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Braeden A Terpou,1 Marissa Bird,1,2 Diya Srinivasan,1 Shalu Bains,3 Laura C Rosella,1,4 Laura Desveaux1,2 1Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada; 2Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; 3Mississauga Hospital, Trillium Health Partners, Mississauga, Ontario, Canada; 4Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, CanadaCorrespondence: Laura Desveaux, Institute for Better Health, Trillium Health Partners, 2085 Hurontario Street, Mississauga, ON, L5B 1B8, Canada, Tel +1 437772-6836, Email Laura.Desveaux@thp.caPurpose: As the COVID-19 pandemic recedes, the importance of population health has come into sharp focus, prompting many health systems to explore leveraging population health data (PHD) for operational planning. This approach requires that healthcare leaders embrace the dual priorities of maintaining excellence in patient care while promoting the overall health of populations. However, many leaders are new to population-based thinking, posing a threat to successful operationalization if mental models are not aligned.Patients and Methods: This qualitative case study explored the alignment of mental models among 13 senior leaders at Trillium Health Partners (THP), one of Canada’s largest community hospitals, as they embark on embedding PHD within operational workflows.Results: All leaders recognized the necessity of adopting a population health approach amid resource constraints and growing pressures. When discussing the operationalization of PHD, two distinct mental models emerged among leaders: one focused on patient care and the other on population health. While executive leaders demonstrated a fluidity in their thinking between the two, programmatic leaders favoured one over the other. For example, some viewed the organization’s focus on PHD as competing with their patient care responsibilities, while others saw the use of PHD as a solution to the organization’s operational pressures. Despite these divergences, leaders unanimously stressed the importance of increasing the organization’s risk tolerance and devolving decision-making as a necessary precursor to realizing the transformation to a PHD-driven approach.Conclusion: These divergent mental models highlight a need to clarify the shared vision for the use of PHD along with its impact on leadership roles and accountabilities. These findings illustrate the current state from which THP aims to evolve and underscore the importance of aligning leaders’ mental models as a critical step to facilitating successful integration of PHD and advancing a collective vision for healthcare transformation.Keywords: health equity, population health management, healthcare leaders, qualitative study

Lianne Jeffs,1–3 Trevor Jamieson,4,5 Marianne Saragosa,5 Geetha Mukerji,3,5,6 Arsh K Jain,7 Rachel Man,7 Laura Desveaux,3,5 James Shaw,3,5 Payal Agarwal,5,8 Jennifer M Hensel,5,9 Maria Maione,10 Megan Nguyen,5 Nike Onabajo,5 R Sacha Bhatia3,5,11 1Sinai Health System, Toronto, ON M5G 1X5, Canada; 2Li Ka Shing Knowledge Institute, St Michael’s Hospital, Toronto, ON M5G 1WB, Canada; 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON M5S 1B2, Canada; 4Department of Medicine, University of Toronto, Division of General Internal Medicine, St Michael’s Hospital, Women’s College Hospital, Toronto, ON M5G 1WB, Canada; 5Institute for Health System Solutions and Virtual Care (WIHV), Women’s College Hospital, Toronto, ON M5S 1B2, Canada; 6Women’s College Hospital, Toronto, ON M5S 1B2, Canada; 7London Health Sciences Centre, London, ON N6A 5W9, Canada; 8Department of Family and Community Medicine, Women’s College Hospital, University of Toronto, Toronto, ON M5S 1B2, Canada; 9Department of Psychiatry, University of Toronto, Women’s College Hospital, Women’s College Research Institute, Women’s College Hospital, Toronto, ON M5S 1B2, Canada; 10St Michael’s Hospital, Toronto, ON M5G 1WB, Canada; 11University Health Network, Toronto, ON M5S 1B2, Canada Background: Although there is a growing body of literature on the outcomes and impacts of remote home management with peritoneal dialysis (PD) patients, less is understood how this virtual care solution impacts the quality and efficiency of the healthcare system care. In this context, a study was undertaken to understand the perceptions of patients and their caregivers, healthcare providers, health system decision makers, and vendors associated with a remote monitoring and tracking solution aimed at enhancing the outcomes and experiences of chronic kidney disease (CKD) patients receiving PD at home. Methods: A qualitative design using semi-structured interviews with 25 stakeholders was used in this study. Narrative data were analyzed by a thematic analysis approach. Results: The following two themes emerged from the data: (1) leveraging data to monitor and intervene to keep patients safe and (2) increasing efficiencies and having control over supplies. Discussion: Our study findings elucidated the ability of patients (and in some cases, caregivers) to monitor and trend their data and order and track directly on-line their dialysis supplies were key to their active participation in managing their CKD and keeping them safe at home. Their active participation and functionality of the virtual care solution also led to enhanced efficiencies (eg, process faster, easier, convenient, time savings) for both patients and healthcare providers. Conclusion: The virtual care solution showed promising signs of a patient-centric approach and may serve as a blueprint for other virtual care solutions for chronic disease management. Keywords: peritoneal dialysis, chronic kidney disease, virtual care, qualitative research, patient centric care

Samantha L Harrison,1 Roger Goldstein,1 Laura Desveaux,1 Verity Tulloch,1 Dina Brooks2 1Department of Respiratory Medicine, West Park Healthcare Centre, Toronto, ON, Canada; 2Department of Medicine Physical Therapy, University of Toronto, Toronto, ON, Canada Abstract: Though the guidelines for the optimal management of chronic obstructive pulmonary disease (COPD) following an acute exacerbation (AE) are well established, issues associated with poor adherence to nonpharmacological interventions such as self-management advice and pulmonary rehabilitation will impact on hospital readmission rates and health care costs. Systems developed for clinically stable patients with COPD may not be sufficient for those who are post-exacerbation. A redesign of the manner in which such interventions are delivered to patients following an AECOPD is necessary. Addressing two or more components of the chronic care model is effective in reducing health care utilization in patients with COPD, with self-management support contributing a key role. By refining self-management support to incorporate the identification and treatment of psychological symptoms and by providing health care professionals adequate time and training to deliver respiratory-specific advice and self-management strategies, adherence to nonpharmacological therapies following an AE may be enhanced. Furthermore, following up patients in their own homes allows for the tailoring of advice and for the delivery of consistent health care messages which may enable knowledge to be retained. By refining the delivery of nonpharmacological therapies following an AECOPD according to components of the chronic care model, adherence may be improved, resulting in better disease management and possibly reducing health care utilization.Keywords: acute exacerbation, chronic obstructive pulmonary disease, pulmonary rehabilitation, self-management, physical activity, oxygen, adherence, chronic care model

The delayed and modest uptake of evidence-based treatments following cardiovascular clinical trials highlights the need for greater attention to implementation early in the development and testing of treatments. However, implementation science is not well understood and is often an afterthought following phase 3 trials. In this review, we describe the goals, frameworks, and methods of implementation science, along with common multilevel barriers and facilitators of implementation. We propose that some of the approaches used for implementation well after a trial has ended can be incorporated into the design of phase 3 trials to foster early post-trial implementation. Approaches include, but are not limited to, engaging broad stakeholders including patients, clinicians, and decision-makers in trial advisory boards; using less restrictive eligibility criteria that ensure both internal validity and generalizability; having trial protocols reviewed by regulators; integrating trial execution with the health care system; evaluating and addressing barriers and facilitators to deployment of the intervention; and undertaking cost-effectiveness and cost utility analyses across jurisdictions. We provide case examples to highlight concepts and to guide end-of-trial implementation., Competing Interests: Funding Support and Author Disclosures CVCT meetings are supported by unrestricted educational grants with no allocation for speakers’ fees. Dr Van Spall has received grants from the Canadian Institutes of Health Research (CIHR) and the Heart and Stroke Foundation (HSF); has institution educational accounts with Boehringer Ingelheim and Novartis; has received consulting fees from the Baim Institute for Clinical Research; has trial committee roles with Medtronic, CardioVascular Research Foundation, and the Colorado Prevention Center Clinical Research; and has received travel and/or meeting attendance support from CVCT. Drs Desveaux, Finch, and Singh have received travel and/or meeting attendance support from CVCT. Dr Lewis has received royalties or licenses from Springer Publishing for Practical Implementation Science. Dr Venter has received Institutional grants from the Bill and Melinda Gates Foundation, SA Medical Research Council, National Institutes for Health, Unitaid, Foundation for Innovative New Diagnostics, Merck and the Children's Investment Fund Foundation, USAID, Merck, Johnson and Johnson, ViiV Healthcare, and Novo Nordisk; has received honoraria for educational events and advisory board participation from Gilead Sciences, ViiV Healthcare, Mylan/Viatris, Merck, Adcock-Ingram, Aspen, Abbott, Roche, Johnson and Johnson, Sanofi, Boehringer Ingelheim, Thermo-Fischer, and Virology Education; has received honorarium from the International National Institutes of Health HIV Data and Safety Monitoring Board; and has received drug donations from ViiV Healthcare, Merck, Johnson and Johnson, and Gilead Sciences for investigator-led clinical studies. Dr Zannad has received consulting fees from 89bio, Applied Therapeutics, Bayer, Boehringer Ingelheim, Bristol Myers Squibb, Cardior Pharmaceuticals, Cellprothera, Cereno Scientific, CEVA, CVRx, Merck, Novartis, Novo Nordisk, Owkin, Pfizer, and Servier; has received honoraria for lectures from Bayer, Boehringer Ingelheim, CEVA, CVRx, Merck, and Novartis; has received fees for participation on a data safety monitoring board or advisory board from Acceleron/Merck; and has equity interests in G3 Pharmaceuticals, Cereno Pharmaceuticals, Cardiorenal, Eshmoun Clinical Research, and CVCT. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. The views expressed in this paper are those of the authors and do not necessarily represent the views of the National Heart, Lung, and Blood Institute; the National Institutes of Health; or the U.S. Department of Health and Human Services. Similarly, the views expressed in this paper by other authors are their personal views and may not be understood or quoted as being made on behalf of or reflecting the position of the organizations with which the authors are employed/affiliated., (Copyright © 2024 American College of Cardiology Foundation. All rights reserved.)

