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Background: The expansion of the Patient-Centred Medical Home model presents a valuable opportunity to enhance the integration of team-based mental health services in primary care settings, thereby meeting the growing demand for such services. Understanding the organizational context of a Patient-Centred Medical Home is crucial for identifying the facilitators and barriers to integrating mental health care within primary care. The main objective of this paper is to present the findings related to the following research question: "What organizational features shape Family Health Teams' capacity to provide mental health services for depression and anxiety across Ontario, Canada?", Methods: Adopting a constructivist grounded theory approach, we conducted interviews with various mental health care providers, and administrators within Ontario's Family Health Teams, in addition to engaging provincial policy informants and community stakeholders. Data analysis involved a team-based approach, including code comparison and labelling, with a dedicated data analysis subcommittee convening monthly to explore coded concepts influencing contextual factors., Results: From the 96 interviews conducted, involving 82 participants, key insights emerged on the organizational contextual features considered vital in facilitating team-based mental health care in primary care settings. Five prominent themes were identified: i) mental health explicit in the organizational vision, ii) leadership driving mental health care, iii) developing a mature and stable team, iv) adequate physical space that facilitates team interaction, and v) electronic medical records to facilitate team communication., Conclusions: This study underscores the often-neglected organizational elements that influence primary care teams' capacity to deliver quality mental health care services. It highlights the significance of strong leadership complemented by effective communication and collaboration within teams to enhance their ability to provide mental health care. Strengthening relationships within primary care teams lies at the core of effective healthcare delivery and should be leveraged to improve the integration of mental health care., Competing Interests: The authors declare that they have no competing interests., (Copyright: © 2024 Ashcroft et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: There are meaningful gaps in equitable access to Primary Health Care (PHC), especially for vulnerable populations after widespread reforms in Western countries. The Innovative Models Promoting Access-to-Care Transformation (IMPACT) research program is a Canadian-Australian collaboration that aims to improve access to PHC for vulnerable populations. Relationships were developed with stakeholders in six regions across Canada and Australia where access-related needs could be identified. The most promising interventions would be implemented and tested to address the needs identified. This realist review was conducted to understand how community coalition and outreach (e.g., mobile or pop-up) services improve access for underserved vulnerable residents., Objective: To inform the development and delivery of an innovative intervention to increase access to PHC for vulnerable populations., Methods: A realist review was conducted in collaboration with the Local Innovative Partnership (LIP) research team and the IMPACT research members who conducted the review. We performed an initial comprehensive systematic search using MEDLINE, EMBASE, PsycINFO, and the Cochrane Library up to October 19, 2015, and updated it on August 8, 2020. Studies were included if they focused on interventions to improve access to PHC using community coalition, outreach services or mobile delivery methods. We included Randomized Controlled Trials (RCTs), and systematic reviews. Studies were screened by two independent reviewers and the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used for data extraction and framework analysis to obtain themes. The LIP research team was also allowed to suggest additional papers not included at screening., Results: We included 43 records, comprising 31 RCTs, 11 systematic reviews, and 1 case control study that was added by the LIP research team. We identified three main themes of PHC interventions to promote access for vulnerable residents, including: 1) tailoring of materials and services decreases barriers to primary health care, 2) services offered where vulnerable populations gather increases the "reach" of the interventions, 3) partnerships and collaborations lead to positive health outcomes. In addition, implementation designs and reporting elements should be considered., Conclusion: Realist reviews can help guide the development of locally adapted primary health care interventions., (© 2023. The Author(s).)

This is the protocol for an evidence and gap map. The objectives are as follows: This EGM aims to map available evidence on the effects of in-person interventions to reduce social isolation and/or loneliness across all age groups in all settings., (© 2023 The Authors. Campbell Systematic Reviews published by John Wiley & Sons Ltd on behalf of The Campbell Collaboration.)

Background: Electronic patient portals are online applications that allow patients access to their own health information, a form of asynchronous virtual care. The long-term impact of portals on the use of traditional primary care services is unclear, but it is an important question at this juncture, when portals are being incorporated into many primary care practices., Objective: We sought to investigate how an electronic patient portal affected the use of traditional, synchronous primary care services over a much longer time period than any existing studies and to assess the impact of portal messaging on clinicians' workload., Methods: We conducted a propensity-score-matched, open-cohort, interrupted time-series evaluation of a primary care portal from its implementation in 2010. We extracted information from the electronic medical record regarding age, sex, education, income, family health team enrollment, diagnoses at index date, and number of medications prescribed in the previous year. We also extracted the annual number of encounters for up to 8 years before and after the index date and provider time spent on secure messaging through the portal., Results: A total of 7247 eligible portal patients and 7647 eligible potential controls were identified, with 3696 patients matched one to one. We found that portal registration was associated with an increase in the number of certain traditional encounters over the time period surrounding portal registration. Following the index year, there was a significant jump in annual number of visits to physicians in the portal arm (0.42 more visits/year vs control, P<.001) but not for visits to nurse practitioners and physician assistants. The annual number of calls to the practice triage nurses also showed a greater increase in the portal arm compared to the control arm after the index year (an additional 0.10 calls, P=.006). The average provider time spent on portal-related work was 5.7 minutes per patient per year., Conclusions: We found that portal registration was associated with a subsequent increase in the number of some traditional encounters and an increase in clerical workload for providers. Portals have enormous potential to truly engage patients as partners in their own health care, but their impact on use of traditional health care services and clerical burden must also be considered when they are incorporated into primary care., (©Karen Ferguson, Mark Fraser, Meltem Tuna, Charles Bruntz, Simone Dahrouge. Originally published in JMIR Medical Informatics (https://medinform.jmir.org), 06.02.2023.)

Background: The onset of the COVID-19 pandemic and introduction of various restrictions resulted in drastic changes to 'traditional' primary healthcare service delivery modalities., Aim: To understand the impact of virtual care on healthcare system performance within the context of Ontario community health centres (CHCs)., Design & Setting: Thematic analysis of qualitative interviews with 36 providers and 31 patients., Method: Semi-structured phone interviews were conducted in the autumn of 2020. Interviews were recorded, transcribed verbatim, and analysed thematically using the quadruple aim framework., Results: The transition to virtual delivery of services has had both positive and negative impacts on care. Virtual care removed certain barriers to care such as access. However, patients and providers found that phone visits impacted quality of care owing to the inability to read body language and having to rely solely on patient descriptions. Video visits allowed for a similar experience to in-person visits but technical issues constrained this interaction. Depending on the service provided, some providers felt they were not providing the same quality of care. However, providers reported reductions in no-show rates and highlighted the efficiency of virtual appointments. Providers also found they were able to collaborate at a similar level before the pandemic and saw improvements in work-life balance. Overall, patients and providers alike preferred virtual visits with those known to them, and for less complex or transactional aspects of care., Conclusion: The study described positive and negative impacts on patient care, population health, health system costs, and provider experience. These results will be useful for primary care organisations in post-pandemic planning; however, future research is needed for a deeper exploration of the impact on quality of care specifically for more complex health concerns., (Copyright © 2022, The Authors.)

Background: Social isolation and loneliness affect one in four older adults in many regions around the world. Social isolation and loneliness are shown to be associated with declines in physical and mental health. Intersecting social determinants of health influence both the risk of being socially isolated and lonely as well as the access and uptake of interventions. Our objective is to evaluate what evidence is available within systematic reviews on how to mitigate inequities in access to and effectiveness of interventions., Methods: We performed an overview of reviews following methods of the Cochrane Handbook for Overviews of Reviews. We selected systematic reviews of effectiveness of interventions aimed at mitigating social isolation and loneliness in older adults (aged 60 or above) published in the last 10 years. In addition, we assessed all primary studies from the most recent systematic review with a broad intervention focus. We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus in collaboration with a librarian scientist. We used a structured framework called PROGRESS-Plus to assess the reporting and consideration of equity. PROGRESS-Plus stands for place of residence, race/ethnicity/culture/language, occupation, gender or sex, religion, education, socioeconomic status (SES), social capital, while "plus" stands for additional factors associated with discrimination and exclusion such as age, disability, and sexual orientation. We assessed whether PROGRESS-Plus factors were reported in description of the population, examination of differential effects, or discussion of applicability or limitations., Results: We identified and assessed 17 eligible systematic reviews. We assessed all 23 primary studies from the most recent systematic review with a broad intervention focus. All systematic reviews and primary studies described the population by one or more PROGRESS-Plus factor, most commonly across place of residence and age, respectively. None of the reviews and five primary studies examined differential effects across one or more PROGRESS-Plus dimension. Nine reviews and four primary studies discussed applicability or limitations of their findings by at least one PROGRESS-Plus factor., Conclusions: Although we know that social isolation and loneliness are worse for the poorest and most socially disadvantaged older adults, the existing evidence base lacks details on how to tailor interventions for these socially disadvantaged older people., (© 2022. The Author(s).)

