Early in the COVID-19 pandemic, Canadian primary care practices rapidly adapted to provide care virtually. Most family physicians lacked prior training or expertise with virtual care. In the absence ...of formal guidance, they made individual decisions about in-person versus remote care based on clinical judgement, their longitudinal relationships with patients, and personal risk assessments. Our objective was to explore Canadian family physicians' perspectives on the strengths and limitations of virtual care implementation for their patient populations during the COVID-19 pandemic and implications for the integration of virtual care into broader primary care practice.
We conducted semi-structured qualitative interviews with family physicians working in four Canadian jurisdictions (Vancouver Coastal health region, British Columbia; Southwestern Ontario; the province of Nova Scotia; and Eastern Health region, Newfoundland and Labrador). We analyzed interview data using a structured applied thematic approach.
We interviewed 68 family physicians and identified four distinct themes during our analysis related to experiences with and perspectives on virtual care: (1) changes in access to primary care; (2) quality and efficacy of care provided virtually; (3) patient and provider comfort with virtual modalities; and (4) necessary supports for virtual care moving forward.
The move to virtual care enhanced access to care for select patients and was helpful for family physicians to better manage their panels. However, virtual care also created access challenges for some patients (e.g., people who are underhoused or living in areas without good phone or internet access) and for some types of care (e.g., care that required access to medical devices). Family physicians are optimistic about the ongoing integration of virtual care into broader primary care delivery, but guidance, regulations, and infrastructure investments are needed to ensure equitable access and to maximize quality of care.
Globally, registered nurses (RNs) are increasingly working in primary care interdisciplinary teams. Although existing literature provides some information about the contributions of RNs towards ...outcomes of care, further evidence on RN workforce contributions, specifically towards patient-level outcomes, is needed. This study synthesized evidence regarding the effectiveness of RNs on patient outcomes in primary care.
A systematic review was conducted in accordance with Joanna Briggs Institute methodology. A comprehensive search of databases (CINAHL, MEDLINE Complete, PsycINFO, Embase) was performed using applicable subject headings and keywords. Additional literature was identified through grey literature searches (ProQuest Dissertations and Theses, MedNar, Google Scholar, websites, reference lists of included articles). Quantitative studies measuring the effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN) that reported related outcomes were included. Articles were screened independently by two researchers and assessed for bias using the Integrated Quality Criteria for Review of Multiple Study Designs tool. A narrative synthesis was undertaken due to the heterogeneity in study designs, RN-led interventions, and outcome measures across included studies.
Forty-six patient outcomes were identified across 23 studies. Outcomes were categorized in accordance with the PaRIS Conceptual Framework (patient-reported experience measures, patient-reported outcome measures, health behaviours) and an additional category added by the research team (biomarkers). Primary care RN-led interventions resulted in improvements within each outcome category, specifically with respect to weight loss, pelvic floor muscle strength and endurance, blood pressure and glycemic control, exercise self-efficacy, social activity, improved diet and physical activity levels, and reduced tobacco use. Patients reported high levels of satisfaction with RN-led care.
This review provides evidence regarding the effectiveness of RNs on patient outcomes in primary care, specifically with respect to satisfaction, enablement, quality of life, self-efficacy, and improvements in health behaviours. Ongoing evaluation that accounts for primary care RNs' unique scope of practice and emphasizes the patient experience is necessary to optimize the delivery of patient-centered primary care.
PROSPERO: International Prospective Register of Systematic Reviews. 2018. ID=CRD42 018090767 .
Internationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of registered nurses (RNs) within primary care teams. Although ...existing literature provides some information regarding RN contributions, further evidence on the impact of RNs towards quality and cost of care is necessary to demonstrate the contribution of this role on health system outcomes. In this study we synthesize international evidence on the effectiveness of RNs on care delivery and system-level outcomes in primary care.
