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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. Key words: practice facilitation; vaccines; COVID-19; process evaluation, INTRODUCTION Many Canadians consider family physicians to be their most trusted source of vaccine information, (1,2) underscoring the important role family doctors play in encouraging vaccine uptake, addressing hesitancies, and [...]

Health equity allows people to reach their full health potential and receive high-quality care that is appropriate for them and their needs, no matter where they live, what they have, or who they are. It is a core element of quality in health care. Around the world, there are many efforts to improve equity through primary care. In order to advance these efforts, it is important to share successes and challenges. Building on our work with international stakeholders to identify key primary care research priorities, we organized the Toronto International Conference on Quality in Primary Care that was held on November 16, 2019. Participants from 8 countries took part. Key recommendations included the establishment of continuous relationships between providers and patients over time, relationships between providers in the health and social sectors, and resources supported proportionally to patient need. Solutions must be generated using team-based approaches that explicitly include people with who have experienced discrimination. Progress will require confronting structural determinants including racism, capitalism, and colonialism. Conference participants suggested practical solutions, such as developing a public transportation program for rural residents to improve community building and the ability to attend medical appointments, and identifying patients who have recently missed clinic visits that may benefit from additional care. These approaches will need to be evaluated through high-quality research and quality improvement, with a knowledge translation that facilitates sustainability and expansion across settings.

We conducted 2 analyses using administrative data to understand whether more family physicians in Ontario, Canada stopped working during the COVID-19 pandemic compared with previous years. First, we found 3.1% of physicians working in 2019 (n = 385/12,247) reported no billings in the first 6 months of the pandemic; compared with other family physicians, a higher portion were aged 75 years or older (13.0% vs 3.4%, P Key words: primary health care; COVID-19; workforce; health services, general practitioners; family physicians, INTRODUCTION The COVID-19 pandemic disrupted how care was delivered by family physicians. To limit transmission, practices adopted a range of measures including active and passive screening, cleaning, strict use of [...]

PURPOSE The Coronavirus disease 2019 (COVID-19) pandemic is an unprecedented global public health crisis. Mass vaccination is the safest and fastest pandemic exit strategy. Mass vaccination clinics are a particularly important tool in quickly achieving herd immunity. Primary care physicians have played a crucial role in organizing and running vaccination clinics. In this special report, we synthesize existing guidelines and peer-reviewed studies to provide physicians with practical guidance on planning and implementing COVID-19 mass vaccination clinics. METHODS PubMed, Ovid MEDLINE and Embase were used to search for relevant literature using search terms that included COVID-19, mass vaccination, and best practice. We also identified and analyzed national and international guidelines. RESULTS Forty-six relevant articles, reports, and guidelines were identified and synthesized. Articles included mass vaccination clinic guidelines and studies before and during the COVID-19 pandemic. Key considerations for COVID-19 mass vaccination clinics include leadership and role designation, site selection, clinic layout and workflow, day-to-day operations, infection prevention, and communication strategies. CONCLUSIONS Planning and implementing a successful COVID-19 mass vaccination clinic requires several key considerations. Primary care plays an important role in organizing clinics and ensuring populations made vulnerable by social and economic policies are being reached. Ongoing data collection is required to evaluate and continuously improve COVID-19 mass vaccination efforts. As the severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) vaccine rollout occurs in various countries, research will be required to identify the main factors for success to inform future pandemic responses. VISUAL ABSTRACT Ann Fam Med 2022;20:149-156. https://doi.org/10.1370/afm.2773., INTRODUCTION In just 2 years, the pandemic of coronavirus disease 2019 (COVID-19) has resulted in 380 million confirmed cases and 10 million deaths, with numbers continuing to rise. (1) Public [...]

