronto; Institute of Health Policy, Management and Evaluation (Kiran, Witiw), University of Toronto; Division of Neurosurgery (Witiw), Department of Surgery, University of Toronto, St Michael's Hospital, Toronto, Ont.
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DeRocher M, Davie S, Kiran T. Using positive deviance to improve timely access in primary care. BMJ Open Qual 2021; 10:bmjoq-2020-001228. [PMID: 34649853 PMCID: PMC8522670 DOI: 10.1136/bmjoq-2020-001228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 09/10/2021] [Indexed: 11/06/2022] Open
Abstract
Background Improving timely access in primary care is a continued challenge in many countries. We used positive deviance to try and identify best practices for achieving timely access in our primary care organisation in Toronto, Canada. Methods Semistructured interviews were used to identify practice strategies used by physicians who successfully maintained a low third next available appointment (TNA) (positive deviants, n=6). We then conducted a cross-sectional survey to understand the prevalence of identified promising practices among all physicians (n=70) in the practice. We used χ2 testing to understand whether uptake of promising practices among survey respondents was different for those with a median TNA of 7 days or less vs a median TNA over 7 days. Results We identified seven promising practice strategies used by positive deviants: adjusting the appointment template based on demand; reviewing the appointment schedule in advance; max-packing of visits; using phone, email and secure messaging; customising care for complex patients; managing planned absences; and involving the interprofessional team. 65 of 70 physicians responded to the survey on promising practices. Uptake of the promising practices was variable among survey respondents. In general, we found no association between uptake of promising practices and median TNA. One exception was that those with a median TNA of 7 or less were more likely to review the schedule in advance to potentially mitigate a visit using phone/email (62% vs 31%, p=0.0159). Conclusion Promising practices used by a small group of physicians (‘positive deviants’) to maintain good access were generally not associated with timely access among a larger sample of physicians in the practice. Our findings highlight the difficulty of untangling physician practice style and its contribution to timely access in primary care.
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Affiliation(s)
- MaryBeth DeRocher
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada .,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sam Davie
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.,MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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Kiran T, Rodrigues JJ, Aratangy T, Devotta K, Sava N, O'Campo P. Awareness and Use of Community Services among Primary Care Physicians. ACTA ACUST UNITED AC 2021; 16:58-77. [PMID: 32813640 DOI: 10.12927/hcpol.2020.26290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Primary care physicians play an important role in care coordination, including initiating referrals to community resources. Yet, it is unclear how awareness and use of community resources vary between physicians practising with and without an extended healthcare team. We conducted a cross-sectional survey of primary care physicians practising in Toronto, Canada, to compare awareness and use of community services between physicians practising in team- and non-team-based practice models. Team-based models included Community Health Centres and Family Health Teams - settings in which the government provides funding for the practice to hire non-physician health professionals, such as social workers, pharmacists, nurse practitioners, registered nurses and others. The survey was mailed to physicians, and reminders were done by phone, fax and e-mail. We used logistic regression to compare awareness between physicians in team-based (N = 89) and non-team-based (N = 138) models after controlling for confounders. We found that fewer than half of the physicians were aware of five of eight centralized intake services (e.g., ConnexOntario, Telehomecare). For most services, team-based physicians had at least twice the odds of being aware of the service compared to non-team-based physicians. Our findings suggest that patients in team-based practices may be doubly advantaged, with access to non-physician health professionals within the practice as well as to physicians who are more aware of community resources.