A systematic review was conducted in accordance with Joanna Briggs Institute methodology. Searches were conducted in CINAHL, MEDLINE Complete, PsycINFO, and Embase for published literature and ProQuest Dissertations and Theses and MedNar for unpublished literature between 2019 and 2022 using relevant subject headings and keywords. Additional literature was identified through Google Scholar, websites, and reference lists of included articles. Studies were included if they measured effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN within the context of an independent or interdependent role) and reported outcomes of these interventions. Included studies were published in English; no date or location restrictions were applied. Risk of bias was assessed using the Integrated Quality Criteria for Review of Multiple Study Designs tool. Due to the heterogeneity of included studies, a narrative synthesis was undertaken.
Seventeen articles were eligible for inclusion, with 11 examining system outcomes (e.g., cost, workload) and 15 reporting on outcomes related to care delivery (e.g., illness management, quality of smoking cessation support). The studies suggest that RN-led care may have an impact on outcomes, specifically in relation to the provision of medication management, patient triage, chronic disease management, sexual health, routine preventative care, health promotion/education, and self-management interventions (e.g. smoking cessation support).
The findings suggest that primary care RNs impact the delivery of quality primary care, and that RN-led care may complement and potentially enhance primary care delivered by other primary care providers. Ongoing evaluation in this area is important to further refine nursing scope of practice policy, determine the impact of RN-led care on outcomes, and inform improvements to primary care infrastructure and systems management to meet care needs.
PROSPERO: International prospective register of systematic reviews. 2018. ID= CRD42018090767 .
ObjectivesPrimary care attachment improves access, chronic disease prevention and management. Growing proportions of Canadians are unattached and registering with provincial primary care waitlists ...for family doctors or nurse practitioners. We compare emergency department utilization and hospitalization by waitlist registration status both before and during the first two waves of COVID-19.
ApproachThis study is the first to link a provincial primary care waitlist with routinely collected administrative billing data. Access and linking required collaboration and processes to establish permissions and rigour. A descriptive cohort design estimates quarterly population-based rates of emergency department utilization and ambulatory care sensitive condition (ACSC) hospitalizations among persons on and off the waitlist between Jan/01/2017-Dec/24/2020. Emergency department utilization and ACSC hospitalization rates by current waitlist status were quantified from physician claims and hospitalization data. Relative differences during COVID-19 first (Q2 2020; April-June 2020) and second waves (Q4 2020; October-December 2020) were compared with the previous year.
ResultsCentralized waitlist and administrative billing data were successfully linked. During the study period, 100,867 primary care-eligible Nova Scotians (10.1% of the population) were on the waitlist. Those on the waitlist had higher emergency department utilization each quarter, and more ACSC hospitalizations for most quarters, than those not on the waitlist. Emergency department utilization was higher for individuals ≥65 years and females; lowest during the first two COVID-19 waves; and differed more by waitlist status for those <65 years. Emergency department contacts and ACSC hospitalizations decreased during COVID-19 relative to the previous year. Emergency department utilization during COVID-19 was lower compared to analogous previous year quarters and this relative difference was more pronounced for those on the waitlist during the second wave of COVID-19.
ConclusionLinking novel data sources identified that Nova Scotians seeking primary care attachment utilize hospital-based services more frequently than those not on the waitlist. Both groups had lower utilization during the COVID-19 pandemic than the year before. The degree to which forgone services produces downstream health burden remains to be seen.