Introduction: We established a patient centric navigation model embedded in primary care (PC) to support access to the broad range of health and social resources; the Access to Resources in the Community (ARC) model., Methods: We evaluated the feasibility of ARC using the rapid cycle evaluations of the intervention processes, patient and PC provider surveys, and navigator log data. PC providers enrolled were asked to refer patients in whom they identified a health and/or social need to the ARC navigator., Results: Participants: 26 family physicians in four practices, and 82 of the 131 patients they referred. ARC was easily integrated in PC practices and was especially valued in the non-interprofessional practices. Patient overall satisfaction was very high (89%). Sixty patients completed the post-intervention surveys, and 33 reported accessing one or more service(s)., Conclusion: The ARC Model is an innovative approach to reach and support a broad range of patients access needed resources. The Model is feasible and acceptable to PC providers and patients, and has demonstrated potential for improving patients' access to health and social resources. This study has informed a pragmatic randomized controlled trial to evaluate the ARC navigation to an existing web and telephone navigation service (Ontario 211)., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2022 The Author(s).)

Background: There has been a large-scale adoption of virtual delivery of primary care as a result of the COVID-19 pandemic., Aim: In this descriptive study, an equity lens is used to explore the impact of transitioning to greater use of virtual care in community health centres (CHCs) across Ontario, Canada., Design & Setting: A cross-sectional survey was administered and electronic medical record (EMR) data were extracted from 36 CHCs., Method: The survey captured CHCs' experiences with the increased adoption of virtual care. A longitudinal analysis of the EMR data was conducted to evaluate changes in health service delivery. EMR data were extracted monthly for a period of time before the pandemic (April 2019-February 2020) and during (April 2020-February 2021)., Results: In comparison with the pre-pandemic period, CHCs experienced a moderate decline in visits made (11%), patients seen (9%), issues addressed (9%), and services provided (15%). During the pandemic period, an average of 54% of visits were conducted virtually, with telephone as the leading virtual modality (96%). Drops in service types ranged from 28%-82%. The distribution of virtual modalities varied according to the provider type. Access to in-person and virtual care did not vary across patient characteristics., Conclusion: The results demonstrate a large shift towards virtual delivery while maintaining in-person care. No meaningful differences were found in virtual versus in-person care related to patient characteristics or rurality of centres. Future studies are needed to explore how to best select the appropriate modality for patients and service types., (Copyright © 2022, The Authors.)

Objectives: To better understand the experience of patients attending community-based primary healthcare practices (CBPHCPs) aimed at improving equity and access to primary care for underserved patients, which have been implemented locally in several countries, including Canada. There are currently little data on how, or to what extent, they mitigate patients' experience of social inequalities in care and improve their access to health. This study explored the impacts of the sociospatial characteristics of these practices on patients' care experience., Design and Methods: Qualitative, multisite, focused ethnographic study based on in-situ observations and interviews, incorporating inductive and deductive analysis, and using the concept of sense of place., Setting: Three CBPHCPs located in deprived urban areas in two provinces of Canada., Participants: 28 structurally marginalised persons (17 women) attending the clinics, ranging in age from 18 to 79 years, and 16 managers, clinicians and practitioners working in these clinics., Results: Data underscored the importance of clinic proximity and accessibility in facilitating patients' navigation of the health system. Patients appreciated the clinics' positive sociospatial characteristics. Non-judgmental environments and informal spaces fostered patients' empowerment and social interaction among themselves and with peer navigators and healthcare professionals. The experience of supportive continuity of care had a positive impact on patients' sense of well-being and, for many, a positive ripple effect and long-term impact on their social integration., Conclusion: These results have important implications for policy given the current context, in which governments are challenged to support primary healthcare that addresses the social determinants of health to achieve greater equity. We conclude that scaling up contextually tailored care and deploying humanistic innovative organisational practices into mainstream care will help narrow the equity gap and reduce current prevalent social inequalities in the health system., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Context: The onset of COVID-19 has required the rapid adoption of virtual services in primary care (PC) practices, and virtual care delivery is likely to continue to some extent post-pandemic. Objective: To understand patient experience with synchronous virtual (telephone (Tel)/Video) appointments and elicit recommendations for its future use. Design: Mixed method, including patient survey co-developed with stakeholders and implemented online Feb-Mar 2021 with large promotional efforts through social media, patient and caregiver organizations, and other networks. We report on the survey results. Eligibility: 1+ virtual encounter in PC. Outcome measures: A) Patient experience scale (12/17 questions for Tel/Video) covering 4 sub-dimensions; B) Access related questions. Questions had 5-point Likert scale items (strongly disagree (-2) to strongly agree (+2)) and were converted into percentage (potential range -100%, +100%) Setting : Ontario, Canada which offers universal coverage for PC visits with no co-payment. Results: 534 eligible respondents (402/18/114 had Tel/Video/both): Females (78%), < 55 years (61%), white (75%), employed (61%), bachelor's degree (74%), family income > 100k (52%). Encounters evaluated were with family physicians (vs other health professionals) for 75%/46% of Tel/Video encounters. A) Patient Experience (Tel/Video) overall score: 75%/78%; Sub-dimensions: technology: 92%/84%, patient-provider relationship: 83%/86%, quality of care: 66%/66%, whole-person care: 43%/53%. Factors associated with a statistically significant(*) > 10% higher overall score in tel and/or video were: non-females: (8%*/14%*), French speaking (13%*/16%*), patient-provider relationship >1 year (16%*/7%), provider age < 50 (5%/15%*), having the choice of appointment time (15%*/21%*). Wanting to show problem to the provider was associated with a lower scores (-23%*/NA). B) Access Respondents overwhelmingly reported that Tel/Video visits reduced time (97%/97%), costs (81%/85%), and was more convenient (91%/91%). The majority wanted Tel (69%) and Video (71%) visits at least as often as in person visits post-covid. Only 5% did not want any future virtual care. Conclusions: Patient experience was largely positive and is influenced by patient/provider factors. Patients and providers may benefit from support/training to optimize care experience. We are now evaluating whether the reasons for visits influences care experience., Competing Interests: Authors report none., (2021 Annals of Family Medicine, Inc.)

Background: Inequitable access to primary health care (PHC) remains a problem for most western countries. Failure to scale up effective interventions has been due, in part, to a failure to share the logic and essential elements of successful programs. The aim of this paper is to describe what we learned about improving access to PHC for vulnerable groups across multiple sites through use of a common theory-based program logic model and a common evaluation approach. This was the IMPACT initiative., Methods: IMPACT's evaluation used a mixed methods design with longitudinal (pre and post) analysis of six interventions. The analysis for this paper included four of the six sites that met study criteria. These sites were located in Canada (Alberta, Quebec and Ontario) and Australia (New South Wales). Using the overarching logic model, unexpected findings were reviewed, and alternative explanations were considered to understand how the mechanisms of each intervention may have contributed to results., Results: Each site addressed their local access problem with different strategies and from different starting points. All sites observed changes in patient abilities to access PHC and provider access capabilities. The combination of intended and observed consequences for consumers and providers was different at each site, but all sites achieved change in both consumer ability and provider capability, even in interventions where there was no activity targeting provider behaviors., Discussion: The model helped to identify, explore and synthesize intended and unintended consequences of four interventions that appeared to have more differences than similarities. Similar outcomes for different interventions and multiple impacts of each intervention on abilities were observed, implying complex causal pathways., Conclusions: All the interventions were a low-cost incremental attempt to address unmet health care needs of vulnerable populations. Change is possible; sustaining change may be more challenging. Access to PHC requires attention to both patient abilities and provider characteristics. The logic model proved to be a valuable heuristic tool for defining the objectives of the interventions, evaluating their impacts, and learning from the comparison of 'cases'., (© 2021. The Author(s).)

