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Objectives: In 2003, Ontario introduced a patient enrolment system as part of health care reforms, aimed at enhancing primary health care services, but it is unclear whether immigrants have benefited from this health care reform. Therefore, we studied whether this reform changed the extent of immigrants' enrolment in primary care services in Ontario between 2003 and 2012.Methods: This is a population-based retrospective cohort study, in which a closed cohort of 9231840 Ontario residents between 1985 and 2003 was created, using linked health administrative and immigration databases. Levels of enrolment for traditional and more comprehensive capitation-based practice between 2003 and 2012 were compared by immigrant status. Logistic regression modelling was used to assess the odds of enrolment on primary care practices.Results: Overall enrolment in primary care practices increased gradually after 2004, until 2012, when two-thirds of the cohort (67%) were enrolled. The immigrants' enrolment level remained consistently lower than that of long-term residents over the study period. By 2012, enrolment of immigrants in capitation-based models was significantly lower (17.3% versus 25.4%). In particular, enrolment in Family Health Teams, considered the most comprehensive care model, was considerably lower in immigrants compared with long-term residents (5.6% versus 18.0%; OR = 0.40, 95% CI: 0.40 to 0.41).Conclusions: Immigrant enrolment rates in new comprehensive primary care models were consistently lower than among long-term residents. This has implication on equitable primary care access for immigrant populations. [ABSTRACT FROM AUTHOR]

Context: Home visits at the end of life decrease hospitalizations and hospital deaths, which reduces healthcare costs and aligns with most patients' wishes. In addition to family physicians, nurse practitioners (NPs) play a critical role in meeting the rising demand for home and community-based palliative care. However, very few population-level studies have examined practice patterns of NPs delivering home-based end-of-life care and the collaboration between physicians and NPs. Objective: To describe the characteristics and outcomes of patients receiving home-based palliative care provided by physicians and NPs in the last 90 days of life. Study design and Analysis: Retrospective population-based study with a descriptive analysis of patient characteristics and multivariate logistic regression analyses of end-of-life outcomes controlling for patients' demographics, health, and healthcare use. Setting or Dataset: Healthcare administrative data in Ontario, Canada. Population studied: Adults 19 years and older who died between January 1, 2018, and December 31, 2019, and received home care in their last 90 days of life (N=103,664). Intervention/Instrument: Receipt of home visits by an NP, physician, or both. Outcome measures: Receipt of medications for symptoms (e.g., pain, delirium/agitation, and terminal secretion) in the last 3 weeks of life, acute care use in the last 3 weeks of life, and location of death. Results: Over half (56.9%) of the decedents did not receive any visits from an NP or physician; 3.8% received at least 1 visit from an NP (and no physician visits), 34.5% received at least 1 visit from a physician (but no NP visits), and 4.9% received at least 1 visit from each. NP visits were more prevalent among patients living in rural areas. Patients who received at least 1 home visit were less likely to be hospitalized, more likely to have received medications for symptom management, and more likely to experience a community-based death. These associations were strongest when patients received home visits from both NPs and physicians. Results from multivariable regression are forthcoming. Conclusions: The receipt of at least 1 NP or physician home visit at the end of life can significantly reduce acute care use, improve access to symptom management medications, and mitigate hospital-based deaths. Collaboration between NPs and physicians was associated with greater benefits to patients' outcomes. [ABSTRACT FROM AUTHOR]

