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Background: Through medicare, residents in Canada are entitled to medically necessary physician services without paying out of pocket, but still many people struggle to access primary care. We conducted a survey to explore people's experience with and priorities for primary care. Methods: We conducted an online, bilingual survey of adults in Canada in fall 2022. We distributed an anonymous link through diverse channels and a closed link to 122 053 people via a national public opinion firm. We weighted completed responses to mirror Canada's population and adjusted for sociodemographic characteristics using regression models. Results: We analyzed 9279 completed surveys (5.9% response rate via closed link). More than one-fifth of respondents (21.8%) reported having no primary care clinician, and among those who did, 34.5% reported getting a same or next-day appointment for urgent issues. Of respondents, 89.4% expressed comfort seeing another team member if their doctor recommended it, but only 35.9%, 9.5%, and 12.4% reported that their practice had a nurse, social worker, or pharmacist, respectively. The primary care attribute that mattered most was having a clinician who 'knows me as a person and considers all the factors that affect my health.' After we adjusted for respondent characteristics, people in Quebec, the Atlantic region, and British Columbia had lower odds of reporting a primary care clinician than people in Ontario (adjusted odds ratio 0.30, 0.33, and 0.39, respectively; p < 0.001). We also observed large provincial variations in timely access, interprofessional care, and walk-in clinic use. Interpretation: More than 1 in 5 respondents did not have access to primary care, with large variation by province. Reforms should strive to expand access to relationship-based, longitudinal care in a team setting., Research over decades has shown that health systems with strong primary care have better health outcomes, better equity in outcomes, and lower costs. (1,2) Yet, worldwide, countries have struggled with [...]

Contexte: Malgre des investissements importants dans un systeme de soins de sante public qui comprend des services preventifs, on continue d'observer des disparites evitables en matiere de sante au Canada. L'equipe avait pour objectif de formuler des recommandations pour des soins de sante preventifs qui puissent ameliorer l'equite en matiere de sante par la priorisation des interventions efficaces a l'intention des groupes defavorises. Methodes: La ligne directrice a ete elaboree par un comite compose de specialistes en soins primaires et de membres de la patientele, avec la contribution d'un groupe de patientes- et patientspartenaires ayant vecu diverses experiences. Apres avoir selectionne les sujets a prioriser, nous avons recense les revues systematiques, les essais randomises et controles recents sur les methodes de depistage et d'autres etudes pertinentes sur l'efficacite du depistage et de la prise en charge. Nous avons utilise l'approche GRADE (Grading of Recommendations, Assessment, Development and Evaluation) pour formuler les recommandations et avons suivi le guide AGREE II (Appraisal of Guidelines for Research and Evaluation) pour rediger le rapport. Il en a ete de meme avec les principes du Guidelines International Network pour la gestion des interets concurrents. Les recommandations ont ete passees en revue par un comite externe d'experts en contenu avant d'etre distribuees a des intervenants a l'echelle nationale pour approbation. Recommandations: Nous avons formule 15 recommandations concernant le depistage et d'autres soins preventifs et 1 recommandation de nature politique visant a ameliorer l'acces aux soins primaires. Ainsi, nous recommandons de prioriser une strategie de communication pour le depistage du cancer colorectal a partir de l'age de 45 ans et pour l'evaluation du risque de maladie cardiovasculaire pour lutter contre les iniquites en matiere de sante et promouvoir la sante. Les interventions particulieres qui devraient etre deployees pour lutter contre les iniquites comprennent l'autodepistage du virus du papillome humain (VPH) et du VIH, et le test de liberation de l'interferon y pour l'infection tuberculeuse. Le depistage de la depression, de la toxicomanie, de la violence conjugale et de la pauvrete devrait egalement permettre aux personnes touchees d'acceder plus facilement a des interventions eprouvees. Nous recommandons une prise de contact systematique avec des professionnels de la sante en soins primaires pour les personnes defavorisees. Interpretation: Les interventions preventives eprouvees peuvent aider a combattre les iniquites en matiere de sante si la priorite est accordee aux personnes defavorisees. Les medecins, les organisations de sante et les gouvernements devraient adopter des mesures fondees sur des donnees probantes et en faire le suivi s'ils veulent promouvoir l'equite en matiere de sante partout au Canada., Les disparites ou iniquites evitables en matiere de sante peuvent en partie etre combattues par des soins de sante primaires et preventifs (1,2). Le fait d'etre defavorise n'est pas une [...]

Background: Avoidable disparities in health outcomes persist in Canada despite substantial investments in a publicly funded health care system that includes preventive services. Our objective was to provide preventive care recommendations that promote health equity by prioritizing effective interventions for people experiencing disadvantages. Methods: The guideline was developed by a primary care provider-patient panel, with input from a patient-partner panel with diverse lived experiences. After selecting priority topics, we searched for systematic reviews and recent randomized controlled trials of screening and other relevant studies of screening accuracy and management efficacy. We used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to develop recommendations and followed the Appraisal of Guidelines for Research and Evaluation (AGREE II) reporting guidance. We managed competing interests using the Guideline International Network principles. The recommendations were externally reviewed by content experts and circulated for endorsement by national stakeholders. Recommendations: We developed 15 screening and other preventive care recommendations and 1 policy recommendation on improving access to primary care. We recommend prioritized outreach for colorectal cancer screening starting at age 45 years and for cardiovascular disease risk assessment, to help address inequities and promote health. Specific interventions that should be rolled out in ways that address inequities include human papillomavirus (HPV) self-testing, HIV self-testing and interferon-Y release assays for tuberculosis infection. Screening for depression, substance use, intimate partner violence and poverty should help connect people experiencing specific disadvantages with proven interventions. We recommend automatic connection to primary care for people experiencing disadvantages. Interpretation: Proven preventive care interventions can address health inequities if people experiencing disadvantages are prioritized. Clinicians, health care organizations and governments should take evidence-based actions and track progress in promoting health equity across Canada., Avoidable disparities in health outcomes, or health inequities, can be partly addressed through primary and preventive care. (1,2) People are not inherently disadvantaged--Canada has a long and continuing history of [...]

