Search

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., Competing Interests: Declaration of Competing Interest This study received funding from CIHR (grant #175285). Aisha Lofters is the Chair in Implementation Science at the Peter Gilgan Centre for Women's Cancers in partnership with the Canadian Cancer Society. She is supported as a Clinician Scientist by the Department of Family and Community Medicine at the University of Toronto. Lauren Lapointe-Shaw is supported by the University of Toronto Department of Medicine, the Toronto General Hospital Research Institute, the Women's College Institute for Health System Solutions and Virtual Care (WIHV), and the Peter Gilgan Centre for Women's Cancers at Women's College Hospital, in partnership with the Canadian Cancer Society. Tara Kiran is the Fidani Chair of Improvement and Innovation at the University of Toronto. She is supported as a Clinician Scientist by the Department of Family and Community Medicine at St. Michael's Hospital and the University of Toronto. Noah M. Ivers is supported by a Canada Research Chair in Implementation of Evidence-based Practice and a Clinician Scholar award from the Department of Family and Community Medicine at Women's College Hospital and the University of Toronto. Simon Berthelot holds a Junior 2 Career Award from the Fonds de recherche du Québec - Santé (FRQS). Simon Berthelot receives research funding from Meridian Bioscience and Abbott to test their bedside COVID screening device in the emergency department setting., (Copyright © 2023. Published by Elsevier Inc.)

Background: Reducing laboratory test overuse is important for high quality, patient-centred care. Identifying priorities to reduce low value testing remains a challenge., Objective: To develop a simple, data-driven approach to identify potential sources of laboratory overuse by combining the total cost, proportion of abnormal results and physician-level variation in use of laboratory tests., Design, Setting and Participants: A multicentre, retrospective study at three academic hospitals in Toronto, Canada. All general internal medicine (GIM) hospitalisations between 1 April 2010 and 31 October 2017., Results: There were 106 813 GIM hospitalisations during the study period, with median hospital length-of-stay of 4.6 days (IQR: 2.33-9.19). There were 21 tests which had a cumulative cost >US$15 400 at all three sites. The costliest test was plasma electrolytes (US$4 907 775), the test with the lowest proportion of abnormal results was red cell folate (0.2%) and the test with the greatest physician-level variation in use was antiphospholipid antibodies (coefficient of variation 3.08). The five tests with the highest cumulative rank based on greatest cost, lowest proportion of abnormal results and highest physician-level variation were: (1) lactate, (2) antiphospholipid antibodies, (3) magnesium, (4) troponin and (5) partial thromboplastin time. In addition, this method identified unique tests that may be a potential source of laboratory overuse at each hospital., Conclusions: A simple multidimensional, data-driven approach combining cost, proportion of abnormal results and physician-level variation can inform interventions to reduce laboratory test overuse. Reducing low value laboratory testing is important to promote high value, patient-centred care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: End-of-rotation resident physician changeover is a key part of postgraduate training but could lead to discontinuity in patient care., Objective: To test whether patients exposed to end-of-rotation resident changeover have longer hospital stays and whether this association is mitigated by separating resident and attending changeover days., Design, Setting, and Participants: This retrospective cohort analysis included adult patients admitted to general internal medicine. The changeover day was the same day (first Monday of month) for both resident and attending physicians until June 30, 2013 (preseparation period), and then intentionally staggered by 1 or more days after July 1, 2013 (postseparation period). This was a multicenter analysis at 4 teaching hospitals in Ontario, Canada, from July 1, 2010, to June 30, 2019. Data analysis was conducted from July 2022 to January 2023., Exposures: Patients were classified as changeover patients if the first Monday was a resident changeover day and as control patients if the first Monday was not a resident changeover day., Main Outcomes and Measures: The primary outcome was length of hospital stay. Secondary outcomes were transfer to critical care, in-hospital death, and rate of discharge per 100 patients on the index day., Results: Of 95 282 patients. 22 773 (24%; mean [SD] age, 67.8 [18.8] years; 11 156 [49%] female patients) were exposed to resident changeover, and 72 509 (76%; mean [SD] age, 67.8 [18.7] years; 35 293 [49%] female patients) were not exposed to resident changeover. Exposure to resident changeover day was associated with a slightly longer hospital stay compared with control days (0.20 [95% CI, 0.09-0.30] days; P < .001) and decreased relative risk of patient discharge on the index day (relative risk, 0.92; 95% CI, 0.86-1.00; P = .047). These associations were similar in the preseparation and postseparation periods. Resident changeover was not associated with an increased risk of transfer to critical care or in-hospital death., Conclusions and Relevance: In this study, a small positive association between exposure to resident physician changeover and length of hospital stay as well as reduced rate of discharge was found. These findings suggest that separating changeover days for resident and attending physicians may not significantly change these associations.