PURPOSE We sought to assess the impact of team-based care on emergency department (ED) use in the context of physicians transitioning from fee-for-service payment to capitation payment in Ontario, Canada. METHODS We conducted an interrupted time series analysis to assess annual ED visit rates before and after transition from an enhanced fee-for-service model to either a team capitation model or a nonteam capitation model. We included Ontario residents aged 19 years and older who had at least 3 years of outcome data both pretransition and post-transition (N = 2,524,124). We adjusted for age, sex, income quintile, immigration status, comorbidity, and morbidity, and we stratified by rurality. A sensitivity analysis compared outcomes for team vs nonteam patients matched on year of transition, age, sex, rurality, and health region. RESULTS We compared 387,507 team and 1,399,103 nonteam patients in big cities, 213,394 team and 380,009 nonteam patients in small towns, and 55,289 team and 78,722 nonteam patients in rural areas. In big cities, after adjustment, the ED visit rate increased by 2.4% (95% CI, 2.2% to 2.5%) per year for team patients and 5.2% (95% CI, 5.1% to 5.3%) per year for nonteam patients in the years after transition (P CONCLUSIONS Adoption of team-based primary care may reduce ED use. Further research is needed to understand optimal team composition and roles. Key words: primary care; utilization; team-based care; interdisciplinary health team; capitation fee; healthcare financing; physician payment models; emergency department use; patient-centered care; health care reform; health policy; primary care practice models; practice-based research, INTRODUCTION Strong primary care is the foundation of a high-functioning health care system and is associated with better outcomes, lower costs, and greater equity. (1) But for the last 2 [...]

Context: One way to build vaccine confidence is through advice from a trusted health professional, like a family physician. We implemented and evaluated a practice facilitation intervention in partnership with Ontario Health, a provincial government agency, to support the family physicians in Ontario known to have the largest number of unvaccinated patients. Objective: To understand how and why this intervention offered to family physicians most in need was used and to identify opportunities to adapt this targeted approach for other aspects of primary care. Study Design and Analysis: This was a qualitative process evaluation embedded within a randomized trial. Data were analyzed using inductive and deductive techniques informed by the Theoretical Domains Framework. Setting or Dataset: Data was collected through interviews with participating and non-participating family physicians, as well as from practice facilitator field notes. Population Studied: Family physicians with the largest number of unvaccinated patients in the province. Intervention/Instrument: Practice facilitators offered physicians support to identify, reach out, and counsel their unvaccinated patients. Outcome Measures: N/A Results: Of the 300 physicians randomized to the intervention, 29% accepted support. Among those who received facilitation, 58% used technical support to identify unvaccinated patients, 29% were linked with medical student volunteers to contact patients on their behalf, and 31% used automated calling to reach patients. The main barriers encountered were: a) gatekeeping from the front-office staff, which prevented the practice facilitator from contacting the physician, b) inability to dedicate extra time, c) technical issues with identifying patients requiring vaccines, and d) belief that outreach to patients would not result in more vaccinations. Facilitators were: a) clinics that had support staff, especially a tech-savvy workforce, b) physician, or the team passionate about COVID-19 vaccine uptake, and therefore willing to prioritize time or resources to outreach, and c) the belief that COVID-19 vaccine uptake was part of their role as a family physician. Conclusion: Strategies to help family physicians regarding vaccine rollout or other primary care areas of public health import must acknowledge the scarcity of time and resources of these physicians, and seek to build trust and relationships over time, including the front-office staff., Presenters Jennifer Shuldiner, PhD, Dominik Nowak, Noah Ivers, MD, PhD, CCFP, Aisha Lofters, MD, Tara Kiran, MD, MSc, CCFP, FCFP, David Kaplan, MD, CCFP, FCFP, MSc, Monica Taljaard, PhD, Michael [...]

Context: Audit and Feedback (A&F), the summary and provision of clinical performance, is a popular quality improvement strategy. We are developing a web-based dashboard that uses data from the electronic medical record to help physicians identify gaps in care and act. However, A&F tools can only be effective if the targeted health professionals actively review their data and take action. In order to maximise the impact of A&F, the design should consider the needs and goals of clinicians. Objective: To describe the development of a user-centered design process to optimize the effect of an A&F dashboard for family physicians. Study Design and Analysis: Our design process includes (1) Prototype development based on A&F theory and input from clinical improvement leaders; (2) a co-creation workshop with family physician quality improvement leaders to develop personas (i.e., fictional characters that represent an archetype character); (3) user-centered interviews with family physicians to learn about the physician's who will be using the dashboard and their context, and their reactions to the dashboard. Setting or Dataset: A workshop for the creation of personas and user- centered qualitative interviews with family physicians. Population Studied: Family physicians who contribute data to the University of Toronto Practice-Based Research Network Intervention/Instrument: Audit and Feedback dashboard Outcome Measures: N/A Results: Our persona workshop produced four personas that enabled the team to identify physician's needs and wishes and facilitated empathy during the design process: Dr. Skeptic, Frazzled Physician, The Eager Implementer, and Sidney Big Wig. Our interviews found that: (1) physicians are interested in how they compare with their peers; however, if their performance was above average, they were not motivated to improve even if gaps in care remained; (2) Burnout levels are high, physicians are trying to catch up on missed care during the pandemic, and were not highly motivated to act on the dashboard data; (3) Features that were important to physicians were integration within the EMR, and up-to-date and accurate data. Conclusions: A successful design of an A&F performance dashboard should consider the serious lack of time and capacity among family physicians to engage in quality improvement work. If designed properly, the QI dashboard can be a great assistance in helping family physicians provide more proactive and targeted care., Presenters Jennifer Shuldiner, PhD, Susie Kim, MD, CCFP, Noah Ivers, MD, PhD, CCFP, Michelle Greiver, MD, MSc, CCFP, Tara Kiran, MD, MSc, CCFP, FCFP, Kelly Thai, Adam Cadotte, [...]