Objective: To describe family physicians who primarily practise in a walk-in clinic setting and compare them with family physicians who provide longitudinal care., Design: A cross-sectional study that linked results from a 2019 physician survey to provincial administrative health care data in Ontario. The characteristics, practice patterns, and patients of physicians primarily working in a walk-in clinic setting were compared with those of family physicians providing longitudinal care., Setting: Ontario., Participants: Physicians who primarily worked in a walk-in clinic setting in 2019, as indicated by an annual physician survey., Main Outcome Measures: Physician demographic and practice characteristics, as well as their patients' demographic and health care utilization characteristics, were reported according to whether the physician was a walk-in clinic physician or a family physician who provided longitudinal care., Results: Compared with the 9137 family physicians providing longitudinal care, the 597 physicians who self-identified as practising primarily in walk-in clinics were more frequently male (67% vs 49%) and more likely to speak a language other than English or French (43% vs 32%). Walk-in clinic physicians tended to have more encounters with patients who were younger (mean 37 vs 47 years), who had lower levels of prior health care utilization (15% vs 19% in highest band), who resided in large urban areas (87% vs 77%), and who lived in highly ethnically diverse neighbourhoods (45% vs 35%). Walk-in clinic physicians tended to have more encounters with unattached patients (33% vs 17%) and with patients attached to another physician outside their group (54% vs 18%)., Conclusion: Physicians who primarily work in walk-in clinics saw many patients from historically underserved groups and many patients who were attached to another family physician., (Copyright © 2024 the College of Family Physicians of Canada.)

Background: Telemedicine in the realm of rehabilitation includes the remote delivery of rehabilitation services using communication technologies (eg, telephone, emails, and video). The widespread application of virtual care grants a suitable time to explore the intersection of compassion and telemedicine, especially due to the impact of COVID-19 and how it greatly influenced the delivery of health care universally., Objective: The purpose of this study was to explore how compassionate care is understood and experienced by physiatrists and patients engaged in telemedicine., Methods: We used a qualitative descriptive approach to conduct interviews with patients and physiatrists between June 2021 and March 2022. Patients were recruited across Canada from social media and from a single hospital network in Toronto, Ontario. Physiatrists were recruited across Canada through social media and the Canadian Association for Physical Medicine and Rehabilitation (CAPM&R) email listserve. Interviews were recorded and transcribed. Data were analyzed thematically., Results: A total of 19 participants were interviewed-8 physiatrists and 11 patients. Two themes capturing physiatrists' and patients' experiences with delivering and receiving compassionate care, especially in the context of virtual care were identified: (1) compassionate care is inherently rooted in health care providers' inner intentions and are, therefore, expressed as caring behaviors and (2) virtual elements impact the delivery and receipt of compassionate care., Conclusions: Compassionate care stemmed from physiatrists' caring attitudes which then manifest as caring behaviors. In turn, these caring attitudes and behaviors enable individualized care and the establishment of a safe space for patients. Moreover, the virtual care modality both positively and negatively influenced how compassion is enacted by physiatrists and received by patients. Notably, there was large ambiguity around the norms and etiquette surrounding virtual care. Nonetheless, the flexibility and person-centeredness of virtual care cause it to be useful in health care settings., (©Marina B Wasilewski, Abirami Vijayakumar, Zara Szigeti, Amanda Mayo, Laura Desveaux, James Shaw, Sander L Hitzig, Robert Simpson. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 06.08.2024.)

Background: High-quality primary care is associated with better health outcomes and more efficient and equitable health system performance. However, the rate of primary care attachment is falling, and timely access to primary care is worsening, driving many patients to use walk-in clinics for their comprehensive primary care needs. This study sought to explore the experiences and perceived roles and responsibilities of walk-in physicians in this current climate. Methods: Qualitative interviews were conducted with nineteen physicians currently providing walk-in care in Ontario, Canada between May and December 2022., Results: Limited capacity for continuity and comprehensiveness of care were identified as major sources of professional tension for walk-in physicians. Divergent perspectives on their roles were anchored in how physicians viewed their professional identity. Some saw providing continuous and comprehensive care as an infringement on their professional role; others saw their professional role as more flexible and responsive to population needs. Regardless of their professional identity, participants reported feeling ill-equipped to manage the swell of unattached patients, citing a lack of time, resources, connectivity to the system, and remuneration flexibility. Conclusions: As practice demands of walk-in clinics change, an evolution in the professional roles and responsibilities of walk-in physicians follows. However, the resources, structure, and incentives of walk-in care have not evolved to reflect this, leaving physicians to set their own professional boundaries with patients. This results in increasing variations in care and confusion across the primary care sector around who is responsible for what, when, and how., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Terpou 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: Childhood cancer treatment while often curative, leads to elevated risks of morbidity and mortality. Survivors require lifelong periodic surveillance for late effects of treatment, yet adherence to guideline-recommended tests is suboptimal. We created ONLOOP to provide adult survivors of childhood cancer with detailed health information, including summaries of their childhood cancer treatment and recommended surveillance tests for early detection of cardiomyopathy, breast cancer, and/or colorectal cancer, with personalized reminders over time., Methods: This is an individually randomized, registry-based pragmatic trial with an embedded process and economic evaluation to understand ONLOOP's impact and whether it can be readily implemented at scale. All adult survivors of childhood cancer in Ontario overdue for guideline-recommended tests will be randomly assigned to one of two arms: (1) intervention or (2) delayed intervention. A letter of information and invitation will detail the ONLOOP program. Those who sign up will receive a personalized toolkit and a screening reminder 6 months later. With the participants' consent, ONLOOP will also send their primary care clinician a letter detailing the recommended tests and a reminder 6 months later. The primary outcome will be the proportion of survivors who complete one or more of the guideline-recommended cardiac, breast, or colon surveillance tests during the 12 months after randomization. Data will be obtained from administrative databases. The intent-to-treat principle will be followed. Based on our analyses of administrative data, we anticipate allocating at least 862 individuals to each trial arm, providing 90% power to detect an absolute increase of 6% in targeted surveillance tests completed. We will interview childhood cancer survivors and family physicians in an embedded process evaluation to examine why and how ONLOOP achieved success or failed. A cost-effectiveness evaluation will be performed., Discussion: The results of this study will determine if ONLOOP is effective at helping adult survivors of childhood cancer complete their recommended surveillance tests. This study will also inform ongoing provincial programs for this high-risk population., Trial Registration: ClinicalTrials.gov NCT05832138., (© 2024. The Author(s).)

Competing Interests: Competing interests: None declared.