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., Competing Interests: Competing interests: Nathan Stall is an associate editor of CMAJ. He was not involved in the editorial decision-making process for this article. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

This prospective study of internal medicine inpatients treated at 2 hospitals in Toronto, Canada, between September 1, 2016, and September 1, 2017, compared patient-report, physician-report, and detailed medical record review to identify specific hospital-acquired complications. Six complications were assessed: delirium, catheter-associated urinary tract infection, acute kidney injury, deep vein thrombosis/pulmonary embolism, hospital-acquired pneumonia, or fall. The study included 207 patients and physician responses were obtained for 156 (75%). Complications were identified in 28 (14%) patients by medical record review, 30 (14%) patients by patient-report, and 11 (7%) patients by physician-report. Fifty-four (26%) patients experienced a complication as identified through at least one of the 3 methods. There was little agreement between the 3 methods (Fleiss' ĸ 0.15, P < 0.001). All 3 sources agreed on the occurrence of a specific complication in only 1 patient (1%). Multiple approaches likely are needed to adequately measure hospital-acquired complications., (Copyright © 2021 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Variations in inpatient medical care are typically attributed to system, hospital or patient factors. Little is known about variations at the physician level within hospitals. We described the physician-level variation in clinical outcomes and resource use in general internal medicine (GIM)., Methods: This was an observational study of all emergency admissions to GIM at seven hospitals in Ontario, Canada, over a 5-year period between 2010 and 2015. Physician-level variations in inpatient mortality, hospital length of stay, 30-day readmission and use of 'advanced imaging' (CT, MRI or ultrasound scans) were measured. Physicians were categorised into quartiles within each hospital for each outcome and then quartiles were pooled across all hospitals (eg, physicians in the highest quartile at each hospital were grouped together). We report absolute differences between physicians in the highest and lowest quartiles after matching admissions based on propensity scores to account for patient-level variation., Results: The sample included 103 085 admissions to 135 attending physicians. After propensity score matching, the difference between physicians in the highest and lowest quartiles for in-hospital mortality was 2.4% (95% CI 0.6% to 4.3%, p<0.01); for readmission was 3.3% (95% CI 0.7% to 5.9%, p<0.01); for advanced imaging was 0.32 tests per admission (95% CI 0.12 to 0.52, p<0.01); and for hospital length of stay was 1.2 additional days per admission (95% CI 0.5 to 1.9, p<0.01). Physician-level differences in length of stay and imaging use were consistent across numerous sensitivity analyses and stable over time. Differences in mortality and readmission were consistent across most sensitivity analyses but were not stable over time and estimates were limited by sample size., Conclusions: Patient outcomes and resource use in inpatient medical care varied substantially across physicians in this study. Physician-level variations in length of stay and imaging use were unlikely to be explained by patient factors whereas differences in mortality and readmission should be interpreted with caution and could be explained by unmeasured confounders. Physician-level variations may represent practice differences that highlight quality improvement opportunities., Competing Interests: Competing interests: AAV and FR are employees of Ontario Health., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities., Methods: We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments., Results: There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% ( n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% ( n = 5297), and for 99.8% ( n = 5284) of these admissions, the patient received laboratory testing, for 86.9% ( n = 4604) the patient received plain radiography, for 41.5% ( n = 2197) the patient received computed tomography and for 81.2% ( n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each., Interpretation: The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases., Competing Interests: Competing interests: None declared., (Copyright 2020, Joule Inc. or its licensors.)