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Affiliation(s)
- Tara Kiran
- Family Physician, St. Michael's Hospital, Associate Professor, Department of Family and Community Medicine, Faculty of Medicine and the Institute of Health Policy, Management and Evaluation, University of Toronto, Scientist, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Jessica J Rodrigues
- Research Coordinator, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Tatiana Aratangy
- Manager, Survey Research Unit, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Kimberly Devotta
- Research Coordinator, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON
| | - Nathalie Sava
- Senior Planner, Health Analytics and Innovation, Toronto Central Local Health Integration Network, Toronto, ON
| | - Patricia O'Campo
- Scientist, MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Professor, Dalla Lana School of Public Health, University of Toronto, Toronto, ON
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Premji K, Sucha E, Glazier RH, Green ME, Wodchis WP, Hogg WE, Kiran T, Frymire E, Freeman TR, Ryan BL. Primary care bonus payments and patient-reported access in urban Ontario: a cross-sectional study. CMAJ Open 2021; 9:E1080-E1096. [PMID: 34848549 PMCID: PMC8648352 DOI: 10.9778/cmajo.20200235] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Rurality strongly correlates with higher pay-for-performance access bonuses, despite higher emergency department use and fewer primary care services than in urban settings. We sought to evaluate the relation between patient-reported access to primary care and access bonus payments in urban settings. METHODS We conducted a cross-sectional, secondary data analysis using Ontario survey and health administrative data from 2013 to 2017. We used administrative data to calculate annual access bonuses for eligible urban family physicians. We linked this payment data to adult (≥ 16 yr) patient data from the Health Care Experiences Survey to examine the relation between access bonus achievement (in quintiles of the proportion of bonus achieved, from lowest [Q1, reference category] to highest [Q5]) and 4 patient-reported access outcomes. The average survey response rate to the patient survey during the study period was 51%. We stratified urban geography into large, medium and small settings. In a multilevel regression model, we adjusted for patient-, physician- and practice-level covariates. We tested linear trends, adjusted for clustering, for each outcome. RESULTS We linked 18 893 respondents to 3940 physicians in 414 bonus-eligible practices. Physicians in small urban settings earned the highest proportion of their maximum potential access bonuses. Access bonus achievement was positively associated with telephone access (Q2 odds ratio [OR] 1.18, 95% confidence interval [CI] 0.98-1.42; Q3 OR 1.34, 95% CI 1.10-1.63; Q4 OR 1.46, 95% CI 1.19-1.79; Q5 OR 1.87, 95% CI 1.50-2.33), after hours access (Q2 OR 1.26, 95% CI 1.09-1.47; Q3 OR 1.46, 95% CI 1.23-1.74; Q4 OR 1.77, 95% CI 1.46-2.15; Q5 OR 1.88, 95% CI 1.52-2.32), wait time for care (Q2 OR 1.01, 95% CI 0.85-1.20; Q3 OR 1.17, 95% CI 0.97-1.41; Q4 OR 1.27, 95% CI 1.05-1.55; Q5 OR 1.63, 95% CI 1.32-2.00) and timeliness (Q2 OR 1.29, 95% CI 0.98-1.69; Q3 OR 1.29, 95% CI 0.94-1.77; Q4 OR 1.58, 95% CI 1.16-2.13; Q5 OR 1.98, 95% CI 1.38-2.82). When stratified by geography, we observed several of these associations in large urban settings, but not in small urban settings. Trend tests were statistically significant for all 4 outcomes. INTERPRETATION Although the access bonus correlated with access in larger urban settings, it did not in smaller settings, aligning with previous research questioning its utility in smaller geographies. The access bonus may benefit from a redesign that considers geography and patient experience.
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Affiliation(s)
- Kamila Premji
- Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont.
