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Context: Many older adults take multiple medications prescribed by a variety of providers, which leads to concerns about medication management, appropriateness, and adverse drug events. Interdisciplinary, team-based primary care models can improve coordination of health care services, which could translate to improved medication management and related outcomes. Objective: Evaluate the impact of interdisciplinary team-based primary care models implemented in two Canadian provinces--Ontario and Quebec--on outcomes related to medication use. Study Design and Analysis: Retrospective cohort analysis of population- level administrative health data. We used difference-in-differences analysis to compare older adults rostered to team-based primary care models, to older adults not rostered to team-based models. Dataset: Data housed at ICES in Ontario and the Institut national d'excellence en sante et services sociaux (INESSS) in Quebec. We focused on fiscal years 1999/00 to 2017/18. Population Studied: Eligible patients were between 66 and 104 years of age. We matched (1-to-1 propensity score matching without replacement) an exposure group of older adults who were rostered to a physician affiliated with a team-based primary care model to a comparison group of older adults rostered to non-team family physicians. Intervention: Quebec's Family Medicine Groups (implemented in 2002) and Ontario's Family Health Teams (implemented in 2005). Outcome Measures: Any adverse drug event resulting in hospitalization, polypharmacy (5+ medication classes), and any potentially inappropriate prescription (adapted from Beer's and STOPP/START criteria). Results: Matched cohorts included 429,104 older adults in Ontario and 310,198 in Quebec. In the year before they rostered, 53% and 40% of older adults had a potentially inappropriate prescription in Ontario and Quebec, respectively. In both provinces, 1% had an adverse drug event. Quebec's Family Medicine Groups were more likely to experience an adverse drug event (RR = 1.14; 95% CI: 1.10-1.17). We found no other differences between the exposure and comparison groups. Conclusions: The implementation of team-based primary care models in Ontario and Quebec was not associated with a variety of outcomes related to medication management. These results point to a need for further investigation of the composition and functioning of primary care teams to determine how they can support older adults with complex health needs, Presenters David Rudoler, PhD, Agnes Grudniewicz, PhD, Nichole Austin, PhD, Sara Allin, PhD, Richard Glazier, MD, MPH, Elisabeth Martin, PhD, Caroline Sirois, PhD, Erin [...]

Context: Polypharmacy and inappropriate medications can lead to adverse drug events and avoidable health systems costs. Family physicians may find it challenging to manage multiple medications for seniors, especially in fragmented systems with multiple prescribers. Interprofessional primary care teams have capacity for improved medication management. However, we know little about how these teams work together to manage medications. Objective: To describe and understand how family physicians and interdisciplinary health providers (IHPs) work together when managing medications for seniors. Study Design and Analysis: Qualitative semi-structured interviews and thematic analysis. Setting: Interprofessional primary care Family Health Teams (FHTs) in Ontario. Population Studied: Administrators, family physicians, and IHPs (nurses, pharmacists, etc.). Results: Interviews (n=38) were conducted across six FHTs in Ontario. The way physicians and IHPs worked together to manage medications for seniors varied in and across FHTs. We identified three themes in the data related to approach to medication management: 1) no engagement with IHPs (i.e., physicians did not refer their patients to the team's IHPs), 2) some engagement (i.e., physicians referred patients to IHPs and IHP-led programs for medication management but rarely engaged in ongoing communication), and 3) shared care (i.e., physicians shared decision-making about care with IHPs, there was ongoing communication between physicians and IHPs). Some IHPs were frustrated with tailoring their approach to care and communication based on the preferences of each physician. These differences were perceived to be a result of hierarchy, work style and use of the electronic medical record, and physician expectations. Trust also appeared to be a factor in that the more physicians interacted with IHPs, the more comfortable and trusting they were giving them an active role in patient care. Regardless of the approach to medication management, participants agreed that physicians had the final say in patient care. Conclusions: Despite the FHT model's emphasis on teamwork, participants did not report a lot of shared care in medication management. While in many cases there was a lack of ongoing communication between IHPs and family physicians, there are opportunities to improve teamwork and strengthen collaboration., Presenters Agnes Grudniewicz, PhD, Monika Roerig, BSc, MA, Julie Vizza, BSc, MHS, Elisabeth Martin, PhD, Sara Allin, PhD, Erin Strumpf, David Rudoler, [...]