Background: Variability in antimicrobial prescribing may indicate an opportunity for improvement in antimicrobial use. We sought to measure physician-level antimicrobial prescribing in adult general medical wards, assess the contribution of patient-level factors to antimicrobial prescribing and evaluate the association between antimicrobial prescribing and clinical outcomes. Methods: Using the General Medicine Inpatient Initiative (GEMINI) database, we conducted a retrospective cohort study of physician-level volume and spectrum of antimicrobial prescribing in adult general medical wards in 4 academic teaching hospitals in Toronto, Ontario, between April 2010 and December 2019. We stratified physicians into quartiles by hospital site based on volume of antimicrobial prescribing (days of therapy per 100 patient-days and antimicrobial-free days) and antibacterial spectrum (modified spectrum score). The modified spectrum score assigns a value to each antibacterial agent based on the breadth of coverage. We assessed patient-level differences among physician quartiles using age, sex, Laboratory-based Acute Physiology Score, discharge diagnosis and Charlson Comorbidity Index. We evaluated the association of clinical outcomes (in-hospital 30-day mortality, length of stay, intensive care unit [ICU] transfer and hospital readmission) with antimicrobial volume and spectrum using multilevel modelling. Results: The cohort consisted of 124 physicians responsible for 124 158 hospital admissions. The median physician-level volume of antimicrobial prescribing was 56.1 (interquartile range 51.7–67.5) days of therapy per 100 patient-days. We did not find any differences in baseline patient characteristics by physician prescribing quartile. The difference in mean prescribing between quartile 4 and quartile 1 was 15.8 days of therapy per 100 patient-days (95% confidence interval [CI] 9.6–22.0), representing 30% higher antimicrobial prescribing in the fourth quartile than the first quartile. Patient in-hospital deaths, length of stay, ICU transfer and hospital readmission did not differ by physician quartile. In-hospital mortality was higher among patients cared for by prescribers with higher modified spectrum scores (odds ratio 1.13, 95% CI 1.04–1.24). Interpretation: We found that physician-level variability in antimicrobial prescribing was not associated with differences in patient characteristics or outcomes in academic general medicine wards. These findings provide support for considering the lowest quartile of physician antimicrobial prescribing within each hospital as a target for antimicrobial stewardship. [ABSTRACT FROM AUTHOR]

Context: Continuity with the same family physician is associated with better patient outcomes and this can be encouraged through patient enrolment models. Access to health care was disrupted by the SARSCoV-2 pandemic and much of primary care shifted to virtual care. Continuity with a family physician in Canada is generally high. It is not known if continuity was disrupted by the pandemic or if continuity varied according to patient enrolment status. Objective: To determine whether continuity of care with the same family physician changed since the pandemic among enrolled and non-enrolled patients. Study design and Analysis: Retrospective analysis of family physician office-based and virtual visits (i.e. telephone or video) 16 months before and 16 months since the onset of pandemic restrictions in Ontario (March 11, 2020). Dataset: Population-based linked physician billing data. Population: All patients residing in Ontario, Canada (population 14.8 million) for whom a family physician/general practitioner could be assigned. Approximately 80% of patients are formally enrolled with a family physician and many non-enrolled patients can be attributed according to the majority of care provided. Outcome measures: Continuity of care, defined as the mean of each patient's proportion of visits to the assigned family physician among all family physician visits, was analyzed for all visits, office visits and virtual visits, for formally enrolled and non-enrolled patients. Results: Among enrolled patients, continuity with the assigned family physician pre-pandemic ranged from 65-68% and this did not decrease with the pandemic. Among non-enrolled patients, the mean proportion of all visits to the assigned family physician ranged from 60-67% before the pandemic and there were decreases by as much as 18% during the pandemic. For virtual visits, there was lower continuity among enrolled than non-enrolled patients before the pandemic, but higher continuity for enrolled than non-enrolled patients during the pandemic. Patients 65 years and older had higher continuity with their own family physician than younger patients in both periods. There were few differences by sex. Conclusions: Since the pandemic, continuity of care has been maintained among patients enrolled to a family physician but declined for patients who are not formally enrolled. Efforts may be needed to address potential disruptions to continuity for patients not formally enrolled to a family physician. [ABSTRACT FROM AUTHOR]