Context: The COVID-19 pandemic has changed the way health care is delivered with significant increases in the use of virtual care. This has raised concerns about possible negative effects on patient experience and access for marginalized populations. Objective: The project aimed to understand patient experience in primary care during the COVID-19 pandemic differed by patient sociodemographic characteristics, particularly related to care seeking behaviors and use, comfort, and views of virtual care. Study Design and Analysis: Cross-sectional survey conducted between May and June 2000. We used chi-squared tests to compare responses by patient sociodemographic characteristics. Setting or Dataset: Thirteen family medicine clinics associated with the University of Toronto. Population Studied: All primary care patients with a valid email address on file and a date of birth during the months of March, April or May. Intervention/Instrument: An anonymous web-based survey emailed to patients. Outcome Measures: Access including the proportion of patients who reported seeking urgent care and the timeliness of the urgent appointment. Virtual care experience including the proportion of patients who used various modalities, their comfort levels with it and whether they wanted it to continue post-pandemic. Results: In total, 7482 participants responded to the survey. Most respondents received care during the study period (68%). Those who reported trouble making ends meet and those with lower self-rated health were more likely to report seeking urgent care, but less likely to report receiving a timely appointment. Patients were generally comfortable with phone (92%), video (95%) and email or secure messaging (91%) but those who reported difficulty making ends meet, poor or fair health and arriving in Canada in the last 10 years, were less comfortable with digital modalities and less interested in these options being available into the future as part of their care. Conclusion: Our study suggests that newcomers, those with a lower income, and those reporting lower health have a stronger preference and comfort for in- person primary care. Further research should explore potential barriers to virtual care and equitable access and how these can be addressed., Presenters Payal Agarwal, Tara Kiran, MD, MSc, CCFP, FCFP, Rick Wang, Christopher Meaney, MSc, Erica Li, MD, MSc, Debbie Elman, MD, CCFP, [...]

Rationale: A common strategy to reduce COPD readmissions is to encourage patient follow-up with a physician within 1 to 2 weeks of discharge, yet evidence confirming its benefit is lacking. We used a new study design called target randomized trial emulation to determine the impact of follow-up visit timing on patient outcomes. Methods: All Ontario residents aged 35 or older discharged from a COPD hospitalization were identified using health administrative data and randomly assigned to those who received and did not receive physician visit follow-up by within seven days. They were followed to all-cause emergency department visits, readmissions or death. Targeted randomized trial emulation was used to adjust for differences between the groups. COPD emergency department visits, readmissions or death was also considered. Results: There were 94,034 patients hospitalized with COPD, of whom 73.5% had a physician visit within 30 days of discharge. Adjusted hazard ratio for all-cause readmission, emergency department visits or death for people with a visit within seven days post discharge was 1.03 (95% Confidence Interval [CI]: 1.01–1.05) and remained around 1 for subsequent days; adjusted hazard ratio for the composite COPD events was 0.97 (95% CI 0.95–1.00) and remained significantly lower than 1 for subsequent days. Conclusion: While a physician visit after discharge was found to reduce COPD events, a specific time period when a physician visit was most beneficial was not found. This suggests that follow-up visits should not occur at a predetermined time but be based on factors such as anticipated medical need. [ABSTRACT FROM AUTHOR]