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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., Competing Interests: Competing interests:: Michael Green reports research support from the Ontario Ministry of Health and the Canadian Institutes of Health Research (CIHR). He is president and board chair of the College of Family Physicians of Canada and sits on the board of AMS Healthcare. Tara Kiran reports honoraria from the Ontario College of Family Physicians, the Ontario Medical Association, the Canadian Medical Association, the Canadian College of Family Physicians, and the Association of Family Health Teams of Ontario. Mina Tadrous reports consulting fees from the Canadian Agency for Drugs and Technologies in Health and Health Canada. Dominik Nowak reports consulting fees from the Alliance for Healthier Communities, the Centre for Effective Practice, the Ontario College of Family Physicians, the Ontario Medical Association, TELUS, and Women’s College Hospital. He is president-elect of the Ontario Medical Association. Holly Witteman is supported by a Canada Research Chair and reports an honorarium from Stanford University. Isaac Bogoch reports research funding from CIHR and consulting fees from the Weapons Threat Reduction Program. David Kaplan reports travel support from the Public Health Agency of Canada; he is chair of the Post–COVID-19 Condition guideline advisory committee and sits on the board of directors with the Musical Stage Company. No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: Adult survivors of childhood cancer are at elevated risk of morbidity and mortality compared to the general population, but their adherence to lifelong periodic surveillance is suboptimal. We aimed to examine adherence to surveillance guidelines for high-yield tests and identify risk factors for nonadherence in adult survivors of childhood cancer., Methods: In this retrospective, population-based cohort study, we used health care administrative data from Ontario, Canada, to identify adult survivors of childhood cancer diagnosed between 1986 and 2014 who were at elevated risk of therapy-related colorectal cancer, breast cancer, or cardiomyopathy. Using a Poisson regression framework, we assessed longitudinal adherence and predictors of adherence to the Children's Oncology Group surveillance guideline., Results: Among 3241 survivors, 327 (10%), 234 (7%), and 3205 (99%) were at elevated risk for colorectal cancer, breast cancer, and cardiomyopathy, respectively. Within these cohorts, only 13%, 6%, and 53% were adherent to recommended surveillance as of February 2020. During a median follow-up of 7.8 years, the proportion of time spent adherent was 14% among survivors at elevated risk for colorectal cancer, 10% for breast cancer, and 43% for cardiomyopathy. Significant predictors of adherence varied across the risk groups, but higher comorbidity was associated with adherence to recommended surveillance., Interpretation: Survivors of childhood cancer in Ontario are rarely up to date for recommended surveillance tests. Tailored interventions beyond specialized clinics are needed to improve surveillance adherence., Competing Interests: Competing interests:: Jennifer Shuldiner reports receiving a Canadian Institutes of Health Research (CIHR) Health System Impact Post-doctoral Fellowship, in support of the current manuscript. Noah Ivers is supported by a CIHR Tier 2 Canada Research Chair in Implementation of Evidence-based Practice (paid to institution). Paul Nathan is supported by a CIHR Foundation Grant and a grant from the United States Department of Defense (both paid to institution). No other competing interests were declared., (© 2024 CMA Impact Inc. or its licensors.)

Background: Academic detailing, an educational outreach service for family physicians, was funded by the Ontario government to address gaps in opioid prescribing and pain management. We sought to evaluate the impact of academic detailing on opioid prescribing, and to understand how and why academic detailing may have influenced opioid prescribing., Methods: In this mixed-methods study, we collected quantitative and qualitative data concurrently from 2017 to 2019 in Ontario, Canada. We analyzed prescribing outcomes descriptively for a sample of participating physicians and compared them with a matched control group. We invited physicians to participate in qualitative interviews to discuss their experiences in academic detailing. Development and analysis of qualitative interviews was informed by the Theoretical Domains Framework. We triangulated qualitative and quantitative findings to understand the mechanisms that drove changes in opioid prescribing., Results: Physicians receiving academic detailing ( n = 238) achieved a greater reduction in opioid prescribing than matched controls ( n = 238). Seventeen physicians completed interviews and reported that academic detailing addressed barriers to pain care, including lack of confidence, difficult interactions with patients and prescribing and tapering decisions. Academic detailing reinforced knowledge about opioid prescribing and pain management. Discussion of complex patients and talking points to use during challenging conversations were described as key drivers of practice change., Interpretation: The findings of this real-world, mixed-methods evaluation explain how an academic detailing service addressed key barriers and enablers to limit high-risk opioid prescribing in primary care. This nuanced understanding will be used to inform, spread and scale academic detailing., Competing Interests: Competing interests: Noah Ivers reports funding from the Canadian Institutes of Health Research, outside the submitted work. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

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., Competing Interests: Competing interests: None declared., (© 2023 CMA Impact Inc. or its licensors.)