IntroductionGiven the recurrent risk of respiratory illness-based pandemics, and the important roles family physicians play during public health emergencies, the development of pandemic plans for ...primary care is imperative. Existing pandemic plans in Canada, however, do not adequately incorporate family physicians’ roles and perspectives. This policy and planning oversight has become increasingly evident with the emergence of the novel coronavirus disease, COVID-19, pandemic. This study is designed to inform the development of pandemic plans for primary care through evidence from four provinces in Canada: British Columbia, Newfoundland and Labrador, Nova Scotia, and Ontario.Methods and analysisWe will employ a multiple-case study of regions in four provinces. Each case consists of a mixed methods design which comprises: (1) a chronology of family physician roles in the COVID-19 pandemic response; (2) a provincial policy analysis; and (3) qualitative interviews with family physicians. Relevant policy and guidance documents will be identified through targeted, snowball and general search strategies. Additionally, these policy documents will be analysed to identify gaps and/or emphases in existing policies and policy responses. Interviews will explore family physicians’ proposed, actual and potential roles during the pandemic, the facilitators and barriers they have encountered throughout and the influence of gender on their professional roles. Data will be thematically analysed using a content analysis framework, first at the regional level and then through cross-case analyses.Ethics and disseminationApproval for this study has been granted by the Research Ethics of British Columbia, the Health Research Ethics Board of Newfoundland and Labrador, the Nova Scotia Health Authority Research Ethics Board and the Western University Research Ethics Board. Findings will be disseminated via conferences and peer-reviewed publications. Evidence and lessons learnt will be used to develop tools for government ministries, public health units and family physicians for improved pandemic response plans for primary care.
IntroductionMany Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to ...understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care.Methods and analysisIn this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events.Ethics and disseminationWe received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences.
Patient access to primary healthcare (PHC) is the foundation of a strong healthcare system and healthy populations. Attachment to a regular PHC provider, a key to healthcare access, has seen a ...decline in some jurisdictions. This study explored the consequences of unattachment from a patient perspective, an under-studied phenomenon to date.
A realist-informed qualitative study was conducted with unattached patients in Nova Scotia, Canada. Semi-structured interviews with nine participants were conducted and transcribed for analysis. The framework method was used to carry out analysis, which was guided by Donabedian's model of assessing healthcare access and quality.
Five key findings were noted in this study: 1) Participants experienced a range of consequences from not having a regular PHC provider. Participants used creative strategies to 2) attempt to gain attachment to a regular PHC provider, and, to 3) address their health needs in the absence of a regular PHC provider. 4) Participants experienced negative feelings about themselves and the healthcare system, and 5) stress related to the consequences and added work of being unattached and lost care.
Unattached patients experienced a burden of care related to lost care and managing their own health and related information, due to the download of medical record management and system navigation to them. These findings may underestimate the consequences for further at-risk populations who would not have been included in our recruitment. This may result in poorer health outcomes, which could be mitigated by interventions at the structural level, such as enhanced centralized waitlists to promote attachment. Such waitlists may benefit from a triage approach to appropriately attach patients based on need.
Abstract
Background
Many family medicine residency graduates indicate a desire to provide obstetric care, but a low proportion of family physicians (FPs) provide obstetric care within their practice. ...This suggests personal preference alone may not account for the low proportion of FPs who ultimately provide full obstetric care. If decisionmakers plan to augment the number of FPs providing obstetric care, barriers to the provision of such care must first be identified. Within this paper, we explore the perspectives of both family practice residents and early-career FPs on the factors that shaped their decision to provide obstetric care.
Methods
In this qualitative study, we analyzed a subset of interview data from three Canadian provinces: British Columbia, Ontario, and Nova Scotia (
n
= 18 family practice residents;
n
= 39 early-career FPs). We used thematic analysis to analyze data relevant to obstetric care practice, applying the socio-ecological model and comparing themes across participant types, gender, and province.
Results
Participants described influences affecting their decision about providing obstetric care. Key influencing factors aligned with the levels of the socio-ecological model of public policy (i.e., liability), community (i.e., community needs), organizational (e.g., obstetric care trade-offs, working in teams, sufficient exposure in training), interpersonal practice preferences (i.e., impact on family life, negative interactions with other healthcare professionals), and individual factors (i.e., defining comprehensive care as “everything but obstetrics”). Many participants were interested in providing obstetric care within their practice but did not provide such care. Participants’ decision-making around providing or not providing obstetric care included considerations of personal preferences and outside influences.
Conclusions
Individual-level factors alone do not account for the decrease in the type and amount of obstetric care offered by FPs. Instead, FPs’ choice to provide or not provide obstetric care is influenced by factors at higher levels of the socio-ecological model. Policymakers who want to encourage obstetric practice by FPs should implement interventions at the public policy, community, organizational, interpersonal, and individual levels.
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