Background: Widespread policy reforms in Canada, the United States and elsewhere over the last two decades strengthened team models of primary care by bringing together family physicians and nurse practitioners with a range of mental health and other interdisciplinary providers. Understanding how patients with depression and anxiety experience newer team-based models of care delivery is essential to explore whether the intended impact of these reforms is achieved, identify gaps that remain and provide direction on strengthening the quality of mental health care., Objective: The main study objective was to understand patients' perspectives on the quality of care that they received for anxiety and depression in primary care teams., Methods: This was a qualitative study, informed by constructivist grounded theory. We conducted focus groups and individual interviews with primary care patients about their experiences with mental health care. Focus groups and individual interviews were recorded and transcribed verbatim. Grounded theory guided an inductive analysis of the data., Results: Forty patients participated in the study: 31 participated in one of four focus groups, and nine completed an individual interview. Participants in our study described their experiences with mental health care across four themes: accessibility, technical care, trusting relationships and meeting diverse needs., Conclusion: Greater attention by policymakers is needed to strengthen integrated collaborative practices in primary care so that patients have similar access to mental health services across different primary care practices, and smoother continuity of care across sectors. The research team is comprised of individuals with lived experience of mental health who have participated in all aspects of the research process., (© 2021 The Authors. Health Expectations published by John Wiley & Sons Ltd.)

Background: Strengthening capacity for mental health in primary care improves health outcomes by providing timely access to coordinated and integrated mental health care. The successful integration of mental health in primary care is highly dependent on the foundation of the surrounding policy context. In Ontario, Canada, policy reforms in the early 2000's led to the implementation of a new interprofessional team-model of primary care called Family Health Teams. It is unclear the extent to which the policy context in Ontario influenced the integration of mental health care in Family Health Teams emerging from this period of policy reform. The research question guiding this study was: what were key features of Ontario's policy context that influenced FHTs capacity to provide mental health services for mood and anxiety disorders?, Methods: A qualitative study informed by constructivist grounded theory. Individual interviews were conducted with executive directors, family physicians, nurse practitioners, nurses, and the range of professionals who provide mental health services in interprofessional primary care teams; community mental health providers; and provincial policy and decision makers. We used an inductive approach to data analysis. The electronic data management programme NVivo11 helped organise the data analysis process., Results: We conducted 96 interviews with 82 participants. With respect to the contextual factors considered to be important features of Ontario's policy context that influenced primary care teams' capacity to provide mental health services, we identified four key themes: i) lack of strategic direction for mental health, ii) inadequate resourcing for mental health care, iii) rivalry and envy, and, iv) variations across primary care models., Conclusions: As the first point of contact for individuals experiencing mental health difficulties, primary care plays an important role in addressing population mental health care needs. In Ontario, the successful integration of mental health in primary care has been hindered by the lack of strategic direction, and inconsistent resourcing for mental health care. Achieving health equity may be stunted by the structural variations for mental health care across Family Health Teams and across primary care models in Ontario.

Patient engagement in primary care research is an increasingly common requirement, as it helps make research more relevant to patients and therefore more valuable. However, there is limited evidence about the outcomes on engagement and actually how it affects research. In Canada, the Canadian Institutes of Health Research has a Strategy for Patient-Oriented Research (SPOR), which in 2016 funded Ontario's INSPIRE-PHC centre of excellence and its Patient Engagement Resource Centre (PERC). PERC conducted an online survey of the three INSPIRE-PHC studies that engaged patients to guide their research. We found that patient partners (PPs) were positive about their experience during research meetings, the value of collaboration, and the support that was provided. They were more involved in early stages of their research projects than in ongoing research activities. PPs valued their experience and also felt they had improved the research process and outcomes. This case study showed how PPs perceive their roles, but a more diverse group of PPs might have more differences in their experience. Background Patient engagement in primary care research is increasing and is now an expectation in many countries and funding agencies. In Canada, the Canadian Institutes of Health Research (CIHR) has mandated that patients be included as partners to guide the research process. Ontario's Patient Engagement Resource Centre (PERC) was established in 2016 by the INNOVATIONS STRENGTHENING PRIMARY HEALTH CARE THROUGH RESEARCH (INSPIRE-PHC), one of 12 centres of excellence in the province funded under the CIHR's Strategy for Patient-Oriented Research (SPOR) initiative. PERC's mission is to support the authentic engagement of patients in primary care research. The present case study examines patients' experience of engagement in INSPIRE-PHC research studies. Methods PERC conducted a web-based evaluation survey across the three INSPIRE-PHC studies that engaged patient partners (PPs). We used data collection tools developed by McMaster University (the Public and Patient Engagement Evaluation Tool (PPEET)) and the Patient-Centred Outcomes Research Institute (Ways of Engaging- ENgagement ACtivity Tool (WE-ENACT)) to assess patient experience and areas of involvement. These included both closed- and open-ended questions. Results The quantitative data showed that PPs were positive about their experience during research meetings, the value of collaboration, and the support that was provided to facilitate engagement. Most of them were highly involved in the initial stages of their research projects but much less involved in operational activities. The qualitative findings showed that, overall, PPs valued their experience, felt prepared to contribute and that their contributions were welcomed. In particular, they considered that they had improved the research process and outcomes. The majority also reported that they had learned from the experience and found it valuable. Conclusions This case study shows that patients engaged in three primary care research studies found the experience to be positive and felt that they had contributed to the research. This study adds to the literature on the evaluation of patient engagement in primary health care research. However, a study of a more diverse sample of PPs might elucidate differences in experience that could enrich future patient engagement activities.

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.

Background: In Ontario, Canada, social workers are employed in a number of primary healthcare (PHC) settings such as Community Health Centres (CHCs) and Family Health Teams (FHTs). However, many aspects of social work practice within PHC settings are unknown., Objectives: The objectives of our study are to determine the amount of social work services provided in CHCs and FHTs, identify the types of services that social workers provide in CHCs and FHTs and ascertain the methods social workers use to deliver services in CHCs and FHTs., Method: An analysis of a cross-sectional data set obtained from a survey conducted in June 2016 in Ontario was performed., Results: The majority of practices (84.2%) had a social worker, although several practices also hosted other types of mental health workers. In virtually all practices with social workers, they (and individuals designated as mental healthcare providers) were also involved in practice level efforts to support mental healthcare delivery. In several practices, the care they delivered extended beyond that related directly to mental healthcare, ranging from preventive care and health promotion (64.5%) to palliative care (16.8%). In several practices, these workers also offered group appointments related to healthy behaviour (43.6%) and self-management (~33%). Interestingly, the role of social workers in practices where they were the sole designated mental healthcare worker was not meaningfully different from practices where other mental health professionals work., Conclusions: In PHC, social workers deliver or support the delivery of mental healthcare, but their role extends beyond that domain to encompass a broader set of services that contribute to the individual's health and wellbeing., (Copyright © 2020 Longwoods Publishing.)