Background: Digital health interventions (DHIs) are a central focus of health care transformation efforts, yet their uptake in practice continues to fall short of their potential. In order to achieve their desired outcomes and impact, DHIs need to reach their target population and need to be used. Many factors can rapidly intersect between this dynamic of users and interventions. The application of theories, models, and frameworks (TMFs) can facilitate the systematic understanding and explanation of the complex interactions between users, practices, technology, and health system factors that underpin research questions. There remains a gap in our understanding of how TMFs have been applied to guide the evaluation of DHIs with real-world health system operations., Objective: This study aims to map TMFs used in studies to guide the evaluation of DHIs. The objectives are to (1) describe the TMFs and the constructs they target, (2) identify how TMFs have been prospectively used (ie, their roles) in primary studies to evaluate DHIs, and (3) to reflect on the relevance and utility of our findings for knowledge users., Methods: This scoping review was conducted in partnership with knowledge users using an integrated knowledge translation approach. We included papers (eg, reports; empirical quantitative, qualitative, and mixed methods studies; conference proceedings; and dissertations) if primary insights resulting from the application of TMFs were presented. Any type of DHI was eligible. Papers published from 2000 and onward were mainly identified from the following databases: MEDLINE (Ovid), CINAHL Complete (EBSCOhost), PsycINFO (Ovid), EBM Reviews (Ovid), and Embase (Ovid)., Results: A total of 156 studies published between 2000 and 2022 were included. A total of 68 distinct TMFs were identified across 85 individual studies. In more than half (85/156, 55%) of the included studies, 1 of following 6 prevailing TMFs were reported: Consolidated Framework for Implementation Research (n=39); the Reach, Effectiveness, Adoption, Implementation, and Maintenance Framework (n=17); the Technology of Acceptance Model (n=16); the Unified Theory on Acceptance and Use of Technology (n=12); the Diffusion of Innovation Theory (n=10); and Normalization Process Theory (n=9). The most common intended roles of the 6 TMFs were to inform data collection (n=86), to inform data analysis (n=69), and to identify key constructs that may serve as barriers and facilitators (n=52)., Conclusions: As TMFs are most often reported to be applied to support data collection and analysis, researchers should consider more clearly synthesizing key insights as practical use cases to both increase the relevance and digestibility of their findings. There is also a need to adapt or develop guidelines for better reporting DHIs and the use of TMFs to guide evaluation. Hence, it would contribute to ensuring ongoing technology transformation efforts are evidence and theory informed rather than anecdotally driven., (©Geneviève Rouleau, Kelly Wu, Karishini Ramamoorthi, Cherish Boxall, Rebecca H Liu, Shelagh Maloney, Jennifer Zelmer, Ted Scott, Darren Larsen, Harindra C Wijeysundera, Daniela Ziegler, Sacha Bhatia, Vanessa Kishimoto, Carolyn Steele Gray, Laura Desveaux. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 05.02.2024.)

Objective: Virtual care presents a promising opportunity to create new communication channels and increase access to healthcare. However, concerns have been raised around the potential for unintended emotional distances created through virtual care environments that could strain patient-provider relationships. While compassionate care is an enabler of emotional connectivity and a core tenant of nursing, little is known about whether or how nurses have adapted their compassion skills into virtual interactions. These concerns are particularly relevant in primary care, where there is a focus on relational continuity (i.e. relationship-based, longitudinal care) and a broad uptake of virtual care. The aim of this study was to explore the meaning of compassionate virtual care and to uncover how nurses operationalized compassionate care through virtual interactions in primary care., Methods: We used a qualitative interpretive descriptive lens to conduct semistructured interviews with primary care nurses (Ontario, Canada) who had provided virtual care (i.e. video visits, remote patient monitoring, or asynchronous messaging). We used a thematic approach to analyze the data., Results: We interviewed 18 nurse practitioners and two registered nurses. Participants described how: (1) compassionate care was central to nursing practice, (2) compassionate care was evolving through virtual nurse-patient interaction, and (3) nurses balanced practice with patients' expectations while providing virtual compassionate care., Conclusions: There is an opportunity to better align nurses' understanding and operationalization of compassionate care in virtual primary care contexts. Exploring how compassionate care is operationalized in primary care settings is a necessary first step to building compassionate competencies across the nursing profession to support the continued virtual evolution of health service delivery., (© The Author(s) 2024.)

Background: While the COVID-19 pandemic dramatically increased virtual care uptake across many health settings, it remains significantly underused in urgent care., Objective: This study evaluated the implementation of a pilot virtual emergency department (VED) at an Ontario hospital that connected patients to emergency physicians through a web-based portal. We sought to (1) assess the acceptability of the VED model, (2) evaluate whether the VED was implemented as intended, and (3) explore the impact on quality of care, access to care, and continuity of care., Methods: This evaluation used a multimethods approach informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. Data included semistructured interviews with patients and physicians as well as postvisit surveys from patients. Interviews were transcribed and analyzed using thematic analysis. Data from the surveys were described using summary statistics., Results: From December 2020 to December 2021, the VED had a mean of 153 (SD 25) visits per month. Among them, 67% (n=677) were female, and 75% (n=758) had a family physician. Patients reported that the VED provided high-quality, timely access to care and praised the convenience, shorter appointments, and benefit of the calm, safe space afforded through virtual appointments. In instances where patients were directed to come into the emergency department (ED), physicians were able to provide a "warm handoff" to improve efficiency. This helped manage patient expectations, and the direct advice of the ED physician reassured them that the visit was warranted. There was broad initial uptake of VED shifts among ED physicians with 60% (n=22) completing shifts in the first 2 months and 42% (n=15) completing 1 or more shifts per month over the course of the pilot. There were no difficulties finding sufficient ED physicians for shifts. Most physicians enjoyed working in the VED, saw value for patients, and were motivated by patient satisfaction. However, some physicians were hesitant as they felt their expertise and skills as ED physicians were underused. The VED was implemented using an iterative staged approach with increased service capabilities over time, including access to ultrasounds, virtual follow-ups after a recent ED visit, and access to blood work, urine tests, and x-rays (at the hospital or a local community laboratory). Physicians recognized the value in supporting patients by advising on the need for an in-person visit, booking a diagnostic test, or referring them to a specialist., Conclusions: The VED had the support of physicians and facilitated care for low-acuity presentations with immediate benefits for patients. It has the potential to benefit the health care system by seeing patients through the web and guiding patients to in-person care only when necessary. Long-term sustainability requires a focus on understanding digital equity and enhanced access to rapid testing or investigations., (©Jennifer Shuldiner, Diya Srinivasan, Laura Desveaux, Justin N Hall. Originally published in JMIR Formative Research (https://formative.jmir.org), 05.12.2023.)

Background: Efforts to maximize the impact of healthcare improvement interventions are hampered when intervention components are not well defined or described, precluding the ability to understand how and why interventions are expected to work., Method: We partnered with two organizations delivering province-wide quality improvement interventions to establish how they envisaged their interventions lead to change (their underlying causal assumptions) and to identify active ingredients (behavior change techniques [BCTs]). The interventions assessed were an audit and feedback report and an academic detailing program. Both focused on supporting safer opioid prescribing in primary care in Ontario, Canada. Data collection involved semi-structured interviews with intervention developers ( n  = 8) and a content analysis of intervention documents. Analyses unpacked and articulated how the interventions were intended to achieve change and how this was operationalized., Results: Developers anticipated that the feedback report would provide physicians with a clear understanding of their own prescribing patterns in comparison to others. In the feedback report, we found an emphasis on BCTs consistent with that assumption ( feedback on behavior ; social comparison ). The detailing was designed to provide tailored support to enable physicians to overcome barriers to change and to gradually enact specific practice changes for patients based on improved communication. In the detailing materials, we found an emphasis on instructions on how to perform the behavior , for a range of behaviors (e.g., tapering opioids, treating opioid use disorder). The materials were supplemented by detailer-enacted BCTs (e.g., social support [practical] ; goal setting [behavior] ; review behavioral goal[s] )., Conclusions: The interventions included a small range of BCTs addressing various clinical behaviors. This work provides a methodological example of how to apply a behavioral lens to surface the active ingredients, target clinical behaviors, and causal assumptions of existing large-scale improvement interventions that could be applied in other contexts to optimize effectiveness and facilitate scale and spread., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Purpose: We offered a practice facilitation intervention to family physicians in Ontario, Canada, known to have large numbers of patients not yet vaccinated against coronavirus disease 2019 (COVID-19)., Methods: We conducted a multimethod process evaluation embedded within a randomized controlled trial (clinical trial #NCT05099497). We collected descriptive statistics regarding engagement and qualitative interview data from family physicians and practice facilitators, as well as data from facilitator field notes. We analyzed and triangulated the data using thematic analysis and mapped barriers to and enablers for implementation to structural, organizational, physician, and patient factors., Results: Of the 300 approached, 90 family physicians (30%) accepted facilitation. Of these, 57% received technical support to identify unvaccinated patients, 29% used trained medical student volunteers to contact patients on their behalf, and 30% used automated calling to reach patients. Key factors affecting engagement with the intervention were staff shortages owing to COVID-19 (structural), clinic characteristics such as technical issues and gatekeeping by staff, which prevented facilitators from talking with physicians (organizational), burnout (physician), and specialized populations that required targeted resources (patient). The facilitator's ability to address technical issues and connect family physicians with medical students helped with engagement., Conclusions: Strategies to help underresourced family physicians serving high-needs populations for issues of public health importance, such as vaccine promotion, must acknowledge the scarcity of physicians' time and provide new resources. To successfully engage family physicians, practice facilitators should seek to build trust and relationships over time, including with front-office staff., (© 2023 Annals of Family Medicine, Inc.)