Background: Immigrants make up one fifth of the Canadian population and this number continues to grow. Adequate access to primary health care is important for this population but it is not clear if this is being achieved. This study explored patient reported access to primary health care of a population of immigrants in Ontario, Canada who were users of the primary care system and compared this with Canadian-born individuals; and by model of primary care practice. Methods: This study uses data from the Comparison of Models of Primary Care Study (COMP-PC), a mixed-methods, practice-based, cross-sectional study that collected information from patients and providers in 137 primary care practices across Ontario, Canada in 2005-2006. The practices were randomly sampled to ensure an equal number of practices in each of the four dominant primary care models at that time: Fee-For-Service, Community Health Centres, and the two main capitation models (Health Service Organization and Family Health Networks). Adult patients of participating practices were identified when they presented for an appointment and completed a survey in the waiting room. Three measures of access were used, all derived from the patient survey: First Contact Access, First Contact Utilization (both based on the Primary Care Assessment Tool) and number of selfreported visits to the practice in the past year. Results: Of the 5,269 patients who reported country of birth 1,099 (20.8%) were born outside of Canada. In adjusted analysis, recent immigrants (arrival in Canada within the past five years) and immigrants in Canada for more than 20 years were less likely to report good health compared to Canadian-born (Odds ratio 0.58, 95% CI 0.36,0.92 and 0.81, 95% CI 0.67,0.99). Overall, immigrants reported equal access to primary care services compared with Canadian-born. Within immigrant groups recently arrived immigrants had similar access scores to Canadian-born but reported 5.3 more primary care visits after adjusting for health status. Looking across models, recent immigrants in Fee-For-Service practices reported poorer access and fewer primary care visits compared to Canadian-born. Conclusions: Overall, immigrants who were users of the primary care system reported a similar level of access as Canadian-born individuals. While recent immigrants are in poorer health compared with Canadian-born they report adequate access to primary care. The differences in access for recently arrived immigrants, across primary care models suggests that organizational features of primary care may lead to inequity in access. [ABSTRACT FROM AUTHOR]

Background: Primary healthcare services must respond to the healthcare-seeking needs of persons with a wide range of personal and social characteristics. In this study, examined whether socially vulnerable persons exhibit lower abilities to access healthcare. First, we examined how personal and social characteristics are associated with the abilities to access healthcare described in the patient-centered accessibility framework and with the likelihood of reporting problematic access. We then examined whether higher abilities to access healthcare are protective against problematic access. Finally, we explored whether social vulnerabilities predict problematic access after accounting for abilities to access healthcare. Methods: This is an exploratory analysis of pooled data collected in the Innovative Models Promoting Access-To-Care Transformation (IMPACT) study, a Canadian-Australian research program that aimed to improve access to primary healthcare for vulnerable populations. This specific analysis is based on 284 participants in four study regions who completed a baseline access survey. Hierarchical linear regression models were used to explore the effects of personal or social characteristics on the abilities to access care; logistic regression models, to determine the increased or decreased likelihood of problematic access. Results: The likelihood of problematic access varies by personal and social characteristics. Those reporting at least two social vulnerabilities are more likely to experience all indicators of problematic access except hospitalizations. Perceived financial status and accumulated vulnerabilities were also associated with lower abilities to access care. Higher scores on abilities to access healthcare are protective against most indicators of problematic access except hospitalizations. Logistic regression models showed that ability to access is more predictive of problematic access than social vulnerability. Conclusions: We showed that those at higher risk of social vulnerability are more likely to report problematic access and also have low scores on ability to seek, reach, pay, and engage with healthcare. Equity-oriented healthcare interventions should pay particular attention to enhancing people's abilities to access care in addition to modifying organizational processes and structures that reinforce social systems of discrimination or exclusion. [ABSTRACT FROM AUTHOR]

Background: Greater continuity and access to primary care results in improved patient health, satisfaction, and reduced healthcare costs. Although patient rostering is considered to be a cornerstone of a high performing primary care system and is believed to improve continuity and access, few studies have examined these relationships. This study examined the impact of the adoption of a patient rostering enhanced fee-for-service model (eFFS) on continuity, coordination of specialized care, and access. Method: A population-based longitudinal study was conducted using health administrative data from urban family practices in Ontario, Canada. Family physicians that transitioned from traditional FFS (tFFS) to eFFS between 2004 and 2013 were followed overtime. Physicians providing comprehensive primary care that had at least 4 years of pre-transition and 2 years of post-transition data were eligible. Patients were attributed to physicians on an annual basis by determining the provider that billed the largest dollar amount over a 2 year period. Outcomes of interest were the usual provider of care index (UPC), a referral index (RI) (% of total primary care referrals for a physician's roster made by the main provider), and emergency department (ED) visits for family practice sensitive conditions (FPSCs). Mixed-effects segmented linear and logistic regressions were used to examine changes in outcomes while controlling for patient and provider contextual factors. Results: Prior to transitioning, UPC was decreasing at a rate of 0.27%/year (95% CI: -0.34 to − 0.21, p < 0.0001). Following the transition, UPC began decreasing by an additional 0.59%/year (95% CI: -0.69 to − 0.49, p < 0.0001) relative to the pre-transition rate. RI decreased by an additional 0.34%/year (95% CI: -0.43 to − 0.24, p < 0.0001) relative to the pre-transition period, where it had been stable. The transition had minimal impact on FPSC ED visits. Conclusion: Continuity and coordination of specialized care slightly decreased upon transition from tFFS to eFFS. This is likely due to physicians working in groups and sharing patients following the transition to the eFFS model. Adoption of an enrolment model with after-hours care did not decrease non-urgent ED use, which may reflect the small impact that primary care access has on these types of ED visits. [ABSTRACT FROM AUTHOR]