Background: Although the current Canadian Task Force on Preventive Health Care guideline recommends that physicians should inform women aged 40-49 years of the potential benefits and harms of screening mammography to support individualized decisions, previous reports of variation in clinical practice at the physician level suggest a lack of guideline-concordant care. We explored determinants (barriers and facilitators) of guideline-concordant care by family physicians regarding screening mammography in this age group., Methods: We conducted qualitative semi-structured interviews by phone with family physicians in the Greater Toronto Area from January to November 2020. We structured interviews using the Theoretical Domains Framework to explore determinants (barriers and facilitators) of 5 physician screening behaviours, namely risk assessment, discussion regarding benefits and harms, decision or referral for mammography, referral for genetic counselling and referral to high-risk screening programs. Two independent researchers iteratively analyzed interview transcripts and deductively coded for each behaviour by domain to identify key behavioural determinants until saturation was reached., Results: We interviewed 18 physicians (mean age 48 yr, 72% self-identified as women). Risk assessment was influenced by physicians' knowledge of risk factors, skills to synthesize risk and beliefs about utility. Physicians had beliefs in their capabilities to have informed patient-centred discussions, but insufficient knowledge regarding the harms of screening. The decision or referral for mammography was affected by emotions related to past patient outcomes, social influences of patients and radiology departments, and knowledge and beliefs about consequences (benefits and harms of screening). Referrals for genetic counselling and to high-risk screening programs were facilitated by their availability and by the knowledge and skills to complete forms. Lack of knowledge regarding which patients qualify and beliefs about consequences were barriers to referral., Interpretation: Insufficient knowledge and skills for performance of risk assessment, combined with a tendency to overestimate benefits of screening relative to harms affected provision of guideline-concordant care. These may be effective targets for future interventions to improve guideline-concordant care., Competing Interests: Competing interests: Alexandra Desnoyers reports consulting fees from Novartis and Pfizer, and payments from Novartis, Pfizer, AstraZeneca, Gilead and Apobiologix. Eitan Amir reports consulting fees from Sandoz, Novartis and Exact Sciences. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Background: Patient engagement is a priority for health care quality improvement and health system design, but many organizations struggle to engage patients meaningfully. We describe patient engagement activities and success factors that influence organizational decision-making in Ontario's patient medical homes., Methods: From March to May 2018, we conducted an online survey focused on practice-level patient engagement that targeted primary care organization leaders at all Ontario family health teams, community health centres, nurse practitioner-led clinics and Aboriginal Health Access Centres. We asked questions from the Measuring Organizational Readiness for Engagement (MORE) and Public and Patient Engagement Evaluation Tool (PPEET) questionnaires. We used factor and mediation analysis to identify organizational conditions and activities that are associated with the outcomes of patient engagement, affecting board decisions, program-level decisions and the formation of collaborative partnerships., Results: We achieved a 53% response rate ( n = 149/283); after removing missing data, our final sample size was 141 respondents. Most respondents perceived that their organization's patient engagement activities and resources were insufficient. Processes that had a direct effect on outcomes (β = 0.7, p < 0.0001) included planning, training and supporting employees; identifying, recruiting and supporting relevant patients; and using leaders. Structures - including an organizational mission and vision for patient engagement, and policies, procedures, job positions, training programs and organizational culture that reflect that mission - indirectly affected outcomes, mediated by the aforementioned processes (β = 0.7, p < 0.0001)., Interpretation: Based on the perceptions of primary care leaders, organizational structures and processes are related to successful patient engagement. Organizations that seek to improve patient engagement should assess their commitment and follow-through with associated resources and activities., Competing Interests: Competing interests: At the time of the study, Jennifer Rayner and Carol Mulder were employees of the Alliance for Healthier Communities and the Association of Family Health Teams of Ontario, respectively. They received no additional incentives for this research project beyond the scope of their employment., (© 2021 CMA Joule Inc. or its licensors.)