Background: Academic detailing, an educational outreach service for family physicians, was funded by the Ontario government to address gaps in opioid prescribing and pain management. We sought to evaluate the impact of academic detailing on opioid prescribing, and to understand how and why academic detailing may have influenced opioid prescribing., Methods: In this mixed-methods study, we collected quantitative and qualitative data concurrently from 2017 to 2019 in Ontario, Canada. We analyzed prescribing outcomes descriptively for a sample of participating physicians and compared them with a matched control group. We invited physicians to participate in qualitative interviews to discuss their experiences in academic detailing. Development and analysis of qualitative interviews was informed by the Theoretical Domains Framework. We triangulated qualitative and quantitative findings to understand the mechanisms that drove changes in opioid prescribing., Results: Physicians receiving academic detailing ( n = 238) achieved a greater reduction in opioid prescribing than matched controls ( n = 238). Seventeen physicians completed interviews and reported that academic detailing addressed barriers to pain care, including lack of confidence, difficult interactions with patients and prescribing and tapering decisions. Academic detailing reinforced knowledge about opioid prescribing and pain management. Discussion of complex patients and talking points to use during challenging conversations were described as key drivers of practice change., Interpretation: The findings of this real-world, mixed-methods evaluation explain how an academic detailing service addressed key barriers and enablers to limit high-risk opioid prescribing in primary care. This nuanced understanding will be used to inform, spread and scale academic detailing., Competing Interests: Competing interests: Noah Ivers reports funding from the Canadian Institutes of Health Research, outside the submitted work. No other competing interests were declared., (© 2023 CMA Impact Inc. or its licensors.)

Background: We developed the Canadian Syncope Pathway (CSP) based on the Canadian Syncope Risk Score (CSRS) to aid emergency department (ED) syncope management. This pilot implementation study assessed patient inclusion, length of transition period, as well as process measures (engagement, reach, adoption, and fidelity) to prepare for multicenter implementation., Methods: A non-randomized stepped wedge trial at two hospitals was conducted over a 7-month period. After 2-3 months in the control condition, the hospitals crossed over in a stepwise fashion to the intervention condition. Study participants were ED and non-ED physicians, or their delegates, and patients (aged ≥ 18 years) with syncope. We aimed to analyze patient characteristics, ED management including disposition decision, and CSRS recommendations application for all eligible patients during the intervention period. Our targets were 95% inclusion rate, 70% adoption (proportion of physicians who applied the pathway), 60% reach (intervention applied to eligible patients) and 70% fidelity (appropriate recommendations application) for all eligible patients. Clinical Trials registration NCT04790058., Results: 1002 eligible patients (mean age 56.6 years; 51.0% males) were included: 349 patients during the control and 653 patients during the intervention period. Physician engagement varied from 39.7% to 97.1% for presentation at meetings. Process measures for the first month and the end of the intervention were: adoption 70.7% (58/82) and 84.4% (103/122), reach 67.5% (108/160) and 55.0% (359/653), fidelity among patients with physician data form completion 86.3% (88/102) and 88.3% (294/333), versus fidelity among all eligible patients 83.8% (134/160) and 83.3% (544/653) respectively with no significant differences in fidelity at one month and the end of the intervention period., Conclusion: In this pilot study, we achieved all prespecified benchmarks for proceeding to the multicenter CSP implementation except reach. Our results indicate a 1-month transition period will be adequate though regular reminders will be needed during full-scale implementation., (© 2023. The Author(s), under exclusive licence to Canadian Association of Emergency Physicians (CAEP)/ Association Canadienne de Médecine d'Urgence (ACMU).)

Background: Emerging adults living with type 1 diabetes (T1D) face a series of challenges with self-management and decreased health system engagement, leading to an increased risk of acute complications and hospital admissions. Effective and scalable strategies are needed to support this population to transfer seamlessly from pediatric to adult care with sufficient self-management capability. While digital health interventions for T1D self-management are a promising strategy, it remains unclear which elements work, how, and for which groups of individuals., Objective: This study aims to evaluate the design and implementation of a multicomponent SMS text message-based digital health intervention to support emerging adults living with T1D in real-world settings. The objectives are to identify the intervention components and associated mechanisms that support user engagement and T1D health care transition experiences and determine the individual characteristics that influence the implementation process., Methods: We used a realist evaluation embedded alongside a randomized controlled trial, which uses a sequential mixed methods design to analyze data from multiple sources, including intervention usage data, patient-reported outcomes, and realist interviews. In step 1, we conducted a document analysis to develop a program theory that outlines the hypothesized relationships among "individual-level contextual factors, intervention components and features, mechanisms, and outcomes," with special attention paid to user engagement. Among them, intervention components and features depict 10 core characteristics such as transition support information, problem-solving information, and real-time interactivity. The proximal outcomes of interest include user engagement, self-efficacy, and negative emotions, whereas the distal outcomes of interest include transition readiness, self-blood glucose monitoring behaviors, and blood glucose. In step 2, we plan to conduct semistructured realist interviews with the randomized controlled trial's intervention-arm participants to test the hypothesized "context-intervention-mechanism-outcome" configurations. In step 3, we plan to triangulate all sources of data using a coincidence analysis to identify the necessary combinations of factors that determine whether and how the desired outcomes are achieved and use these insights to consolidate the program theory., Results: For step 1 analysis, we have developed the initial program theory and the corresponding data collection plan. For step 2 analysis, participant enrollment for the randomized controlled trial started in January 2023. Participant enrollment for this realist evaluation was anticipated to start in July 2023 and continue until we reached thematic saturation or achieved informational power., Conclusions: Beyond contributing to knowledge on the multiple pathways that lead to successful engagement with a digital health intervention as well as target outcomes in T1D care transitions, embedding the realist evaluation alongside the trial may inform real-time intervention refinement to improve user engagement and transition experiences. The knowledge gained from this study may inform the design, implementation, and evaluation of future digital health interventions that aim to improve transition experiences., International Registered Report Identifier (irrid): PRR1-10.2196/46115., (©Ruoxi Wang, Geneviève Rouleau, Gillian Lynn Booth, Anne-Sophie Brazeau, Noor El-Dassouki, Madison Taylor, Joseph A Cafazzo, Marley Greenberg, Meranda Nakhla, Rayzel Shulman, Laura Desveaux. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 13.09.2023.)