Introduction: While early psychosis intervention (EPI) has proliferated in recent years amid evidence of its effectiveness, programmes often struggle to deliver consistent, recovery-based care. NAVIGATE is a manualised model of EPI with demonstrated effectiveness consisting of four components: individualised medication management, individual resiliency training, supported employment and education and family education. We aim to implement NAVIGATE in geographically diverse EPI programmes in Ontario, Canada, evaluating implementation and its effect on fidelity to the EPI model, as well as individual-level outcomes (patient/family member-reported and interviewer-rated), system-level outcomes (captured in provincial administrative databases) and engagement of participants with lived experience., Methods and Analysis: This is a multisite, non-randomised pragmatic hybrid effectiveness-implementation type III mixed methods study coordinated at the Centre for Addiction and Mental Health (CAMH) in Toronto. Implementation is supported by the Provincial System Support Program, a CAMH-based programme with provincial offices across Ontario, and Extension of Community Healthcare Outcomes Ontario Mental Health at CAMH and the University of Toronto. The primary outcome is fidelity to the EPI model as measured using the First Episode Psychosis Services-Fidelity Scale. Four hundred participants in the EPI programmes will be recruited and followed using both individual-level assessments and health administrative data for 2 years following NAVIGATE initiation. People with lived experience will be engaged in all aspects of the project, including through youth and family advisory committees., Ethics and Dissemination: Research ethics board approval has been obtained from CAMH and institutions overseeing the local EPI programmes. Study findings will be reported in scientific journal articles and shared with key stakeholders including youth, family members, programme staff and policymakers., Trial Registration Number: NCT03919760; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Each year, half a million patients with a potential neck (c-spine) injury are transported to Ontario emergency departments (EDs). Less than 1.0% (1/100) of these patients have a neck bone fracture. Even less (1/200, 0.5%) have a spinal cord injury or nerve damage. Currently, paramedics transport all trauma victims (with or without an injury) by ambulance using a backboard, cervical collar, and head immobilizers. Importantly, prolonged immobilization is often unnecessary; it causes patient discomfort and pain, decreases community access to paramedics, contributes to ED crowding, and is very costly. We therefore developed the Canadian C-Spine Rule (CCR) for alert and stable trauma patients. This decision rule helps ED physicians and triage nurses to safely and selectively remove immobilization, without x-rays and missed injury. We successfully taught Ottawa paramedics to use the CCR in the field in a single-center study., Objective: This study aimed to improve patient care and health system efficiency and outcomes by allowing paramedics to assess eligible low-risk trauma patients with the CCR and selectively transport them without immobilization to the ED., Methods: We propose a pragmatic stepped-wedge cluster randomized design with health economic evaluation, designed collaboratively with knowledge users. Our 36-month study will consist of a 12-month setup and training period (year 1), followed by the stepped-wedge trial (year 2) and a 12-month period for study completion, analyses, and knowledge translation. A total of 12 Ontario paramedic services of various sizes distributed across the province will be randomly allocated to one of three sequences. Paramedic services in each sequence will cross from the control condition (usual care) to the intervention condition (CCR implementation) at intervals of 3 months until all communities have crossed to the intervention. Data will be collected on all eligible patients in each paramedic service for a total duration of 12 months. A major strength of our design is that each community will have implemented the CCR by the end of the study., Results: Interim results are expected in December 2019 and final results in 2020. If this multicenter trial is successful, we expect the Ontario Ministry of Health will recommend that paramedics evaluate all eligible patients with the CCR in the Province of Ontario., Conclusions: We conservatively estimate that in Ontario, more than 60% of all eligible trauma patients (300,000 annually) could be transported safely and comfortably, without c-spine immobilization devices. This will significantly reduce patient pain and discomfort, paramedic intervention times, and ED length of stay, thereby improving access to paramedics and ED care. This could be achieved rapidly and with lower health care costs compared with current practices (possible cost saving of Can $36 [US $25] per immobilization or Can $10,656,000 [US $7,335,231] per year)., Trial Registration: ClinicalTrials.gov NCT02786966; https://clinicaltrials.gov/ct2/show/NCT02786966., International Registered Report Identifier (irrid): DERR1-10.2196/16966., (©Christian Vaillancourt, Manya Charette, Monica Taljaard, Kednapa Thavorn, Elizabeth Hall, Brent McLeod, Dean Fergusson, Jamie Brehaut, Ian Graham, Lisa Calder, Tim Ramsay, Peter Tugwell, Peter Kelly, Sheldon Cheskes, Refik Saskin, Amy Plint, Martin Osmond, Colin Macarthur, Sharon Straus, Paula Rochon, Denis Prud'homme, Simone Dahrouge, Susan Marlin, Ian G Stiell. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 01.06.2020.)

Background: Participants in voluntary research present a different demographic profile than those who choose not to participate, affecting the generalizability of many studies. Efforts to evaluate these differences have faced challenges, as little information is available from non-participants. Leveraging data from a recent randomized controlled trial that used health administrative databases in a jurisdiction with universal medical coverage, we sought to compare the quality of care provided by participating and non-participating physicians prior to the program's implementation in order to assess whether participating physicians provided a higher baseline quality of care., Methods: We conducted clustered regression analyses of baseline data from provincial health administrative databases. Participants included all family physicians who were eligible to participate in the Improved Delivery of Cardiovascular Care (IDOCC) project, a quality improvement project rolled out in a geographically defined region in Ontario (Canada) between 2008 and 2011. We assessed 14 performance indicators representing measures of access, continuity, and recommended care for cancer screening and chronic disease management., Results: In unadjusted and patient-adjusted models, patients of IDOCC-participating physicians had higher continuity scores at the provider (Odds Ratio (OR) [95% confidence interval]: 1.06 [1.03-1.09]) and practice (1.06 [1.04-1.08]) level, lower risk of emergency room visits (Rate Ratio (RR): 0.93 [0.88-0.97]) and hospitalizations (RR:0.87 [0.77-0.99]), and were more likely to have received recommended diabetes tests (OR: 1.25 [1.06-1.49]) and cancer screening for cervical cancer (OR: 1.32 [1.08-1.61] and breast cancer (OR: 1.32 [1.19-1.46]) than patients of non-participating physicians. Some indicators remained statistically significant in the model after adjusting for provider factors., Conclusions: Our study demonstrated a participation bias for several quality indicators. Physician characteristics can explain some of these differences. Other underlying physician or practice attributes also influence interest in participating in quality improvement initiatives and existing quality levels. The standard for addressing participation bias by controlling for basic physician and practice level variables is inadequate for ensuring that results are generalizable to primary care providers and practices.

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., (© The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Introduction: Access to primary healthcare (PHC) has a fundamental influence on health outcomes, particularly for members of vulnerable populations. Innovative Models Promoting Access-to-Care Transformation (IMPACT) is a 5-year research programme built on community-academic partnerships. IMPACT aims to design, implement and evaluate organisational innovations to improve access to appropriate PHC for vulnerable populations. Six Local Innovation Partnerships (LIPs) in three Australian states (New South Wales, Victoria and South Australia) and three Canadian provinces (Ontario, Quebec and Alberta) used a common approach to implement six different interventions. This paper describes the protocol to evaluate the processes, outcomes and scalability of these organisational innovations., Methods and Analysis: The evaluation will use a convergent mixed-methods design involving longitudinal (pre and post) analysis of the six interventions. Study participants include vulnerable populations, PHC practices, their clinicians and administrative staff, service providers in other health or social service organisations, intervention staff and members of the LIP teams. Data were collected prior to and 3-6 months after the interventions and included interviews with members of the LIPs, organisational process data, document analysis and tools collecting the cost of components of the intervention. Assessment of impacts on individuals and organisations will rely on surveys and semistructured interviews (and, in some settings, direct observation) of participating patients, providers and PHC practices., Ethics and Dissemination: The IMPACT research programme received initial ethics approval from St Mary's Hospital (Montreal) SMHC #13-30. The interventions received a range of other ethics approvals across the six jurisdictions. Dissemination of the findings should generate a deeper understanding of the ways in which system-level organisational innovations can improve access to PHC for vulnerable populations and new knowledge concerning improvements in PHC delivery in health service utilisation., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To characterize the process of end-of-career attrition among primary care physicians., Design: Longitudinal, open cohort, population-based study of primary care physicians using health administrative data from ICES. Setting Ontario., Participants: All family physicians providing comprehensive care between 1992 and 2013., Main Outcome Measures: Changes in workload and scopes of practice over time., Results: The cohort included 15 552 family physicians who provided comprehensive care at some point during the study period. Physicians reduced workloads and narrowed scopes of practice in advance of full retirement at an average age of 70.5 (95% CI 70.1 to 70.8) years. Female physicians provided fewer clinical services than male physicians did and retired 5 years earlier. Canadian medical graduates provided fewer clinical services and retired 2 years earlier than international medical graduates did. Up to 60% of physicians stopped providing comprehensive primary care before retirement, continuing with other clinical activities, at reduced workloads, for an average of 3 years before retiring fully., Conclusion: End-of-career practice patterns are characterized by gradual, modest changes in the provision of services rather than abrupt declines, and the retirement process unfolds differently for different physicians. This study highlights the importance of considering physician workload, scope of practice, and demographic factors for more accurate prediction of physician retirement trends and effective work force planning., (Copyright© the College of Family Physicians of Canada.)

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.

