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BackgroundIn Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. ObjectiveThe aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. MethodsA multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. ResultsPhase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. ConclusionsThe end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. International Registered Report Identifier (IRRID)PRR1-10.2196/25619

BackgroundExpanding healthcare innovations from the local to national level is a complex pursuit requiring careful assessment of all relevant factors. In this study (a component of a larger eConsult programme of research), we aimed to identify the key factors involved in the spread and scale-up of a successful regional eConsult model across Canada.MethodsWe conducted a constant comparative thematic analysis of stakeholder discussions captured during a full-day National eConsult Forum meeting held in Ottawa, Canada, on 11 December 2017. Sixty-four participants attended, representing provincial and territorial governments, national organisations, healthcare providers, researchers and patients. Proceedings were recorded, transcribed and underwent qualitative analysis using the Framework for Applied Policy Research.ResultsThis study identified four main themes that were critical to support the intentional efforts to spread and scale-up eConsult across Canada, namely (1) identifying population care needs and access problems, (2) engaging stakeholders who were willing to roll up their sleeves and take action, (3) building on current strategies and policies, and (4) measuring and communicating outcomes.ConclusionsEfforts to promote innovation in healthcare are more likely to succeed if they are based on an understanding of the forces that drive the spread and scale-up of innovation. Further research is needed to develop and strengthen the conceptual and applied foundations of the spread and scale-up of healthcare innovations, especially in the context of emergent learning health systems across Canada and beyond.

Context: Cardiac rehabilitation (CR) aims for the patient to regain functional abilities following a myocardial infarction (MI). CR is often offered as a specialty in large urban population centres, but rarely offered in smaller or urban regions. Nurses play a pivotal role in CR. To date, the components of nurse-led CR that may improve patient health are not documented. Many CR programs are found in urban areas and it is not known how these programs can be adapted to a rural context. Before creating a CR program in a rural area, it is essential to identify relevant literature to inform the creation of interventions. Objective: To identify the components of a nurse-led CR program for people who suffered an MI. Study Design: Scoping review following Arksey and O'Malley's six steps. Data collection and extraction: We designed and performed the search strategy in collaboration with an information specialist. We included studies published between 2005 and 2020 that described a nurse-led cardiac rehabilitation program and used any design (RCT, quasi- experimental, experimental, qualitative, cohort or descriptive). We considered the keyword categories: cardiac rehabilitation, nursing, myocardial infarction. Ebesco, Cochrane and Scopus databases were consulted. Titles, abstracts and articles were sorted by JB and validated by MEP and MB. We used the Endnote platform to manage references. Data were extracted and classified by intervention category. The extraction was validated by all authors. Results: After removing duplicates, 762 articles were retained. Fourteen articles were selected for data extraction. The analysis allowed us to categorize the interventions into 4 categories: 1) Interventions promoting the early recruitment of participants; 2) Interventions favoring the use of technologies; 3) Interventions based on multiple components, 4) Interventions based on surveillance and monitoring activities. Conclusion: We identified 4 key characteristics of nurse-led CR models. We also found that CR is not common in rural areas. The components of a CR program in an urban center could potentially be adapted to rural areas. Nurses can take on a pivotal role in a CR program offer with different modalities., Presenters Jessica Bernier, MSc, RN, Marie-Eve Poitras, PhD, MSc, RN, Mylaine Breton, [...]

Context: Virtual pre-consultation screening of patient needs may offer opportunities to improve the care and health outcomes of older patients in primary care, especially those with multiple care needs. Objective: We sought to implement and evaluate the effectiveness of a multidimensional virtual pre-consultation tool in the primary care setting to support rapid and standardized needs assessment for older persons. Study Design and Analysis: Pragmatic, multi-center, 1:1 individually randomized trial design. Implementation was conducted using a participatory approach over a 3-month period. Baseline and 3-month follow-up data were collected through phone-based questionnaires. An intention-to-treat analysis was carried out. Setting: Four university-affiliated interprofessional primary care clinics, two clinics in one urban region (Montreal) and two in one rural region (Abitibi) in Quebec, Canada. Population Studied: Patients 65 years and older with a consultation with a primary care provider (physician, nurse, social worker, other) during the implementation period in one of the participating clinics. Intervention: A virtual pre-consultation tool, ESOGER, was administered as a phone-based questionnaire by a member of the clinic staff to eligible patients prior to their consultation with the primary care provider. The ESOGER tool provides a general assessment of the physical, social, mental and cognitive health needs of older adults and produces a summary report available to clinicians at the time of consultation. Outcome Measures: The primary endpoint consisted of the EQ-5D quality of life score at 3-month follow-up. Secondary endpoints were unplanned primary care visits, visits to the ED and hospital admissions in last 3 months. Results: Of the 659 eligible patients contacted to date, 345 (52.3%) agreed to participate and have been randomized. Follow-up assessments are ongoing with a loss to follow-up of 22.8% and will be completed by August 2022. Final results of the intention-to-treat analysis will be presented overall and stratified by urban and rural sites. Conclusions: Intended consequences of this intervention include an increased responsiveness of consultations for providers resulting in improved care of older patients. Overall, we hope results will support the implementation of evidence-based, multidimensional and virtual pre-consultation tools for older persons in the primary care setting., Presenters Nadia Sourial, PhD, Janusz Kaczorowski, PhD, Amelie Quesnel-Vallee, Marie Therese Lussier, MD, FCFP, MSc, Vladimir Khanassov, MD, MSc, Mylaine Breton, PhD, Elise Develay, MSc, Geraldine Layani, MD, MSc, Clinical [...]