Walk-in clinics are typically viewed as high-volume locations for managing acute issues but also may serve as a location for primary care, including cancer screening, for patients without a family physician. In this population-based cohort study, we compared breast, cervical and colorectal cancer screening up-to-date status for people living in the Canadian province of Ontario who were formally enrolled to a family physician versus those not enrolled but who had at least one encounter with a walk-in clinic physician in the previous year. Using provincial administrative databases, we created two mutually exclusive groups: i) those who were formally enrolled to a family physician, ii) those who were not enrolled but had at least one visit with a walk-in clinic physician from April 1, 2019 to March 31, 2020. We compared up to date status for three cancer screenings as of April 1, 2020 among screen-eligible people. We found that people who were not enrolled and had seen a walk-in clinic physician in the previous year consistently were less likely to be up to date on cancer screening than Ontarians who were formally enrolled with a family physician (46.1% vs. 67.4% for breast, 45.8% vs. 67.4% for cervical, 49.5% vs. 73.1% for colorectal). They were also more likely to be foreign-born and to live in structurally marginalized neighbourhoods. New methods are needed to enable screening for people who are reliant on walk-in clinics and to address the urgent need in Ontario for more primary care providers who deliver comprehensive, longitudinal care., Competing Interests: Declaration of Competing Interest This study received funding from CIHR (grant #175285). Aisha Lofters is the Chair in Implementation Science at the Peter Gilgan Centre for Women's Cancers in partnership with the Canadian Cancer Society. She is supported as a Clinician Scientist by the Department of Family and Community Medicine at the University of Toronto. Lauren Lapointe-Shaw is supported by the University of Toronto Department of Medicine, the Toronto General Hospital Research Institute, the Women's College Institute for Health System Solutions and Virtual Care (WIHV), and the Peter Gilgan Centre for Women's Cancers at Women's College Hospital, in partnership with the Canadian Cancer Society. Tara Kiran is the Fidani Chair of Improvement and Innovation at the University of Toronto. She is supported as a Clinician Scientist by the Department of Family and Community Medicine at St. Michael's Hospital and the University of Toronto. Noah M. Ivers is supported by a Canada Research Chair in Implementation of Evidence-based Practice and a Clinician Scholar award from the Department of Family and Community Medicine at Women's College Hospital and the University of Toronto. Simon Berthelot holds a Junior 2 Career Award from the Fonds de recherche du Québec - Santé (FRQS). Simon Berthelot receives research funding from Meridian Bioscience and Abbott to test their bedside COVID screening device in the emergency department setting., (Copyright © 2023. Published by Elsevier Inc.)

Background: The Canadian Syncope Risk Score (CSRS) was developed to improve syncope management in emergency department settings. Evidence-based tools often fail to have the intended impact because of suboptimal uptake or poor implementation., Objective: In this paper, we aimed to describe the process of developing evidence-based implementation strategies to support the deployment and use of the CSRS in real-world emergency department settings to improve syncope management among physicians., Methods: We followed a systematic approach for intervention development, including identifying who needs to do what differently, identifying the barriers and enablers to be addressed, and identifying the intervention components and modes of delivery to overcome the identified barriers. We used the Behaviour Change Wheel to guide the selection of implementation strategies. We engaged CSRS end users (ie, emergency medicine physicians) in a user-centered design approach to generate and refine strategies. This was achieved over a series of 3 qualitative user-centered design workshops lasting 90 minutes each with 3 groups of emergency medicine physicians., Results: A total of 14 physicians participated in the workshops. The themes were organized according to the following intervention development steps: theme 1-identifying and refining barriers and theme 2-identifying the intervention components and modes of delivery. Theme 2 was subdivided into two subthemes: (1) generating high-level strategies and developing strategies prototypes and (2) refining and testing strategies. The main strategies identified to overcome barriers included education in the format of meetings, videos, journal clubs, and posters (to address uncertainty around when and how to apply the CSRS); the development of a web-based calculator and integration into the electronic medical record (to address uncertainty in how to apply the CSRS); a local champion (to address the lack of team buy-in); and the dissemination of evidence summaries and feedback through email communications (to address a lack of evidence about impact)., Conclusions: The ability of the CSRS to effectively improve patient safety and syncope management relies on broad buy-in and uptake across physicians. To ensure that the CSRS is well positioned for impact, a comprehensive suite of strategies was identified to address known barriers., (©Geneviève Rouleau, Venkatesh Thiruganasambandamoorthy, Kelly Wu, Bahareh Ghaedi, Phuong Anh Nguyen, Laura Desveaux. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 13.06.2023.)

The COVID-19 pandemic forced health systems to rapidly shift to deliver healthcare virtually, however, there is a limited understanding of this shift from the patient's perspective. We conducted semi-structured interviews with patients in three clinical areas (mental health, chronic care, and surgical care) and used patient journey mapping to visualize their experiences. Themes suggest that (1) patient's preference of modalities was contextually dependent, (2) that providers must continually converse with patients to select appropriate modalities, and (3) that providers must account for multiple factors such as a patient's digital and health literacy, comfort level with the modality and their medical needs., Competing Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Background: The acceleration of technology-based primary care during the COVID-19 pandemic outpaced the ability to understand whether and how it impacts care delivery and outcomes. As technology-based care continues to evolve, focusing on the core construct of compassion in a primary care context will help ensure high-quality patient care and increased patient autonomy and satisfaction. The ability to successfully operationalize the use of technology in patient-clinician interactions hinges on understanding not only how compassionate care is experienced in this context but also how clinicians can create it., Objective: The objectives of this study were to understand whether and how compassionate behaviors are experienced in technology-based primary care interactions and identify the individual and contextual drivers that influence whether and how these behaviors occur., Methods: We conducted a series of qualitative one-on-one interviews with primary care physicians, nurses, and patients. Qualitative data were initially analyzed using an inductive thematic analysis approach to identify preliminary themes for each participant group independently. We then looked across participant groups to identify areas of alignment and distinction. Descriptions of key behaviors that participants identified as elements of a compassionate interaction and descriptions of key drivers of these behaviors were inductively coded and defined at this stage., Results: A total of 74 interviews were conducted with 40 patients, 20 nurses, and 14 primary care physicians. Key behaviors that amplified the experience of compassion included asking the patient's modality preference, using video to establish technology-based presence, sharing the screen, and practicing effective communication. Participants' knowledge or skills as well as their beliefs and emotions influenced whether or not these behaviors occurred. Contextual elements beyond participants' control influenced technology-based interactions, including resource access, funding structures, culture, regulatory standards, work structure, societal influence, and patient characteristics and needs. A high-yield, evidence-based approach to address the identified drivers of compassion-focused clinician behavior includes a combination of education, training, and enablement., Conclusions: Much of the patient experience is influenced by clinician behavior; however, clinicians need a supportive system and adequate supports to evolve new ways of working to create the experience of compassionate care. The current state of technology-based care operationalization has led to widespread burnout, societal pressure, and shifting expectations of both clinicians and the health system more broadly, threatening the ability to deliver compassionate care. For clinicians to exhibit compassionate behaviors, they need more than just adequate supports; they also need to receive compassion from and experience the humanity of their patients., (©Laura Desveaux, Kelly Wu, Geneviève Rouleau, Diya Srinivasan, Rhea Azavedo, Marlena Dang Nguyen, Danielle Martin, Carolyn Steele Gray. Originally published in JMIR Formative Research (https://formative.jmir.org), 31.05.2023.)

Explore characteristics of the facilitator, group, and interaction that influence whether a group discussion about data leads to the identification of a clearly specified action plan. Peer-facilitated group discussions among primary care physicians were carried out and recorded. A follow-up focus group was conducted with peer facilitators to explore which aspects of the discussion promoted action planning. Qualitative data was analyzed using an inductive-deductive thematic analysis approach using the conceptual model developed by Cooke et al. Group discussions were coded case-specifically and then analyzed to identify which themes influenced action planning as it relates to performance improvement. Physicians were more likely to interact with practice-level data and explore actions for performance improvement when the group facilitator focused the discussion on action planning. Only one of the three sites (Site C) converged on an action plan following the peer-facilitated group discussion. At Site A, physicians shared skepticism of the data, were defensive about performance, and explained performance as a product of factors beyond their control. Site B identified several potential actions but had trouble focusing on a single indicator or deciding between physician- and group-level actions. None of the groups discussed variation in physician-level performance indicators, or how physician actions might contribute to the reported outcomes. Peer facilitators can support data interpretation and practice change; however their success depends on their personal beliefs about the data and their ability to identify and leverage change cues that arise in conversation. Further research is needed to understand how to create a psychologically safe environment that welcomes open discussion of physician variation., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Society of Behavioral Medicine.)