Background: Community-based health and social resources can help individuals with complex health and social needs achieve their health goals. However, there is often inadequate access to these resources due to a lack of physician and patient awareness of available resources and the presence of social barriers that limit an individual's ability to reach these services. Navigation services, where a person is tasked with helping connect patients to community resources, embedded within primary care may facilitate access and strengthen the continuity of care for patients., Objective: This study aims to describe the protocol to assess whether the implementation of the Access to Resources in the Community (ARC) navigation model (an innovative approach to navigation services) is feasible, including its potential to achieve its intended outcomes, and to assess the viability of the evaluation approach., Methods: The study consists of a single-arm, prospective, explanatory, mixed-methods, pre-post design feasibility study focusing on primary care practice settings with vulnerable populations. Participants include primary care providers and patients., Results: Enrollment is closed with 82 patients. Navigation services have ended for 69 patients., Conclusions: The study of an innovative complex intervention requires an adequate assessment of the feasibility of the intended approach during which the potential challenges of the planned intervention and need for its adaptation may be uncovered. Undertaking a feasibility study of the ARC navigation model from a conceptually clear and methodologically solid protocol will inform on the practicality and acceptability of the approach, demand for the services, ease of implementation, quality of integration of the new services within primary care, and practicality and potential for efficacy prior to initiating a randomized controlled trial., Trial Registration: ClinicalTrials.gov NCT03105635; https://clinicaltrials.gov/ct2/show/NCT03105635 (Archived by WebCite at hhttp://www.webcitation.org/75FrwXORl)., International Registered Report Identifier (irrid): RR1-10.2196/11022., (©Simone Dahrouge, Alain Gauthier, Francois Chiocchio, Justin Presseau, Claire Kendall, Manon Lemonde, Marie-Hélène Chomienne, Andrea Perna, Darene Toal-Sullivan, Rose A Devlin, Patrick Timony, Denis Prud'homme. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 24.01.2019.)

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.

Competing Interests: Competing interests: None declared.

Study Question: The Cardiovascular Health Awareness Program (CHAP) cardiovascular risk reduction program consisted of sessions run by local volunteers in local pharmacies during which cardiovascular risk was assessed, healthy lifestyle and preventive care was promoted, and the participants were oriented to local resources to support changes in modifiable risk factors. A clustered randomized trial implemented in September 2006 across 39 communities targeting community-dwelling individuals 65 years and older showed a significant reduction in hospitalization one year after its implementation (rate ratio of 91 [95% confidence interval (CI): 86%-97%]). This study explores the impact of CHAP in the first five years., Methods: Using health administrative data housed at the Institute for Clinical Evaluative Sciences, we established a closed cohort consisting of all individuals eligible in these communities at the study onset whom we followed over time. We assessed hospitalizations and survival using a negative binomial model for count data and Cox regression to assess time to first event, accounting for the clustered design. The primary outcome was the rate of cardiovascular-related hospitalizations defined as congestive heart failure, stroke or acute myocardial infarction., Results: Most estimates pointed to an advantage for the intervention arm, but only all-cause mortality reached statistical significance (hazard ratio [95% CI] = 0.955 [0.914-0.999]). The hospitalization cardiovascular-related hospitalization rate ratio was (0.958, 95% CI: 0.898-1.022) in favour of the intervention communities, translating to an estimated 408 averted hospitalizations over the five-year period. There was no evidence of the effect of time from start of intervention., Conclusions: The consistent direction of the outcomes in favour of the intervention arms suggests that CHAP likely had a meaningful impact on reducing cardiovascular-related morbidity and mortality. Given the low cost of the intervention, further development of CHAP should be pursued., Competing Interests: The analyses, conclusions, opinions and statements expressed herein are those of the author, and not necessarily those of CIHI. This does not alter our adherence to all the PLOS ONE policies on sharing data and materials.

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.

Nurse practitioners (NPs) in Ontario work in a number of settings, including physician-led, interprofessional Family Health Teams (FHTs). However, many aspects of NP practice within the FHTs are unknown. Our study aimed to describe the characteristics of NP practice in FHTs and the relationships between NPs and physicians within this model. This cross-sectional descriptive study analyzed NP service and diagnostic code data collected for every NP patient encounter from 2012 to 2015. Encounter data were linked to health administrative data housed at the Institute for Clinical Evaluative Sciences to allow for comparison with physician service and diagnostic codes. Findings demonstrated that NPs saw patients across all age groups for one to more than five problems per encounter and that NPs handled both acute and episodic care and chronic disease management issues. Patients with chronic conditions had more encounters with physicians than with NPs. In addition, compared to physicians, NPs saw more female than male patients. Our findings provide a snapshot of NP practice in FHTs and may be useful in informing other practice models in Ontario, elsewhere in Canada, and internationally. More evidence is needed, however, to clarify the responsibilities of the NPs in collaborative relationships with physicians and to embed policies that will ensure that NPs work to their full potential. In addition, applying service coding to all health care providers in FHTs could enhance data on interprofessional teams and the individual clinicians that comprise them.

Background: Despite the apparent benefits to teaching, many faculty members are reluctant to participate in medical education research (MER) for a variety of reasons. In addition to the further demand on their time, physicians often lack the confidence to initiate MER projects and require more support in the form of funding, structure and guidance. These obstacles have contributed to a decline in physician participation in MER as well as to a perceived decay in its quality. As a countermeasure to encourage physicians to undertake research, the Department of Family Medicine at the University of Ottawa implemented a programme in which physicians receive the funding, coaching and support staff necessary to complete a 2-year research project. The programme is intended primarily for first-time researchers and is meant to serve as a gateway to a research career funded by external grants. Since its inception in 2010, the Program for Innovation in Medical Education (PIME) has supported 16 new clinician investigators across 14 projects., Methods: We performed a programme evaluation 3 years after the programme launched to assess its utility to participants. This evaluation employed semi-structured interviews with physicians who performed a research project within the programme., Results: Programme participants stated that their confidence in conducting research had improved and that they felt well supported throughout their project. They appreciated the collaborative nature of the programme and remarked that it had improved their willingness to solicit the expertise of others. Finally, the programme allowed participants to develop in the scholarly role expected by family physicians in Canada., Conclusion: The PIME may serve as a helpful model for institutions seeking to engage faculty physicians in Medical Education Research and to thereby enhance the teaching received by their medical learners.

Objectives: Family health teams (FHTs), an interprofessional primary care practice model, were established in Ontario in 2005. As of October 2014, 191 FHT organizations were in operation, and 111 (58%) included one or several pharmacists. The objective of this study was to document the focus of pharmacist activities in FHTs., Approach: We invited all 155 known FHT pharmacists to a web-based survey. The survey was constructed using information obtained from previously done semi-structured telephone interviews with pharmacists working in FHTs. The survey consisted of a list of activities, grouped into 5 main categories, and participants were asked to estimate time spent on each category. Free-text response questions allowed participants to identify activities not listed. Survey results were analyzed using descriptive statistics and content analysis for open-ended responses., Results: Seventy (45%) pharmacists completed the survey. The mean respondent age was 43 years, and the average length of time working in an FHT was 4 years. All pharmacists reported being engaged in some form of direct patient care, including managing single therapeutic issues (96%), conducting general medication reviews (70%) and medication reconciliation after hospitalization (63%). Most reported providing education and drug information (83%). Pharmacists felt their work would increase patient medication adherence (94%) and physician adherence to recommended guidelines (86%), as well as reduce inappropriate prescribing (93%), polypharmacy (90%), emergency room and hospital utilization (70%-81%)., Conclusion: Pharmacists in FHTs are strongly focused on direct patient care activities, managing specific medication issues and unstructured drug information to physicians. The majority of pharmacists reported that their activities had a substantial impact on patient medication use and health. The findings from this survey can assist pharmacists new to FHT practice, health policy planning and health research to assess associations between pharmacist activities and measures of health and health care system performance., Competing Interests: Declaration of Conflicting Interests:The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Background: The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) collects extensive data on primary care patients but it currently does not gather reliable information on outcomes in other settings. The objectives of this study were to link electronic medical record (EMR) data from Ontario patients in the CPCSSN with administrative data from the Institute for Clinical Evaluative Sciences (ICES), to assess the representativeness of the CPCSSN population, and to identify people with diabetes in the CPCSSN data and describe their emergency department (ED) visits and hospital admissions over a 2-year period (2010-2012) by HbA1c level., Methods: We conducted a cross-sectional study linking 2014 Ontario CPCSSN data with ICES administrative data and a retrospective cohort study using the 2014 data extraction linked with data from the Ontario health care registry, hospital discharge abstracts and a database of emergency department visits. Demographics of CPCSSN patients were compared with those of the Ontario population. Patients with a CPCSSN diagnosis of diabetes were compared by HbA1c category for ED visits, hospital admissions and diagnosis of diabetes-related complications., Results: The linkage rate was 99%. We identified 12 358 patients with diabetes, 2356 of whom were missing data on HbAIc, for a final sample of 10 002. Patients with diabetes had a mean age of 64 years. Those with a higher HbA1c were younger, more likely to be male, had a lower income, had more comorbidities and were more likely to live in rural or suburban areas than patients with a lower HbA1c. Over the study period 31.8% of patients had 1 or more ED visits and 13.7% had a hospital admission for a diabetes-related complication. Patients with HbA1c greater than 8 had significantly more hospital admissions, ED visits and diabetes-related complications than patients with a lower HbA1c ., Interpretation: The linkage between EMR and administrative data was successful. In this study population, higher HbA1c values were associated with increased ED visits and hospital admissions, with an increasing gradient as HbA1c increased from less than 7% to greater than 8%., Competing Interests: Competing interests: None declared., (Copyright 2017, Joule Inc. or its licensors.)