Context: People experiencing homelessness (PEH) face several social and health challenges, including stigma and discrimination, and barriers to access healthcare and navigate health systems. These barriers contribute to unmet needs and a nearly 30-year gap in life expectancy compared to the general population. While the health and social consequences of homelessness have received considerable attention in the literature, we know less about how health systems have adapted and reformed to better meet the needs of PEH. Objective: To uncover the types and features of primary care models that may contribute to improved access to primary care for PEH across selected high-income countries' health systems. Study Design: Scoping review of academic and grey literature between 2015-2021, and 10 expert informant consultations. Setting: Primary care in non- traditional settings in high-income countries. Population Studied: PEH. Results: A wide range of primary care models in non-traditional healthcare settings are in place across high-income countries. Usual sites for these services include shelters and facilities that serve individuals with substance-use disorders, mobile outreach, and hub-and-spoke models. While most of the models targeted the general population of PEH, some focused on families, youth, specific genders, and Indigenous peoples. We did not uncover any robust evaluations of the impacts on access or health outcomes, but we see some indication of positive experiences among clients, frequent contacts, and potentially reduced emergency department visits. We identified six considerations for improving access to primary care in these settings: Foster positive relationships between PEH and healthcare providers; Include peer support workers and interprofessional team members to address complex needs; Establish a welcoming and inclusive environment to encourage access and social connectedness; Support system navigation and build connections to mainstream care; Enable collection and sharing of health information to improve care continuity and support evaluation; Adopt sustainable and adaptive funding models. Conclusions: The challenges faced by PEH are similar across countries, though approaches to improve primary care vary. Overall, there is a lack of sustained or large-scale reforms to primary care that align with the needs of PEH. Future reform efforts could incorporate these considerations to improve care experiences and health outcomes for this population., Presenters Sara Allin, PhD, Mariana Morales, Monika Roerig, BSc, MA, Sarah [...]

Childhood disabilities entail a range of immediate and long-term economic costs that have important implications for the well-being of the child, the family, and society but that are difficult to measure. In an extensive research review, Mark Stabile and Sara Allin examine evidence about three kinds of costs--direct, out-of-pocket costs incurred as a result of the child's disability; indirect costs incurred by the family as it decides how best to cope with the disability; and long-term costs associated with the child's future economic performance. Not surprisingly, the evidence points to high direct costs for families with children with disabilities, though estimates vary considerably within these families. Out-of-pocket expenditures, particularly those for medical costs, for example, are higher among families with children with a special health care need. An important indirect cost for these families involves decisions about employment. Stabile and Allin examine several studies that, taken together, show that having a child with disabilities increases the likelihood that the mother (and less often the father) will either curtail hours of work or stop working altogether. Researchers also find that having a child with disabilities can affect a mother's own health and put substantial strains on the parents' relationship. In the longer term, disabilities also compromise a child's schooling and capacity to get and keep gainful employment as an adult, according to the studies Stabile and Allin review. Negative effects on future well-being appear to be much greater, on average, for children with mental health problems than for those with physical disabilities. Stabile and Allin calculate that the direct costs to families, indirect costs through reduced family labor supply, direct costs to disabled children as they age into the labor force, and the costs of safety net programs for children with disabilities average $30,500 a year per family with a disabled child. They note that the cost estimates on which they base their calculation vary widely depending on the methodology, jurisdiction, and data used. Because their calculations do not include all costs, notably medical costs covered through health insurance, they represent a lower bound. On that basis, Stabile and Allin argue that many expensive interventions to prevent and reduce childhood disability might well be justified by a cost-benefit calculation. (Contains 117 endnotes, 1 table and 2 figures.)

Background: Recreational cannabis policies are being considered in many jurisdictions internationally. Given that cannabis use is more prevalent among people with depression, legalisation may lead to more adverse events in this population. Cannabis legalisation in Canada included the legalisation of flower and herbs (phase 1) in October 2018, and the deregulation of cannabis edibles one year later (phase 2). This study investigated disparities in cannabis-related emergency department (ED) visits in depressed and non-depressed individuals in each phase. Methods: Using administrative data, we identified all adults diagnosed with depression 60 months prior to legalisation (n = 929 844). A non-depressed comparison group was identified using propensity score matching. We compared the pre–post policy differences in cannabis-related ED-visits in depressed individuals v. matched (and unmatched) non-depressed individuals. Results: In the matched sample (i.e. comparison with non-depressed people similar to the depressed group), people with depression had approximately four times higher risk of cannabis-related ED-visits relative to the non-depressed over the entire period. Phases 1 and 2 were not associated with any changes in the matched depressed and non-depressed groups. In the unmatched sample (i.e. comparison with the non-depressed general population), the disparity between individuals with and without depression is greater. While phase 1 was associated with an immediate increase in ED-visits among the general population, phase 2 was not associated with any changes in the unmatched depressed and non-depressed groups. Conclusions: Depression is a risk factor for cannabis-related ED-visits. Cannabis legalisation did not further elevate the risk among individuals diagnosed with depression. [ABSTRACT FROM AUTHOR]