Background: While audit & feedback (A&F) is an effective implementation intervention, the design elements which maximize effectiveness are unclear. Partnering with a healthcare quality advisory organization already delivering feedback, we conducted a pragmatic, 2 × 2 factorial, cluster-randomized trial to test the impact of variations in two factors: (A) the benchmark used for comparison and (B) information framing. An embedded process evaluation explored hypothesized mechanisms of effect., Methods: Eligible physicians worked in nursing homes in Ontario, Canada, and had voluntarily signed up to receive the report. Groups of nursing homes sharing physicians were randomized to (A) physicians' individual prescribing rates compared to top-performing peers (the top quartile) or the provincial median and (B) risk-framed information (reporting the number of patients prescribed high-risk medication) or benefit-framed information (reporting the number of patients not prescribed). We hypothesized that the top quartile comparator and risk-framing would lead to greater practice improvements. The primary outcome was the mean number of central nervous system-active medications per resident per month. Primary analyses compared the four arms at 6 months post-intervention. Factorial analyses were secondary. The process evaluation comprised a follow-up questionnaire and semi-structured interviews., Results: Two hundred sixty-seven physicians (152 clusters) were randomized: 67 to arm 1 (median benchmark, benefit framing), 65 to arm 2 (top quartile benchmark, benefit framing), 75 to arm 3 (median benchmark, risk framing), and 60 to arm 4 (top quartile benchmark, risk framing). There were no significant differences in the primary outcome across arms or for each factor. However, engagement was low (27-31% of physicians across arms downloaded the report). The process evaluation indicated that both factors minimally impacted the proposed mechanisms. However, risk-framed feedback was perceived as more actionable and more compatible with current workflows, whilst a higher target might encourage behaviour change when physicians identified with the comparator., Conclusions: Risk framing and a top quartile comparator have the potential to achieve change. Further work to establish the strategies most likely to enhance A&F engagement, particularly with physicians who may be most likely to benefit from feedback, is required to support meaningfully addressing intricate research questions concerning the design of A&F., Trial Registration: ClinicalTrials.gov, NCT02979964 . Registered 29 November 2016., (© 2023. The Author(s).)

Introduction: Transition from paediatric to adult care can be challenging for youth living with type 1 diabetes (T1D), as many youth feel unprepared to transfer to adult care and are at high risk for deterioration of glycaemic management and acute complications. Existing strategies to improve transition experience and outcomes are limited by cost, scalability, generalisability and youth engagement. Text messaging is an acceptable, accessible and cost-effective way of engaging youth. Together with adolescents and emerging adults and paediatric and adult T1D providers, we co-designed a text message-based intervention, Keeping in Touch (KiT), to deliver tailored transition support. Our primary objective is to test the effectiveness of KiT on diabetes self-efficacy in a randomised controlled trial., Methods and Analysis: We will randomise 183 adolescents with T1D aged 17-18 years within 4 months of their final paediatric diabetes visit to the intervention or usual care. KiT will deliver tailored T1D transition support via text messages over 12 months based on a transition readiness assessment. The primary outcome, self-efficacy for diabetes self-management, will be measured 12 months after enrolment. Secondary outcomes, measured at 6 and 12 months, include transition readiness, perceived T1D-related stigma, time between final paediatric and first adult diabetes visits, haemoglobin A1c, and other glycaemia measures (for continuous glucose monitor users), diabetes-related hospitalisations and emergency department visits and the cost of implementing the intervention. The analysis will be intention-to-treat comparing diabetes self-efficacy at 12 months between groups. A process evaluation will be conducted to identify elements of the intervention and individual-level factors influencing implementation and outcomes., Ethics and Dissemination: The study protocol version 7 July 2022 and accompanying documents were approved by Clinical Trials Ontario (Project ID: 3986) and the McGill University Health Centre (MP-37-2023-8823). Study findings will be presented at scientific conferences and in peer-reviewed publications., Trial Registration Number: NCT05434754., Competing Interests: Competing interests: RS and A-SB have received speaking fees from Dexcom. EG is the Site Co-Investigator role for Medtronic study grant to the institution and Chair of Epic® Pediatric Endocrinology Specialty Steering Board. IZ reports receiving personal fees from Abbott Diabetes Care and Novo Nordisk Canada Inc. and research funding support from the University of Toronto, Navigator Limited, the Medical Psychiatry Alliance, Regional Municipality of Peel, Community Foundation of Mississauga, Canadian Institutes of Health Research (CIHR), and Social Sciences and Humanities Research Council of Canada (SSHRC). MH is recipient of the 2019 Canadian Society of Endocrinology and Metabolism’s Young Investigator Award, and a FRQS Senior salary award. Her research has been funded by the Canadian Institutes of Health Research (CIHR), Heart and Stroke Foundation of Canada, Diabète Québec and Fonds de recherche en Santé du québec (FRQS)., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Walk-in clinics are common in North America and are designed to provide acute episodic care without an appointment. We sought to describe a sample of walk-in clinic patients in Ontario, Canada, which is a setting with high levels of primary care attachment., Methods: We performed a cross-sectional study using health administrative data from 2019. We compared the sociodemographic characteristics and health care utilization patterns of patients attending 1 of 72 walk-in clinics with those of the general Ontario population. We examined the subset of patients who were enrolled with a family physician and compared walk-in clinic visits to family physician visits., Results: Our study found that 562 781 patients made 1 148 151 visits to the included walk-in clinics. Most (70%) patients who attended a walk-in clinic had an enrolling family physician. Walk-in clinic patients were younger (mean age 36 yr v. 41 yr, standardized mean difference [SMD] 0.24), yet had greater health care utilization (moderate and high use group 74% v. 65%, SMD 0.20) than the general Ontario population. Among enrolled Ontarians, walk-in patients had more comorbidities (moderate and high count 50% v. 45%, SMD 0.10), lived farther from their enrolling physician (median 8 km v. 6 km, SMD 0.21) and saw their enrolling physician less in the previous year (any visit 67% v. 80%, SMD 0.30). Walk-in encounters happened more often after hours (16% v. 9%, SMD 0.20) and on weekends (18% v. 5%, SMD 0.45). Walk-in clinics were more often within 3 km of patients' homes than enrolling physicians' offices (0 to < 3 km: 32% v. 22%, SMD 0.21)., Interpretation: Our findings suggest that proximity of walk-in clinics and after-hours access may be contributing to walk-in clinic use among patients enrolled with a family physician. These findings have implications for policy development to improve the integration of walk-in clinics and longitudinal primary care., Competing Interests: Competing interests: Lauren Lapointe-Shaw is supported by the University of Toronto Department of Medicine, the Toronto General Hospital Research Institute, the Women’s College Institute for Health System Solutions and Virtual Care and the Peter Gilgan Centre for Women’s Cancers at the Women’s College Hospital, in partnership with the Canadian Cancer Society. Tara Kiran is the Fidani Chair of Improvement and Innovation at the University of Toronto and is supported as a clinician scientist by the Department of Family and Community Medicine at St. Michael’s Hospital and the University of Toronto. Noah M. Ivers is supported by a Canada Research Chair in Implementation of Evidence-based Practice and a clinician scholar award from the Department of Family and Community Medicine at the Women’s College Hospital and the University of Toronto., (© 2023 CMA Impact Inc. or its licensors.)

Introduction: The widespread and rapid implementation of virtual care has introduced evolutionary changes in the context, process, and way primary care is delivered. The objectives of this study were to: (1) understand whether and how virtual care has shifted the therapeutic relationship; (2) describe the core components of compassionate care from the patient perspective and (3) identify how and in what circumstances compassionate care might be amplified., Methods: Participants living in Ontario, Canada were eligible if they had interacted with their primary care clinician following the rapid implementation of virtual care in March 2020, irrespective of virtual care use. One-on-one semi-structured interviews were conducted with all participants and data were analyzed using inductive thematic analysis., Results: Four themes emerged across 36 interviews: (1) Virtual care shifts communication patterns but the impact on the therapeutic relationship is unclear; (2) Rapid implementation of virtual care limited perceived quality and access among those who did not have the option to utilize it; (3) Patients perceive five key elements as central to compassion in a virtual context; and (4) Leveraging technology to fill gaps within and beyond the visit is a step towards improving experiences for all., Discussion: Virtual care has transformed the ways in which patient-clinician communication operates in primary care. Patients with access to virtual care described largely positive experiences, while those whose interactions were limited to phone visits experienced decreased quality and access to care. Attention must shift to identifying effective strategies to support the health workforce in building virtual compassion competencies.

Objective: To explore primary care physician (PCP) perspectives on the clinical utility of virtual visits., Design: Qualitative design involving semistructured interviews., Setting: Primary care practices within 5 regions in southern Ontario., Participants: Primary care physicians representing different practice sizes and remuneration models., Methods: Interviews were conducted with PCPs who were involved in a large-scale pilot implementation of virtual visits (patient-provider asynchronous messaging, or synchronous audio or video communication). The first phase involved a convenience sample of users in the first 2 regions where the pilot was initiated; after implementation in all 5 regions, purposive sampling was used to ensure diversity within the sample (eg, physicians representing different use frequencies of virtual visits, regions, and remuneration models). Interviews were audiorecorded and transcribed. An inductive thematic analysis was used to identify prominent themes and subthemes., Main Findings: Twenty-six physicians were interviewed. Fifteen were recruited using convenience sampling and 11 through purposive sampling. Four themes regarding the clinical utility of virtual visits were identified: virtual visits can effectively resolve many patient concerns, with some variation in PCP comfort using virtual visits for specific conditions; virtual visits are beneficial for a range of patients but some patients might overuse or inappropriately use them; PCPs prefer to use asynchronous messaging (eg, text or online messaging) because of its convenience and flexibility; and virtual visits can provide value at the patient, provider, and health system levels., Conclusion: While participants believed that virtual visits can be appropriately used to resolve a variety of clinical concerns, they found in practice that virtual visits are fundamentally different from face-to-face encounters. Professional guidelines on appropriate use cases should be established to develop a standard framework for virtual care., (Copyright © 2023 the College of Family Physicians of Canada.)