Introduction: There is strong consensus that prevention and management of common mental disorders (CMDs) should occur in primary care and evidence suggests that treatment of CMDs in these settings can be effective. New interprofessional team-based models of primary care have emerged that are intended to address problems of quality and access to mental health services, yet many people continue to struggle to access care for CMDs in these settings. Insufficient attention directed towards the incentives and disincentives that influence care for CMDs in primary care, and especially in interprofessional team-based settings, may have resulted in missed opportunities to improve care quality and control healthcare costs. Our research is driven by the hypothesis that a stronger understanding of the full range of incentives and disincentives at play and their relationships with performance and other contextual factors will help stakeholders identify the critical levers of change needed to enhance prevention and management of CMDs in interprofessional primary care contexts. Participant recruitment began in May 2016., Methods and Analysis: An explanatory qualitative design, based on a constructivist grounded theory methodology, will be used. Our study will be conducted in the Canadian province of Ontario, a province that features a widely implemented interprofessional team-based model of primary care. Semistructured interviews will be conducted with a diverse range of healthcare professionals and stakeholders that can help us understand how various incentives and disincentives influence the provision of evidence-based collaborative care for CMDs. A final sample size of 100 is anticipated. The protocol was peer reviewed by experts who were nominated by the funding organisation., Ethics and Dissemination: The model we generate will shed light on the incentives and disincentives that are and should be in place to support high-quality CMD care and help stimulate more targeted, coordinated stakeholder responses to improving primary mental healthcare quality., Competing Interests: Conflicts of Interest: None declared., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.)

Background: Studies evaluating primary care quality across physician gender are limited to primary and secondary prevention., Objectives: Investigate the relationship between family physician gender and quality of primary care using indicators that cover 5 key dimensions of primary care., Research Design: Cross-sectional analysis using linked health administrative datasets (April 1, 2008 to March 31, 2010)., Subjects: All family physicians working in the 3 main primary care models in the province of Ontario (Canada), providing general care and having a panel size >1200., Measures: Indicators of cancer screening (3), chronic disease management (9), continuity (2), comprehensiveness (2), and access (5)., Results: A total of 4195 physicians (31% female) were eligible. Adjusting for provider and patient factors, patients of female physicians were more likely to have received recommended cancer screening (odds ratios [95% confidence interval (CI)] (OR) range: 1.24 [1.18-1.30], 1.85 [1.78-1.92]) and diabetes management (OR: 1.04 [1.01-1.08], 1.28 [1.05-1.57]). They had fewer emergency room visits (rate ratio [95% CI] (RR) range: 0.83 [0.79-0.87]) and hospitalizations (RR: 0.89 [0.86-0.93]), and higher referrals (RR: 1.12 [1.09-1.14]). There was evidence of effect modification by patient gender (female vs. male) for hospitalization (RR: 0.74 [0.70-0.79] vs. 0.96 [0.90-1.02]) and emergency room visits (RR: 0.84 [0.81-0.88] vs. 0.98 [0.94-1.01]). Lower emergency room visits were also more evident in more complex patients of female physicians. There were no significant differences in the continuity or comprehensiveness measures., Conclusions: The indicators assessed in this study point to a benefit for patients under the care of female physicians. Potential explanations are discussed.

Background: Practice facilitation has been associated with meaningful improvements in disease prevention and quality of patient care. Using practice facilitation, the Improved Delivery of Cardiovascular Care (IDOCC) project aimed to improve the delivery of evidence-based cardiovascular care in primary care practices across a large health region. Our goal was to evaluate IDOCC's impact on adherence to processes of care delivery., Methods: A pragmatic stepped wedge cluster randomized trial recruiting primary care providers in practices located in Eastern Ontario, Canada (ClinicalTrials.gov: NCT00574808). Participants were randomly assigned by region to one of three steps. Practice facilitators were intended to visit practices every 3-4 (year 1-intensive) or 6-12 weeks (year 2-sustainability) to support changes in practice behavior. The primary outcome was mean adherence to indicators of evidence-based care measured at the patient level. Adherence was assessed by chart review of a randomly selected cohort of 66 patients per practice in each pre-intervention year, as well as in year 1 and year 2 post-intervention., Results: Eighty-four practices (182 physicians) participated. On average, facilitators had 6.6 (min: 2, max: 11) face-to-face visits with practices in year 1 and 2.5 (min: 0 max: 10) visits in year 2. We collected chart data from 5292 patients. After adjustment for patient and provider characteristics, there was a 1.9 % (95 % confidence interval (CI): -2.9 to -0.9 %) and 4.2 % (95 % CI: -5.7 to -2.6 %) absolute decrease in mean adherence from baseline to intensive and sustainability years, respectively., Conclusions: IDOCC did not improve adherence to best-practice guidelines. Our results showed a small statistically significant decrease in mean adherence of questionable clinical significance. Potential reasons for this result include implementation challenges, competing priorities in practices, a broad focus on multiple chronic disease indicators, and use of an overall index of adherence. These results contrast with findings from previously reported facilitation trials and highlight the complexities and challenges of translating research findings into clinical practice., Trial Registration: ClinicalTrials.gov NCT00574808.

Objective: To describe the models of practice used by nurse practitioners (NPs) and FPs in community health centres (CHCs), and to examine the roles of NPs and FPs in these models., Design: Cross-sectional study using an organizational survey completed by managers of the CHC sites, as well as administrative data on patient sociodemographic characteristics and encounter activities., Setting: A total of 21 CHCs (13 main sites and 8 satellite sites) operating in eastern Ontario during the period from December 1, 2006, to November 30, 2008., Participants: A total of 44 849 patients, 53 full-time equivalent FPs, and 41 full-time equivalent NPs., Main Outcome Measures: Family physicians' and NPs' models of practice, the sociodemographic characteristics and medical profiles of patients who were treated in each model of practice, and FPs' and NPs' use of time., Results: Patients were attributed to 1 of 3 models of practice in CHCs based on the proportion of visits to FPs and NPs: FP care (53% of patients), NP care (29%), and shared care (18%). Patients who received care in the NP model of practice were younger and more likely to be female, be homeless, and not have postsecondary education.Patients who received care in the FP model of practice had more complex medical conditions (cardiovascular disease, mental illness, lung disease, and diabetes) and more annual visits. Patients who received care in the shared care model had intermediate profiles. Nurse practitioners performed more off-site care and walk-in visits. Family physicians and NPs spent a similar proportion of time performing various duties such as direct clinical care and administration tasks., Conclusion: Although NPs mainly cared for their own patient panels (in the NP care model), they did share some patients with FPs and provide some care to patients under the FP model of practice. Patients who were cared for by FPs and NPs had quite different characteristics.