Background: Despite significant investments to support primary care internationally, income-based inequities in access to quality health care are present in many high-income countries. This study aims to determine whether low- and middle-income groups are more likely to report poor quality of primary care (PC) than high-income groups cross-nationally. Methods: The 2011 Commonwealth Fund Telephone Survey of Sicker Adults is a cross-sectional study across eleven countries. Respondents were recruited from randomly selected households. We used data from surveys conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. We identified all questions relating to primary care performance, and categorized these into five dimensions: 1) access to care, 2) coordination 3) patient-centered care, and 4) technical quality of care. We used logistic regression with low and middle-income as the comparison groups and high-income as the referent. Results: Fourteen thousand two hundred sixty-two respondents provided income data. Countries varied considerably in their extent of income disparity. Overall, 24.7% were categorized as low- and 13.9% as high-income. The odds of reporting poor access to care were higher for low- and middle-income than high-income respondents in Canada, New Zealand and the US. Similar results were found for Sweden and Norway on coordination; the opposite trend favoring the low- and middle-income groups was found in New Zealand, United Kingdom, and the United States. The odds of reporting poor patient-centered care were higher for low-income than high-income respondents in the Netherlands, Norway, and the US; in Australia, this was true for low- and middle-income respondents. On technical quality of care, the odds of reporting poor care were higher for the low- and middle-income comparisons in Canada and Norway; in Germany, the odds were higher for low-income respondents only. The odds of reporting poor technical quality of care were higher for high-income than low-income respondents in the Netherlands. Conclusion: Inequities in quality PC for low and middle income groups exist on at least one dimension in all countries, including some that in theory provide universal access. More research is needed to fully understand equity in the PC sector. [ABSTRACT FROM AUTHOR]

Background: Primary care has been reformed in recent years in Ontario, Canada, with a move away from traditional fee-for-service to enhanced fee-for-service and capitation-based models. It is unclear how new models have affected disparities in cancer screening. We evaluated whether Ontario’s enhanced fee-for-service model was associated with a change in the gaps in cancer screening for people living with low income and people who are foreign-born. Methods: We conducted a population-based longitudinal analysis from 2002 to 2013 of Ontario family physicians who transitioned from traditional fee-for-service to enhanced fee-for-service. The binary outcomes of interest were adherence to cervical, breast and colorectal cancer screening recommendations. Outcomes were analyzed using mixed-effects logistic regression. Analyses produced annual odds ratios comparing the odds of being up-to-date for screening among patients in enhanced fee-for-service versus patients in traditional fee-for-service for each social stratum separately. We calculated the ratios of stratum-specific odds ratios to assess whether the transition from traditional to enhanced fee-for-service was associated with a change in screening gaps between immigrants and long-term residents, and between people in the lowest and highest neighbourhood income quintiles. Results: Throughout the study period, cancer screening was consistently lower among immigrants and among people in the lowest income quintile. Transition to enhanced fee-for-service was generally associated with increased screening uptake for all, however for most years, ratios of ratios were significantly less than 1 for all three cancer screening types, indicating that there was a widening of the screening gap between immigrants and long-term residents and between people living in the lowest vs. highest income quintile associated with transitions. Conclusion: The transition to enhanced fee-for-service in Ontario was generally associated with a widening of screening inequities for foreign-born and low-income patients. [ABSTRACT FROM AUTHOR]