| | - Ewa Sucha
- Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Richard H Glazier
- Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Michael E Green
- Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Walter P Wodchis
- Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - William E Hogg
- Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Tara Kiran
- Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Eliot Frymire
- Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Thomas R Freeman
- Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont
| | - Bridget L Ryan
- Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont
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Kiran T, Mangala JN, Anjana K, Manjulakumari D. Heterologous expression of a substance which inhibits receptivity and calling in Helicoverpa armigera (Hübner). Insect Mol Biol 2021; 30:472-479. [PMID: 34013596 DOI: 10.1111/imb.12718] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 02/06/2021] [Accepted: 03/19/2021] [Indexed: 06/12/2023]
Abstract
The accessory glands of male moths secrete several proteins, which are known to affect post-mating behaviour in females such as calling, reduction in receptivity, rate of egg maturation and laying, sperm maintenance and release and formation of mating plug. Helicoverpa armigera (Hübner) is a polyphagous pest of numerous crops and it is widely distributed on the Indian subcontinent where it causes severe economic losses. In the present study, receptivity- and calling-inhibiting substance (RCIS), a peptide secreted from the accessory glands of male H. armigera, was sequenced, cloned and expressed in a prokaryote, Escherichia coli. RCIS is a peptide comprising 58 amino acids and had a theoretical molecular weight of 6.03 kDa. It showed 64% similarity with pheromonostatic peptide 1, identified in Helicoverpa zea (Kingan et al., 1995) but differed regarding deletion of four and one amino acids at positions 14-17 and 44, respectively, and insertion of one and five amino acids at position 38 and the terminal position of RCIS, respectively. H. armigera females injected with recombinant RCIS showed reduced receptivity and calling behaviour (in 70-80% of the treated individuals), and mating frequencies decreased by 80%. Recombinant RCIS may be employed to artificially induce non-receptivity in virgin females in order to prevent reproduction.
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Affiliation(s)
- T Kiran
- Department of Microbiology and Biotechnology, Bangalore University, Bengaluru, India
| | - J N Mangala
- Department of Microbiology and Biotechnology, Bangalore University, Bengaluru, India
| | - K Anjana
- Department of Microbiology and Biotechnology, Bangalore University, Bengaluru, India
| | - D Manjulakumari
- Department of Microbiology and Biotechnology, Bangalore University, Bengaluru, India
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Griffiths S, Stephen G, Kiran T, Okrainec K. "She knows me best": a qualitative study of patient and caregiver views on the role of the primary care physician follow-up post-hospital discharge in individuals admitted with chronic obstructive pulmonary disease or congestive heart failure. BMC Fam Pract 2021; 22:176. [PMID: 34488652 PMCID: PMC8421240 DOI: 10.1186/s12875-021-01524-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 08/18/2021] [Indexed: 11/23/2022]
Abstract
Background Patients with chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF) are at high-risk of readmission after hospital discharge. There is conflicting evidence however on whether timely follow-up with a primary care provider reduces that risk. The objective of this study is to understand the perspectives of patients with COPD and CHF, and their caregivers, on the role of primary care provider follow-up after hospital discharge. Methods A qualitative study design with semi-structured interviews was conducted among patients or their family caregivers admitted with COPD or CHF who were enrolled in a randomized controlled study at three acute care hospitals in Ontario, Canada. Participants were interviewed between December 2017 to January 2019, the majority discharged from hospital at least 30 days prior to their interview. Interviews were analyzed independently by three authors using a deductive directed content analysis, with the fourth author cross-comparing themes. Results Interviews with 16 participants (eight patients and eight caregivers) revealed four main themes. First, participants valued visiting their primary care provider after discharge to build upon their longitudinal relationship. Second, primary care providers played a key role in coordinating care. Third, there were mixed views on the ideal time for follow-up, with many participants expressing a desire to delay follow-up to stabilize following their acute hospitalization. Fourth, the link between the post-discharge visit and preventing hospital readmissions was unclear to participants, who often self-triaged based on their symptoms when deciding on the need for emergency care. Conclusions Patients and caregivers valued in-person follow-up with their primary care provider following discharge from hospital because of the trust established through pre-existing longitudinal relationships. Our results suggest policy makers should focus on improving rates of primary care provider attachment and systems supporting informational continuity. Supplementary Information The online version contains supplementary material available at 10.1186/s12875-021-01524-7.
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Affiliation(s)
- Sarah Griffiths
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Gaibrie Stephen
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, ON, Canada
| | - Tara Kiran
- Department of Family and Community Medicine, St. Michael's Hospital, Toronto, ON, Canada.,Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada.,MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Karen Okrainec
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Toronto General Hospital Research Institute, University Health Network, Toronto, ON, Canada. .,Department of Medicine, University Health Network, Toronto, ON, Canada. .,Toronto Western Hospital, 399 Bathurst Street, 8EW-408, Toronto, ON, M5T 2S8, Canada.
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