Background: Several new primary care models have been implemented in Ontario, Canada over the past two decades. These practice models differ in team structure, physician remuneration, and group size. Few studies have examined the impact of these models on specialist referrals. We compared specialist referral rates amongst three primary care models: 1) Enhanced Fee-for-service, 2) Capitation- Non-Interdisciplinary (CAP-NI), 3) Capitation - Interdisciplinary (CAP-I)., Methods: We conducted a cross-sectional study using health administrative data from primary care practices in Ontario from April 1st, 2008 to March 31st, 2010. The analysis included all family physicians providing comprehensive care in one of the three models, had at least 100 patients, and did not have a prolonged absence (eight consecutive weeks). The primary outcome was referral rate (# of referrals to all medical specialties/1000 patients/year). A multivariable clustered Poisson regression analysis was used to compare referral rates between models while adjusting for provider (sex, years since graduation, foreign trained, time in current model) and patient (age, sex, income, rurality, health status) characteristics., Results: Fee-for-service had a significantly lower adjusted referral rate (676, 95% CI: 666-687) than the CAP-NI (719, 95% confidence interval (CI): 705-734) and CAP-I (694, 95% CI: 681-707) models and the interdisciplinary CAP-I group had a 3.5% lower referral rate than the CAP-NI group (RR = 0.965, 95% CI: 0.943-0.987, p = 0.002). Female and Canadian-trained physicians referred more often, while female, older, sicker and urban patients were more likely to be referred., Conclusions: Primary care model is significantly associated with referral rate. On a study population level, these differences equate to 111,059 and 37,391 fewer referrals by fee-for-service versus CAP-NI and CAP-I, respectively - a difference of $22.3 million in initial referral appointment costs. Whether a lower rate of referral is more appropriate or not is not known and requires further investigation. Physician remuneration and team structure likely account for the differences; however, further investigation is also required to better understand whether other organizational factors associated with primary care model also impact referral.

Objective: To describe patient-reported access to primary health care across 4 organizational models of primary care in Ontario, and to explore how access is associated with patient, provider, and practice characteristics., Design: Cross-sectional survey., Setting: One hundred thirty-seven randomly selected primary care practices in Ontario using 1 of 4 delivery models (fee for service, established capitation, reformed capitation, and community health centres)., Participants: Patients included were at least 18 years of age, were not severely ill or cognitively impaired, were not known to the survey administrator, had consenting providers at 1 of the participating primary care practices, and were able to communicate in English or French either directly or through a translator., Main Outcome Measures: Patient-reported access was measured by a 4-item scale derived from the previously validated adult version of the Primary Care Assessment Tool. Questions were asked about physician availability during and outside of regular office hours and access to health information via telephone. Responses to the scale were normalized, with higher scores reflecting greater patient-reported access. Linear regressions were used to identify characteristics independently associated with access to care., Results: Established capitation model practices had the highest patient-reported access, although the difference in scores between models was small. Our multilevel regression model identified several patient factors that were significantly (P = .05) associated with higher patient-reported access, including older age, female sex, good-to-excellent self-reported health, less mental health disability, and not working. Provider experience (measured as years since graduation) was the only provider or practice characteristic independently associated with improved patient-reported access., Conclusion: This study adds to what is known about access to primary care. The study found that established capitation models outperformed all the other organizational models, including reformed capitation models, independent of provider and practice variables save provider experience. This suggests that the capitation models might provide better access to care and that it might take time to realize the benefits of organizational reforms.

Background: As health systems evolve, it is essential to evaluate their impact on the delivery of health services to socially disadvantaged populations. We evaluated the delivery of primary health services for different socio-economic groups and assessed the performance of different organizational models in terms of equality of health care delivery in Ontario, Canada., Methods: Cross sectional study of 5,361 patients receiving care from primary care practices using Capitation, Salaried or Fee-For-Service remuneration models. We assessed self-reported health status of patients, visit duration, number of visits per year, quality of health service delivery, and quality of health promotion. We used multi-level regressions to study service delivery across socio-economic groups and within each delivery model. Identified disparities were further analysed using a t-test to determine the impact of service delivery model on equity., Results: Low income individuals were more likely to be women, unemployed, recent immigrants, and in poorer health. These individuals were overrepresented in the Salaried model, reported more visits/year across all models, and tended to report longer visits in the Salaried model. Measures of primary care services generally did not differ significantly between low and higher income/education individuals; when they did, the difference favoured better service delivery for at-risk groups. At-risk patients in the Salaried model were somewhat more likely to report health promotion activities than patients from Capitation and Fee-For-Service models. At-risk patients from Capitation models reported a smaller increase in the number of additional clinic visits/year than Fee-For-Service and Salaried models. At-risk patients reported better first contact accessibility than their non-at-risk counterparts in the Fee-For-Service model only., Conclusions: Primary care service measures did not differ significantly across socio-economic status or primary care delivery models. In Ontario, capitation-based remuneration is age and sex adjusted only. Patients of low socio-economic status had fewer additional visits compared to those with high socio-economic status under the Capitation model. This raises the concern that Capitation may not support the provision of additional care for more vulnerable groups. Regions undertaking primary care model reforms need to consider the potential impact of the changes on the more vulnerable populations.

Objective: To determine whether models of primary care service delivery differ in their provision of family-centred care (FCC) and to identify practice characteristics associated with FCC., Design: Cross-sectional study., Setting: Primary care practices in Ontario (ie, 35 salaried community health centres, 35 fee-for-service practices, 32 capitation-based health service organizations, and 35 blended remuneration family health networks) that belong to 4 models of primary care service delivery., Participants: A total of 137 practices, 363 providers, and 5144 patients., Main Outcome Measures: Measures of FCC in patient and provider surveys were based on the Primary Care Assessment Tool. Statistical analyses were conducted using linear mixed regression models and generalized estimating equations., Results: Patient-reported FCC scores were high and did not vary significantly by primary care model. Larger panel size in a practice was associated with lower odds of patients reporting FCC. Provider-reported FCC scores were significantly higher in community health centres than in family health networks (P = .035). A larger number of nurse practitioners and clinical services on-site were both associated with higher FCC scores, while scores decreased as the number of family physicians in a practice increased and if practices were more rural., Conclusion: Based on provider and patient reports, primary care reform strategies that encourage larger practices and more patients per family physician might compromise the provision of FCC, while strategies that encourage multidisciplinary practices and a range of services might increase FCC.

Background: Although we are observing a general move towards larger primary care practices, surprisingly little is known about the influence of key components of practice organization on primary care. We aimed to determine the relationships between practice size, and revenue sharing agreements, and quality of care., Methods: As part of a large cross sectional study, group practices were randomly selected from different primary care service delivery models in Ontario. Patient surveys and chart reviews were used to assess quality of care. Multilevel regressions controlled for patient, provider and practice characteristics., Results: Positive statistically significant associations were found between the logarithm of group size and access, comprehensiveness, and disease prevention. Negative significant associations were found between logarithm group size and continuity. No differences were found for chronic disease management and health promotion. Practices that shared revenues were found to deliver superior health promotion compared to those who did not. Interacting group size with the presence of a revenue-sharing arrangement had a negative impact on health promotion., Conclusions: Despite the limitations of our study, our findings have provided preliminary evidence of the tradeoffs inherent with increasing practice size. Larger group size is associated with better access and comprehensiveness but worse continuity of care. Revenue sharing in group practices was associated with higher health promotion compared to sharing only common costs. Further work is required to better inform policy makers and practitioners as to whether the pattern revealed in larger practices mitigates any of the previously reported benefits of continuity of primary care. We found few benefits of revenue sharing--even then the effect of revenue sharing on health promotion seemed diminished in larger practices.

Background: Continuity is a fundamental tenet of primary care, and highly valued by patients; it may also improve patient outcomes and lower cost of health care. It is thus important to investigate factors that predict higher continuity. However, to date, little is known about the factors that contribute to continuity. The purpose of this study was to analyse practice, provider and patient predictors of continuity of care in a large sample of primary care practices in Ontario, Canada. Another goal was to assess whether there was a difference in the continuity of care provided by different models of primary care., Methods: This study is part of the larger a cross-sectional study of 137 primary care practices, their providers and patients. Several performance measures were evaluated; this paper focuses on relational continuity. Four items from the Primary Care Assessment Tool were used to assess relational continuity from the patient's perspective., Results: Multilevel modeling revealed several patient factors that predicted continuity. Older patients and those with chronic disease reported higher continuity, while those who lived in rural areas, had higher education, poorer mental health status, no regular provider, and who were employed reported lower continuity. Providers with more years since graduation had higher patient-reported continuity. Several practice factors predicted lower continuity: number of MDs, nurses, opening on weekends, and having 24 hours a week or less on-call. Analyses that compared continuity across models showed that, in general, Health Service Organizations had better continuity than other models, even when adjusting for patient demographics., Conclusions: Some patients with greater health needs experience greater continuity of care. However, the lower continuity reported by those with mental health issues and those who live in rural areas is concerning. Furthermore, our finding that smaller practices have higher continuity suggests that physicians and policy makers need to consider the fact that 'bigger is not always necessarily better'.