Context The advanced access (AA) model is based on several core pillars, including balancing appointment supply and demand, regularly adjusting supply, optimizing appointment systems and collaboration practices. Exposure of family medicine resident to AA within university family medicine groups (U-FMGs) is a promising strategy to widen its dissemination. It is also essential to reflect on aspects of the model that could be adopted as well as those requiring adaptation to improve the residency experience. Objective Determine compatibility of U-FMG residency programs with AA pillars. Study Design and Analysis Cross-sectional survey of local residency program characteristics with respect to AA pillars. Program compatibility with 4 AA pillars was categorized inductively by a research team that included clinicians, AA experts, a residency program expert and 4 family medicine residents. Setting 46 U-FMGs in Quebec, Canada Population studied The chief resident and academic director of each U-FMG Instrument A de novo online survey questionnaire piloted with 3 former chief residents. The survey included 32 questions about family group practices, residency rotation programs, opportunities to collaborate with other professionals and training received on AA. The questionnaire and 2 reminders were sent by email to all respondents. Outcome measures Characteristics of residency programs were grouped by AA pillar. A three-level score (compatible, moderately compatible, or not very compatible with the principles of AA) was assigned to each group of characteristics of local U-FMG residency programs. Results 38 of 46 U-FMGs participated (82.6%). No U-FMG obtained a score of compatible for all 4 pillars considered. Balancing appointment supply and demand appeared to be adequate for >70% of U-FMGs. However, 60% of U-FMG appointment systems were not very compatible with the AA model, mostly because the proportion of the schedule reserved for urgent appointments was insufficient. Opportunities for collaboration were compatible with AA principles in 32% of programs. Almost 66% of programs offered training on AA. Conclusions Our study highlights the heterogeneity among residency programs with respect to their compatibility with AA. Our theoretical approach limits the objective assessment of the impact on timely access for patients. A second part of the project correlating AA indicators with residency program characteristics is ongoing., Presenters Marie-Eve Boulais, MD, BSc, David Perrier, MD, BSc, Francois Racine-Hemmings, MD, MSc, Nadia Deville-Stoetzel, Mylaine Breton, PhD, Isabelle Gaboury, [...]

Context: Implementing interprofessional advanced access (AA) requires reorganizing the practices of all team members to improve the timeliness of primary care. Often, team members do not know how to engage in a meaningful change process journey. Evidence-based change strategies that address fundamental care delivery processes could help improve timely access to the appropriate professionals while improving satisfaction of both staff and patients. Objective: To describe foundational evidence-based change strategies used by external facilitators to improve interprofessional AA in primary healthcare (PHC) clinics. Study design and analysis: Participatory action research was used to analyze change strategies and steps required for their implementation. AA indicators (3rd next available appointment, continuity of care, and availability for urgent care) were followed longitudinally to adapt the change strategies and assess their progressive impacts. This process led to the development of change packages. Setting: 8 interprofessional PHC clinics in Quebec, Canada. Population studied: Physicians, nurse practitioners, nurses, social workers and pharmacists. Intervention: External facilitators supported PHC clinics while relying on quality improvement techniques according to the Model for Improvement. Outcomes: Change packages: standardized tools to inform the planning, implementation, and monitoring of change strategies. These include: 1) Steps required to implement the strategy; 2) Key indicators to monitor change and evaluate the strategy's success; 3) Lessons learned from the process. Results: 4 different change packages were developed. 3 change packages support transformation of appointment systems, including a prioritization algorithm for appointment scheduling, integration of time slots for urgent care, and integration of an online appointment scheduler. One change package aims to improve patient flow and professional autonomy using collective orders. The contents of these change packages, including lessons learnt and impacts on key indicators of AA across participating clinics, will be presented. Conclusions: Improving AA in PHC is complex, but essential change strategies appeared to be common first steps among clinics undertaking this journey. Resulting change packages provide road maps to successfully guide the improvement of AA, lay a strong foundation for further improvement steps, and build a culture of improvement within and among PHC clinics., Presenters Isabelle Gaboury, PhD, Mylaine Breton, PhD, Francois Bordeleau, MSc, Kathy Perreault, PsyD, MPsy, Elisabeth Martin, MSc, Marie-Eve Poitras, PhD, MSc, RN, Sabina Malham, PhD, MSc, RM, Lara Maillet, PhD, [...]