Background: Lack of patient access to family physicians in Canada is a concern. The role of recent physician graduates in this problem of supply of primary care services has not been established. We sought to establish whether career stage or graduation cohort were related to family physician practice volume and continuity of care over time. Methods: We conducted a retrospective cohort study of family physician practice from 1997/98 to 2017/18. We collected administrative health and physician claims data in British Columbia, Manitoba, Ontario and Nova Scotia. We included all physicians who registered with their respective provincial regulatory colleges as having a medical specialty of family practice or who had billed the provincial health insurance system for patient care as family physicians, or both. We used regression models to isolate the effects of 3-year categories of years in practice (at all career stages), time period and cohort on patient contacts and physician-level continuity of care. Results: Between 1997/98 and 2017/18, the median number of patient contacts per provider per year fell by between 515 and 1736 contacts in the 4 provinces examined. Median contacts peaked at 27-29 years in practice in all provinces, and median physician-level continuity of care increased until 30 or more years in practice. We found no association between graduation cohort and patient contacts or physician-level continuity of care. Interpretation: Recent cohorts of family physicians practise similarly to their predecessors in terms of practice volumes and continuity of care. Because family physicians of all career stages showed declining patient contacts, we suggest that system-wide solutions to recent challenges in the accessibility of primary care in Canada are needed., Access to primary care services in Canada falls short of comparable countries. (1) Despite increasing absolute numbers of family physicians, (2) evidence suggests that the volume of patient contacts and [...]

If I Didn't Have YOU Alan Katz ILLUSTRATED BY Chris [...]

Background: Inappropriate health care leads to negative patient experiences, poor health outcomes and inefficient use of resources. We aimed to conduct a systematic review of inappropriately used clinical practices in Canada. Methods: We searched multiple bibliometric databases and grey literature to identify inappropriately used clinical practices in Canada between 2007 and 2021. Two team members independently screened citations, extracted data and assessed methodological quality. Findings were synthesized in 2 categories: diagnostics and therapeutics. We reported ranges of proportions of inappropriate use for all practices. Medians and interquartile ranges (IQRs), based on the percentage of patients not receiving recommended practices (underuse) or receiving practices not recommended (overuse), were calculated. All statistics are at the study summary level. Results: We included 174 studies, representing 228 clinical practices and 28900762 patients. The median proportion of inappropriate care, as assessed in the studies, was 30.0% (IQR 12.0%56.6%). Underuse (median 43.9%, IQR 23.8%-66.3%) was more frequent than overuse (median 13.6%, IQR 3.2%30.7%). The most frequently investigated diagnostics were glycated hemoglobin (underused, range 18.0%-85.7%, n = 9) and thyroid-stimulating hormone (overused, range 3.0%-35.1%, n = 5). The most frequently investigated therapeutics were statin medications (underused, range 18.5%-71.0%, n = 6) and potentially inappropriate medications (overused, range 13.5%-97.3%, n = 9). Interpretation: We have provided a summary of inappropriately used clinical practices in Canadian health care systems. Our findings can be used to support health care professionals and quality agencies to improve patient care and safety in Canada., As health care systems struggle with sustainability, there is increased recognition that a substantial percentage of the health care received is inappropriate. (1) Inappropriate health care occurs when effective clinical [...]

Background: Understanding inequalities in SARS-CoV-2 transmission associated with the social determinants of health could help the development of effective mitigation strategies that are responsive to local transmission dynamics. This study aims to quantify social determinants of geographic concentration of SARS-CoV-2 cases across 16 census metropolitan areas (hereafter, cities) in 4 Canadian provinces, British Columbia, Manitoba, Ontario and Quebec. Methods: We used surveillance data on confirmed SARS-CoV-2 cases and census data for social determinants at the level of the dissemination area (DA). We calculated Gini coefficients to determine the overall geographic heterogeneity of confirmed cases of SARS-CoV-2 in each city, and calculated Gini covariance coefficients to determine each city's heterogeneity by each social determinant (income, education, housing density and proportions of visible minorities, recent immigrants and essential workers). We visualized heterogeneity using Lorenz (concentration) curves. Results: We observed geographic concentration of SARS-CoV-2 cases in cities, as half of the cumulative cases were concentrated in DAs containing 21%-35% of their population, with the greatest geographic heterogeneity in Ontario cities (Gini coefficients 0.32-0.47), followed by British Columbia (0.23-0.36), Manitoba (0.32) and Quebec (0.28-0.37). Cases were disproportionately concentrated in areas with lower income and educational attainment, and in areas with a higher proportion of visible minorities, recent immigrants, high-density housing and essential workers. Although a consistent feature across cities was concentration by the proportion of visible minorities, the magnitude of concentration by social determinant varied across cities. Interpretation: Geographic concentration of SARS-CoV-2 cases was observed in all of the included cities, but the pattern by social determinants varied. Geographically prioritized allocation of resources and services should be tailored to the local drivers of inequalities in transmission in response to the resurgence of SARS-CoV-2., The COVID-19 epidemic in Canada has varied in size and trajectory across provinces and large cities. (1,2) At the national level (3) and within regions, (4,5) the burden of confirmed [...]