Objective: To determine if patient poverty is associated with increased workload for primary care providers (PCPs)., Design: Linkage of administrative data identifying patient poverty and comorbidity with survey data about the organizational structure of community health centres (CHCs)., Setting: Ontario's 73 CHCs., Participants: A total of 64 CHC sites (N=63 included in the analysis)., Main Outcome Measures: Patient poverty was determined in 2 different ways: based on receipt of Ontario Drug Benefits (identifying recipients of welfare, provincial disability support, and low-income seniors' benefits) or residence in low-income neighbourhoods. Patient comorbidities were determined through administrative diagnostic data from the CHCs and the Institute for Clinical Evaluative Sciences. Primary care workload was determined by examining PCP panel size (the number of patients cared for by a full-time-equivalent PCP during a 2-year interval)., Results: The CHCs with higher proportions of poor patients had smaller panel sizes. The smaller panel sizes were entirely explained by the medical comorbidity profile of the poor patients., Conclusion: Poor patients generate a higher workload for PCPs in CHCs; however, this is principally because they are sicker than higher-income patients are. Further information is required about the spectrum of services used by poor patients in CHCs.

Practice facilitation has proven to be effective in improving the quality of primary care. A practice facilitator is a health professional, usually external to the practice, who regularly visits the practice to provide support in change management that targets improvements in the delivery of care. Our environmental scan shows that several initiatives across Canada utilize practice facilitation as a quality improvement method; however, many are conducted in isolation as there is a lack of coordinated effort, knowledge translation and dissemination in this field across the country. We recommend that investments be made in capacity building, knowledge exchange and facilitator training, and that partnership building be considered a priority in this field., (Copyright © 2013 Longwoods Publishing.)

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 self-reported 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.

Background: Primary care plays a key role in the prevention and management of cardiovascular disease (CVD). We examined primary care practice adherence to recommended care guidelines associated with the prevention and management of CVD for high risk patients., Methods: We conducted a secondary analysis of cross-sectional baseline data collected from 84 primary care practices participating in a large quality improvement initiative in Eastern Ontario from 2008 to 2010. We collected medical chart data from 4,931 patients who either had, or were at high risk of developing CVD to study adherence rates to recommended guidelines for CVD care and to examine the proportion of patients at target for clinical markers such as blood pressure, lipid levels and hemoglobin A1c., Results: Adherence to preventive care recommendations was poor. Less than 10% of high risk patients received a waistline measurement, half of the smokers received cessation advice, and 7.7% were referred to a smoking cessation program. Gaps in care exist for diabetes and kidney disease as 54.9% of patients with diabetes received recommended hemoglobin-A1c screenings, and only 55.8% received an albumin excretion test. Adherence rates to recommended guidelines for coronary artery disease, hypertension, and dyslipidemia were high (>75%); however <50% of patients were at target for blood pressure or LDL-cholesterol levels (37.1% and 49.7% respectively), and only 59.3% of patients with diabetes were at target for hemoglobin-A1c., Conclusions: There remain significant opportunities for primary care providers to engage high risk patients in prevention activities such as weight management and smoking cessation. Despite high adherence rates for hypertension, dyslipidemia, and coronary artery disease, a significant proportion of patients failed to meet treatment targets, highlighting the complexity of caring for people with multiple chronic conditions.

Objective: To measure the effect of nurse practitioner and pharmacist consultations on the appropriate use of medications by patients., Design: We studied patients in the intervention arm of a randomized controlled trial. The main trial intervention was provision of multidisciplinary team care and the main outcome was quality and processes of care for chronic disease management., Setting: Patients were recruited from a single publicly funded family health network practice of 8 family physicians and associated staff serving 10 000 patients in a rural area near Ottawa, Ont., Participants: A total of 120 patients 50 years of age or older who were on the practice roster and who were considered by their family physicians to be at risk of experiencing adverse health outcomes., Intervention: A pharmacist and 1 of 3 nurse practitioners visited each patient at his or her home, conducted a comprehensive medication review, and developed a tailored plan to optimize medication use. The plan was developed in consultation with the patient and the patient's doctor. We assessed medication appropriateness at the study baseline and again 12 to 18 months later., Main Outcome Measures: We used the medication appropriateness index to assess medication use. We examined associations between personal characteristics and inappropriate use at baseline and with improvements in medication use at the follow-up assessment. We recorded all drug problems encountered during the trial., Results: At baseline, 27.2% of medications were inappropriate in some way and 77.7% of patients were receiving at least 1 medication that was inappropriate in some way. At the follow-up assessments these percentages had dropped to 8.9% and 38.6%, respectively (P < .001). Patient characteristics that were associated with receiving inappropriate medication at baseline were being older than 80 years of age (odds ratio [OR] = 5.00, 95% CI 1.19 to 20.50), receiving more than 4 medications (OR = 6.64, 95% CI 2.54 to 17.4), and not having a university-level education (OR = 4.55, 95% CI 1.69 to 12.50)., Conclusion: We observed large improvements in the appropriate use of medications during this trial. This might provide a mechanism to explain some of the reductions in mortality and morbidity observed in other trials of counseling and advice provided by pharmacists and nurses., Trial Registration Number: NCT00238836 (ClinicalTrials.gov).

The ratio of patients to physicians has long been used as a tool for measuring and planning healthcare resources in Canada. Some current changes in primary care, such as enrolment of patients with physicians, make this ratio easier to calculate, while others, such as changing practice structure, make it more complex to interpret. Based on information gleaned from a review of the literature, we argue that before panel size can be used as an accountability measure for individual physicians or practices in primary care, we must understand its relationship to quality and outcomes at individual and population levels, as well as the contextual factors that affect it.

Background: Several jurisdictions attempting to reform primary care have focused on changes in physician remuneration. The goals of this study were to compare the delivery of preventive services by practices in four primary care funding models and to identify organizational factors associated with superior preventive care., Methods: In a cross-sectional study, we included 137 primary care practices in the province of Ontario (35 fee-for-service practices, 35 with salaried physicians [community health centres], 35 practices in the new capitation model [family health networks] and 32 practices in the established capitation model [health services organizations]). We surveyed 288 family physicians. We reviewed 4108 randomly selected patient charts and assigned prevention scores based on the proportion of eligible preventive manoeuvres delivered for each patient., Results: A total of 3284 patients were eligible for at least one of six preventive manoeuvres. After adjusting for patient profile and contextual factors, we found that, compared with prevention scores in practices in the new capitation model, scores were significantly lower in fee-for-service practices (β estimate for effect on prevention score = -6.3, 95% confidence interval [CI] -11.9 to -0.6) and practices in the established capitation model (β = -9.1, 95% CI -14.9 to -3.3) but not for those with salaried remuneration (β = -0.8, 95% CI -6.5 to 4.8). After accounting for physician characteristics and organizational structure, the type of funding model was no longer a statistically significant factor. Compared with reference practices, those with at least one female family physician (β = 8.0, 95% CI 4.2 to 11.8), a panel size of fewer than 1600 patients per full-time equivalent family physician (β = 6.8, 95% CI 3.1 to 10.6) and an electronic reminder system (β = 4.6, 95% CI 0.4 to 8.7) had superior prevention scores. The effect of these three factors was largely but not always consistent across the funding models; it was largely consistent across the preventive manoeuvres., Interpretation: No funding model was clearly associated with superior preventive care. Factors related to physician characteristics and practice structure were stronger predictors of performance. Practices with one or more female physicians, a smaller patient load and an electronic reminder system had superior prevention scores. Our findings raise questions about reform initiatives aimed at increasing patient numbers, but they support the adoption of information technology.