Objective: To understand the impact of virtual visits on primary care physician (PCP) work flows., Design: Qualitative semistructured interviews., Setting: Primary care practices within 5 regions in southern Ontario., Participants: Physicians representing primary care practices of various sizes and remuneration models (eg, capitation and fee-for-service models)., Methods: Interviews were conducted with PCPs involved in a large-scale pilot project implementing virtual visits (via a Web-based application) into clinical practices. Convenience and purposive sampling were used to recruit PCPs between January 2018 and March 2019. To obtain a representative sample, participants were sought from a variety of practice types and geographic regions. High and low users of virtual visits were included. Interviews were audiorecorded and transcribed. An inductive thematic analysis was used to identify prominent themes and subthemes., Main Findings: Twenty-six physicians were interviewed (n=15 using convenience sampling and n=11 through purposive sampling). Four themes were identified: PCPs employ diverse approaches to integrate virtual care into their work flow; PCPs recognize that implementing virtual visits requires upfront time and effort but have variable perceptions regarding long-term impact of virtual care on processes; asynchronous messaging is preferable to synchronous audio or video visits; and strategies were identified to improve the integration of virtual visits., Conclusion: The potential of virtual care to improve work flow is dependent on the way these visits are implemented and used. Dedicated time for implementation, emphasis on using asynchronous secure messaging, and access to clinical champions and structured change management support were associated with more seamless integration of virtual visits., (Copyright © 2023 the College of Family Physicians of Canada.)

Background: Canadian and US Task Forces recommend against routine mammography screening for women age 40-49 at average breast cancer risk as harms outweigh benefits. Both suggest individualized decisions based on the relative value women place on potential screening benefits and harms. Population-based data reveal variation in primary care professionals (PCPs) mammography rates in this age group after adjusting for sociodemographic factors, highlighting the need to explore PCP screening perspectives and how this informs clinical behaviours. Results from this study will inform interventions that can improve guideline concordant breast screening for this age group., Methods: Qualitative semi-structured interviews were performed with PCPs in Ontario, Canada. Interviews were structured using the theoretical domains framework (TDF) to explore determinants of breast cancer screening best-practice behaviours: (1) risk assessment; (2) discussion regarding benefits and harms; and (3) referral for screening., Analysis: Interviews were transcribed and analyzed iteratively until saturation. Transcripts were coded deductively by behaviour and TDF domain. Data that did not fit within a TDF code were coded inductively. The research team met repeatedly to identify potential themes that influenced or were important consequences of the screening behaviours. The themes were tested against further data, disconfirming cases, and different PCP demographics., Results: Eighteen physicians were interviewed. The theme of perceived guideline clarity (a lack of clarity on guideline-concordant practices) influenced all behaviours and moderated the extent to which the risk assessment and discussion occurred. Many were unaware of how risk-assessment factored into the guidelines and/or did not perceive that a shared-care discussion was guideline-concordant. Deferral to patient preference (screening referral without a complete discussion of benefits and harms) occurred when the PCPs had low knowledge regarding harms and/or if they experienced regret (TDF domain: emotion) resulting from prior clinical experiences. Older providers described patient's influence impacting their decisions and physicians trained outside Canada, practicing in higher-resourced areas, and female physicians described being influenced by beliefs about consequences of benefits of screening., Conclusion: Perceived guideline clarity is an important driver of physician behaviour. Improving guideline concordant care should start by clarifying the guideline itself. Thereafter, targeted strategies include building skills in identifying and overcoming emotional factors and communication skills important for evidence-based screening discussions., (© 2023. The Author(s).)

Competing Interests: Competing interests: None declared.

Background: Funding changes in response to the COVID-19 pandemic supported the growth of direct-to-consumer virtual walk-in clinics in several countries. Little is known about patients who attend virtual walk-in clinics or how these clinics contribute to care continuity and subsequent health care use., Objective: The objective of the present study was to describe the characteristics and measure the health care use of patients who attended virtual walk-in clinics compared to the general population and a subset that received any virtual family physician visit., Methods: This was a retrospective, cross-sectional study in Ontario, Canada. Patients who had received a family physician visit at 1 of 13 selected virtual walk-in clinics from April 1 to December 31, 2020, were compared to Ontario residents who had any virtual family physician visit. The main outcome was postvisit health care use., Results: Virtual walk-in patients (n=132,168) had fewer comorbidities and lower previous health care use than Ontarians with any virtual family physician visit. Virtual walk-in patients were also less likely to have a subsequent in-person visit with the same physician (309/132,168, 0.2% vs 704,759/6,412,304, 11%; standardized mean difference [SMD] 0.48), more likely to have a subsequent virtual visit (40,030/132,168, 30.3% vs 1,403,778/6,412,304, 21.9%; SMD 0.19), and twice as likely to have an emergency department visit within 30 days (11,003/132,168, 8.3% vs 262,509/6,412,304, 4.1%; SMD 0.18), an effect that persisted after adjustment and across urban/rural resident groups., Conclusions: Compared to Ontarians attending any family physician virtual visit, virtual walk-in patients were less likely to have a subsequent in-person physician visit and were more likely to visit the emergency department. These findings will inform policy makers aiming to ensure the integration of virtual visits with longitudinal primary care., (©Lauren Lapointe-Shaw, Christine Salahub, Cherryl Bird, R Sacha Bhatia, Laura Desveaux, Richard H Glazier, Lindsay Hedden, Noah M Ivers, Danielle Martin, Yingbo Na, Sheryl Spithoff, Mina Tadrous, Tara Kiran. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 12.01.2023.)

Background: In Ontario, Canada, a government agency known as Ontario Health is responsible for making audit and feedback reports available to all family physicians to encourage ongoing quality improvement. The confidential report provides summary data on 3 key areas of practice: safe prescription, cancer screening, and diabetes management., Objective: This report was redesigned to improve its usability in line with evidence. The objective of this study was to explore how the redesign was perceived, with an emphasis on recipients' understanding of the report and their engagement with it., Methods: We conducted qualitative semistructured interviews with family physicians who had experience with both versions of the report recruited through purposeful and snowball sampling. We analyzed the transcripts following an emergent and iterative approach., Results: Saturation was reached after 17 family physicians participated. In total, 2 key themes emerged as factors that affected the perceived usability of the report: alignment between the report and the recipients' expectations and capacity to engage in quality improvement. Family physicians expected the report and its quality indicators to reflect best practices and to be valid and accurate. They also expected the report to offer feedback on the clinical activities they perceived to be within their control to change. Furthermore, family physicians expected the goal of the report to be aligned with their perspective on feasible quality improvement activities. Most of these expectations were not met, limiting the perceived usability of the report. The capacity to engage with audit and feedback was hindered by several organizational and physician-level barriers, including the lack of fit with the existing workflow, competing priorities, time constraints, and insufficient skills for bridging the gaps between their data and the corresponding desired actions., Conclusions: Despite recognized improvements in the design of the report to better align with best practices, it was not perceived as highly usable. Improvements in the presentation of the data could not overcome misalignment with family physicians' expectations or the limited capacity to engage with the report. Integrating iterative evaluations informed by user-centered design can complement evidence-based guidance for implementation strategies. Creating a space for bringing together audit and feedback designers and recipients may help improve usability and effectiveness., (©Geneviève Rouleau, Catherine Reis, Noah Ivers, Laura Desveaux. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 06.01.2023.)