Background: The Wait Time Alliance recently established wait time benchmarks for rheumatology consultations in Canada. Our aim was to quantify wait times to primary and rheumatology care for patients with rheumatic diseases., Methods: We identified patients from primary care practices in the Electronic Medical Record Administrative data Linked Database who had referrals to Ontario rheumatologists over the period 2000-2013. To assess the full care pathway, we identified dates of symptom onset, presentation in primary care and referral from electronic medical records. Dates of rheumatologist consultations were obtained by linking with physician service claims. We determined the duration of each phase of the care pathway (symptom onset to primary care encounter, primary care encounter to referral, and referral to rheumatologist consultation) and compared them with established benchmarks., Results: Among 2430 referrals from 168 family physicians, 2015 patients (82.9%) were seen by 146 rheumatologists within 1 year of referral. Of the 2430 referrals, 2417 (99.5%) occurred between 2005 and 2013. The main reasons for referral were osteoarthritis (32.4%) and systemic inflammatory rheumatic diseases (30.6%). Wait times varied by diagnosis and geographic region. Overall, the median wait time from referral to rheumatologist consultation was 74 (interquartile range 27-101) days; it was 66 (interquartile range 18-84) days for systemic inflammatory rheumatic diseases. Wait time benchmarks were not achieved, even for the most urgent types of referral. For systemic inflammatory rheumatic diseases, most of the delays occurred before referral., Interpretation: Rheumatology wait times exceeded established benchmarks. Targeted efforts are needed to promote more timely access to both primary and rheumatology care. Routine linkage of electronic medical records with administrative data may help fill important gaps in knowledge about waits to primary and specialty care.

Background: Continuity of care has been shown to be poor following in-hospital discharge, and there are substantially fewer resources to facilitate follow-up care arrangements after discharge from an emergency department. Our objective was to assess the frequency, timeliness and predictors for obtaining follow-up care following discharge from an emergency department in Ontario with a new diagnosis of atrial fibrillation., Methods: We conducted a retrospective cohort study involving all patients discharged from the 157 nonpediatric emergency departments in Ontario, who received a new diagnosis of atrial fibrillation between 2007 and 2012. We determined the frequency of follow-up care with a family physician, cardiologist or internist within 7 (timely) and 30 days of the emergency department visit, and assessed the association of emergency and family physician characteristics, including primary care model type, with obtaining timely follow-up care., Results: Among 14 907 patients discharged from Ontario emergency departments with a new, primary diagnosis of atrial fibrillation, half (n = 7473) had timely follow-up care. At 30 days, 2678 patients (18.0%) still had not obtained follow-up care. Among emergency and family physician factors, lack of a family physician had the largest independent association with acquiring timely follow-up care (odds ratio [OR] 0.58, 95% confidence interval [CI] 0.50-0.69). Using patients with a family physician belonging to a primarily fee-for-service remuneration model as the comparison group, patients with a family physician belonging to a capitation-based Family Health Network, as part of a Family Health Team, were less likely to receive timely follow-up care (OR 0.73, 95% CI 0.62-0.86), as were those whose family physician belonged to the same model type that was not part of a Family Health Team (OR 0.77, 95% CI 0.60-0.97)., Interpretation: Only half of the patients who were discharged from an emergency department in Ontario with a new diagnosis of atrial fibrillation were seen within 7 days of discharge. The most influential factor was having a family physician; patients with a family physician being remunerated via primarily fee-for-service methods were more likely to be seen within 7 days than those who were reimbursed through a primarily capitation model. Systems-wide solutions are needed to ensure timely follow-up care is available for all patients with chronic diseases.

Background: Strategic clinical networks, a recent development in the health system in Alberta, have been charged with bringing together front-line clinicians, researchers and policy-makers to identify variation in clinical care, and to propose standards, pathways and innovative solutions to improve access and quality of care. Here, we describe a collaborative workshop held between researchers and the Obesity, Diabetes and Nutrition Strategic Clinical Network to describe barriers to and facilitators of care for people with diabetes and to identify quality improvement interventions that should be prioritized., Methods: Through collaboration between health researchers and the strategic clinical network, and using principles of the knowledge-to-action cycle, we identified barriers to and facilitators of diabetes care using data from a patient survey and a provider focus group (5 primary care physicians and 1 diabetes educator). In addition, we identified best evidence from a systematic review of quality improvement initiatives in diabetes. This information was reviewed at a multistakeholder workshop where potential quality improvement initiatives were considered at various service levels., Results: A pilot survey involving 59 patients with diabetes and a focus group of primary care and allied health care providers identified several important barriers to optimal outcomes in diabetes care, including patient-level financial barriers to care and difficulty navigating the health system. Our collaborative discussion using the knowledge-to-action cycle prioritized feasible, evidence-based interventions to improve outcomes for patients with diabetes, including enabling care by allied health care providers and creating clear care maps and processes for system navigation., Interpretation: We identified important barriers to achieving optimal outcomes in diabetes that may be overcome through the use of evidence-based quality improvement interventions. As recommended within the knowledge-to-action cycle, future research is required to determine whether program implementation improves outcomes and is cost-effective.