Background: To evaluate screening and treatment strategies, large-scale real-world data on liver disease-related outcomes are needed. We sought to validate health administrative data for identification of cirrhosis, decompensated cirrhosis and hepatocellular carcinoma among patients with known liver disease. Methods: Primary patient data were abstracted from patients of the Toronto Center for Liver Disease with viral hepatitis (2006–2014), and all patients with liver disease from the Kingston Health Sciences Centre Hepatology Clinic (2013). We linked clinical information to health administrative data and tested a range of coding algorithms against the clinical reference standard. Results: A total of 6,714 patients had primary chart data abstracted. A single physician visit code for cirrhosis was sensitive (98–99%), and a single hospital diagnostic code for cirrhosis was specific (91–96%). The most sensitive algorithm for decompensated cirrhosis was one cirrhosis code with any of: a hospital diagnostic code, death code, or procedure code for decompensation (range 88–99% across groups). The most specific was one cirrhosis code and one hospital diagnostic code (range 89–98% across groups). Two physician visit codes or a single hospital diagnostic code, death code, or procedure code combined with a code for cirrhosis were sensitive and specific for hepatocellular carcinoma (sensitivity 94–96%, specificity 93–98%). Conclusion: These sensitive and specific algorithms can be used to define patient cohorts or detect clinical outcomes using health administrative data. Our results will facilitate research into the adequacy of screening and treatment for patients with chronic viral hepatitis or other liver diseases. [ABSTRACT FROM AUTHOR]

Context: To improve access to care and continuity during the COVID-19 pandemic, family physicians increased their use of virtual care. However, there were concerns that having family physicians see fewer patients in-person was leading to an increase in emergency department (ED) use. Objective: We aimed to understand whether the use of virtual care in the primary care setting was associated with increased emergency department visits. Study design and Analysis: Population-based study comparing the mean ED visits in Feb to Oct 2019 (pre-pandemic) with those in Feb to Oct 2021, stratified by the family physician's percent of care delivered virtually in 2021. Setting or Dataset: Linked health administrative data in Ontario, Canada where primary care and ED visits are fully insured and free at the point-of-care for all permanent residents. Population studied: All family physicians with billings from February to October 2021 (n=15,155) and all patients living in Ontario and attached to a family physician as of March 31, 2021 (n=14,705,864). Outcome measures: The mean number of ED visits among patients, stratified by the percent of care delivered virtually by their attached physician. Results: Mean total ED visits decreased by 15% from 299 per 1000 people in 2019 to 254 visits per 1000 people in 2021. From February to October 2021, 9.2% (n=1,395), 28.1% (n=4,262), 17.8% (n=2,691) and 2.6% (n=400) physicians provided 0%, >60-80%, >80-<100%, and 100% of care virtually, respectively. The largest proportion of patients were seen by physicians who provided >60-80% of care virtually (31.7%, n=4,657,341). Patients whose family physicians provided 100% of visits in-person had the highest mean number of ED visits (488 per 1000), while patients whose physicians delivered >80%-<100% care virtually had the lowest volume of ED use (243 visits per 1000). Trends in ED use across physician virtual care strata were similar in 2019. Conclusions: Family physicians with a higher proportion of virtual encounters did not have higher rates of emergency department use among their patients. Differences observed in patient ED use across levels of physician virtual care provision were similar in 2019, suggesting pre-existing patterns unrelated to the expansion of virtual care during the pandemic. [ABSTRACT FROM AUTHOR]

Objective: To assess the cost-effectiveness of six treatment strategies for patients diagnosed with recurrent Clostridium difficile infection (CDI) in Canada: 1. oral metronidazole; 2. oral vancomycin; 3.oral fidaxomicin; 4. fecal transplantation by enema; 5. fecal transplantation by nasogastric tube; and 6. fecal transplantation by colonoscopy. Perspective: Public insurer for all hospital and physician services. Setting: Ontario, Canada. Methods: A decision analytic model was used to model costs and lifetime health effects of each strategy for a typical patient experiencing up to three recurrences, over 18 weeks. Recurrence data and utilities were obtained from published sources. Cost data was obtained from published sources and hospitals in Toronto, Canada. The willingness-to-pay threshold was $50,000/QALY gained. Results: Fecal transplantation by colonoscopy dominated all other strategies in the base case, as it was less costly and more effective than all alternatives. After accounting for uncertainty in all model parameters, there was an 87% probability that fecal transplantation by colonoscopy was the most beneficial strategy. If colonoscopy was not available, fecal transplantation by enema was cost-effective at $1,708 per QALY gained, compared to metronidazole. In addition, fecal transplantation by enema was the preferred strategy if the probability of recurrence following this strategy was below 8.7%. If fecal transplantation by any means was unavailable, fidaxomicin was cost-effective at an additional cost of $25,968 per QALY gained, compared to metronidazole. Conclusion: Fecal transplantation by colonoscopy (or enema, if colonoscopy is unavailable) is cost-effective for treating recurrent CDI in Canada. Where fecal transplantation is not available, fidaxomicin is also cost-effective. [ABSTRACT FROM AUTHOR]