Background: Although the current Canadian Task Force on Preventive Health Care guideline recommends that physicians should inform women aged 40-49 years of the potential benefits and harms of screening mammography to support individualized decisions, previous reports of variation in clinical practice at the physician level suggest a lack of guideline-concordant care. We explored determinants (barriers and facilitators) of guideline-concordant care by family physicians regarding screening mammography in this age group., Methods: We conducted qualitative semi-structured interviews by phone with family physicians in the Greater Toronto Area from January to November 2020. We structured interviews using the Theoretical Domains Framework to explore determinants (barriers and facilitators) of 5 physician screening behaviours, namely risk assessment, discussion regarding benefits and harms, decision or referral for mammography, referral for genetic counselling and referral to high-risk screening programs. Two independent researchers iteratively analyzed interview transcripts and deductively coded for each behaviour by domain to identify key behavioural determinants until saturation was reached., Results: We interviewed 18 physicians (mean age 48 yr, 72% self-identified as women). Risk assessment was influenced by physicians' knowledge of risk factors, skills to synthesize risk and beliefs about utility. Physicians had beliefs in their capabilities to have informed patient-centred discussions, but insufficient knowledge regarding the harms of screening. The decision or referral for mammography was affected by emotions related to past patient outcomes, social influences of patients and radiology departments, and knowledge and beliefs about consequences (benefits and harms of screening). Referrals for genetic counselling and to high-risk screening programs were facilitated by their availability and by the knowledge and skills to complete forms. Lack of knowledge regarding which patients qualify and beliefs about consequences were barriers to referral., Interpretation: Insufficient knowledge and skills for performance of risk assessment, combined with a tendency to overestimate benefits of screening relative to harms affected provision of guideline-concordant care. These may be effective targets for future interventions to improve guideline-concordant care., Competing Interests: Competing interests: Alexandra Desnoyers reports consulting fees from Novartis and Pfizer, and payments from Novartis, Pfizer, AstraZeneca, Gilead and Apobiologix. Eitan Amir reports consulting fees from Sandoz, Novartis and Exact Sciences. No other competing interests were declared., (© 2022 CMA Impact Inc. or its licensors.)

Investigating the mechanisms of behavior change interventions provides a more fulsome understanding of how and why interventions work (or don't work). We assessed mechanisms of two interventions (mailouts alone, and mailouts plus telephone support, informed by the Health Action Process Approach (HAPA) and Habit Theory), designed to increase medication adherence after myocardial infarction. We conducted a process evaluation alongside a pragmatic trial. Medication adherence was assessed via self-report at 12-months in the trial, and participants in all trial groups were invited to contemporaneously complete an additional questionnaire assessing targeted mechanisms (HAPA constructs and automaticity). We used multiple regression-based mediation models to investigate indirect effects. Of 589 respondents, 497 were analyzed (92 excluded due to missing data). Mailouts plus telephone support had statistically significant but small effects on intention, social support, action planning, coping planning, and automaticity. There were no indirect effects of interventions on medication adherence via these constructs. Therefore, while this intervention led to changes in proposed mechanisms, these changes were not great enough to lead to behavior change. Refinements (and subsequent evaluation) of the interventions are warranted, and our findings indicate that this could involve offering more intensive support to form plans and identify cues for taking medications, in addition to providing physical supports to encourage self-monitoring, feedback, and habit formation. Trial registration: ClinicalTrials.gov: NCT02382731., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: COVID-19 necessitated the rapid implementation and uptake of virtual health care; however, virtual care's potential role remains unclear in the urgent care setting. In December 2020, the first virtual emergency department (ED) in the Greater Toronto Area was piloted at Sunnybrook Health Sciences Centre by connecting patients to emergency physicians through an online portal., Objective: This study aims to understand whether and how ED physicians were able to integrate a virtual ED alongside in-person operations., Methods: We conducted semistructured interviews with ED physicians guided by the Normalization Process Theory (NPT). The NPT provides a framework to understand how individuals and teams navigate the process of embedding new models of care as part of normal practice. All physicians who had worked within the virtual ED model were invited to participate. Data were analyzed using a combination of inductive and deductive techniques informed by the NPT., Results: A total of 14 physicians were interviewed. Participant experiences were categorized into 1 of 2 groups: 1 group moved to normalize the virtual ED in practice, while the other described barriers to routine adoption. These groups differed in their perception of the patient benefits as well as the perceived role in the virtual ED. The group that normalized the virtual ED model saw value for patients (coherence) and was motivated by patient satisfaction witnessed (reflexive monitoring) at the end of the virtual appointment. By contrast, the other group did not find virtual ED work reflective of the perceived role of urgent care (cognitive participation) and felt their skills as ED physicians were underutilized. The limited ability to examine patients and a sense that patient issues were not fully resolved at the end of the virtual appointment caused frustration among the second group., Conclusions: As further digital integration within the health care system occurs, it will be essential to support the evolution of staff skill sets to ensure physicians are satisfied with the care they are providing to their patients, while also ensuring the technology and process are efficient., (©Jennifer Shuldiner, Diya Srinivasan, Justin N Hall, Carl R May, Laura Desveaux. Originally published in JMIR Human Factors (https://humanfactors.jmir.org), 12.09.2022.)

Background: Unnecessary antibiotic use is associated with adverse side effects and rising rates of resistance at the individual and population level. This study used a theory-informed approach to identify potentially modifiable determinants of antibiotic prescribing for patients presenting to primary care with upper respiratory tract infection symptoms., Methods: Qualitative interviews were conducted with primary care physicians in Ontario, Canada who were identified as medium- or high-volume antibiotic prescribers (high volume defined as top 20 th percentile versus "medium" defined as 40 th to 60 th percentile). The interview guide and analysis were informed by the Theoretical Domains Framework. Each interview was coded by two research team members. Sampling and analysis continued until thematic saturation was achieved., Results: Twenty family physicians were interviewed. Physicians felt that many decisions about prescribing for upper respiratory tract infection symptoms were straightforward (i.e., black and white). However, intention to avoid prescribing in cases where an antibiotic was not indicated clinically did not always align with the provider action or expectation of the patient. Clinical decisions were influenced by the Theoretical Domain Framework domains that were both internal to the physician (Knowledge, Skills, Social/Professional Role, and Belief about Capabilities) and external to the physician (Social Influence, Belief about Consequences, Reinforcement, Emotions, and Behavioural Regulation). The Environmental Context and Resources played a key role. Physicians reported significant differences in their approach to antibiotic prescribing within episodic (walk-in) or continuity of care settings, as the presence (or not) of longitudinal physician-patient relationships seemed to moderate the role of these factors on the decision-making process in cases of uncertainty., Conclusions: Antibiotic prescribing in primary care is a complex decision-making process in which context may outweigh biology during encounters featuring clinical uncertainty. Differential skill in handling uncertainty and tactics used to operationalize guideline recommendations in the real world seems to contribute to observed variation in prescribing patterns, as much or more than differences in knowledge of best practices., (© 2022. The Author(s).)

Background: Normalization Process Theory (NPT) identifies mechanisms that have been demonstrated to play an important role in implementation processes. It is now widely used to inform feasibility, process evaluation, and implementation studies in healthcare and other areas of work. This qualitative synthesis of NPT studies aims to better understand how NPT explains observed and reported implementation processes, and to explore the ways in which its constructs explain the implementability, enacting and sustainment of complex healthcare interventions., Methods: We will systematically search Scopus, PubMed and Web of Science databases and use the Google Scholar search engine for citations of key papers in which NPT was developed. This will identify English language peer-reviewed articles in scientific journals reporting (a) primary qualitative or mixed methods studies; or, (b) qualitative or mixed methods evidence syntheses in which NPT was the primary analytic framework. Studies may be conducted in any healthcare setting, published between June 2006 and 31 December 2021. We will perform a qualitative synthesis of included studies using two parallel methods: (i) directed content analysis based on an already developed coding manual; and (ii) unsupervised textual analysis using Leximancer® topic modelling software., Other: We will disseminate results of the review using peer reviewed publications, conference and seminar presentations, and social media (Facebook and Twitter) channels. The primary source of funding is the National Institute for Health Research ARC North Thames. No human subjects or personal data are involved and no ethical issues are anticipated., Competing Interests: Competing interests: All authors except Alyson Hillis have been involved in the development or use of Normalization Process Theory.

This study analyzed patient-described barriers and facilitators related to diabetes management, focusing on how these differ by glycemia and across individual characteristics. A cross-sectional telephone survey was conducted with adult patients with diabetes in Alberta, Canada, asking two open-ended questions to describe the most helpful and difficult components of their diabetes management. Responses were analyzed using directed content analysis using the Theoretical Domains Framework as a template. The most frequently cited facilitator was care context and information, and the most frequently cited barriers were cognitive challenges and structural barriers, with patient-perceived barriers and facilitators varying by individual-level factors., (© 2022 by the American Diabetes Association.)