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The Person-Centered Primary Care Measure (PCPCM) is a relatively new and concise yet comprehensive measure of primary care quality. The objectives of this study are to administer the PCPCM in Canada and to understand whether there is an association between the PCPCM and sociodemographic and patient experience measures.The PCPCM was added to the routine patient experience survey administered at a multi-site academic primary care practice in Toronto, Canada. The survey was administered to patients with an e-mail on file and included questions on demographics, timely access, patient-centeredness, care continuity, and the PCPCM. Descriptive statistics were used to summarize the PCPCM. We used 1-way analysis of variance to determine whether there was an association between the PCPCM and patient demographics and patient experience measures at the team level.We analyzed 2581 survey responses. The mean PCPCM score was 3.47. The PCPCM was higher for people with better health status (The 11-item PCPCM is a feasible and meaningful measure that reflects patient-reported access, continuity, and patient-centeredness and can be incorporated into primary care patient experience surveys to evaluate and improve quality of care.

Injury places a heavy burden on public-health resources that is not distributed evenly in space, making the mapping of injury and its socio-demographic risk factors an effective tool for prevention planning. In a survey of health-related interactive Web mapping applications we found great variation with respect to content, cartography, and technical aspects. Based on the survey results, input from a group of potential end users, cartographic design principles, and data-set requirements, we created a Web site with static, animated, and interactive injury maps. We mapped injury rates and possible socio-demographic risk factors for the City of Toronto. Through the three functionally different types of maps, a variety of ways to explore the same public-health data sets could be demonstrated. The results highlight the practical options available to public-health analysts and decision makers who wish to expand their data-exploration and decision-support tools with a spatial component.

The Canadian Institutes of Health Research - Institute of Health Services and Policy Research's (IHSPR) Strategic Plan 2021-2026 (CIHR IHSPR 2021) aims to accelerate healthcare system transformation to achieve the Quadruple Aim and health equity through research. This special issue features a collection of commentaries from academic and health system leaders who were invited to respond to IHSPR's strategic plan and share insights regarding the opportunities the plan presents and areas where more attention may be needed. The present paper features a response from the IHSPR team and outlines the next steps regarding implementation. IHSPR is deeply grateful to the commentary authors for their insight, advice and recommendations, which will help to inform the implementation of the plan.

Recent research identified that workplace factors play a role in the development of diabetes mellitus (DM). This study examines the longitudinal association of work-related overqualification with the incidence of DM over a 14-year follow-up period.We used data from the 2003 Canadian Community Health Survey linked to the Ontario Health Insurance Plan and the Canadian Institute for Health Information Discharge Abstract databases. Cox proportional hazards regression models were performed to evaluate the relationship between overqualification and the incidence of DM.Over the study period, there were 91,835 person-years of follow-up (median follow-up = 13.7 years). The final sample included 7026 respondents (mean [standard deviation] age at baseline = 47.1 [8.2]; 47% female). An elevated risk of DM was associated with substantial overqualification (hazard ratio = 1.58, 95% confidence interval = 1.01-2.49) after adjustment for sociodemographic, health, and work variables. Additional adjustment for body mass index and health behaviors attenuated this risk (hazard ratio = 1.30, 95% confidence interval = 0.81-2.08). Underqualification was not associated with the incidence of DM in adjusted regression models. We did not observe any statistical difference in the effects of overqualification on DM risk across sex or education groups.This study adds to the growing body of research literature uncovering the relationships between work exposures and DM risk. The results from the study suggest that higher body mass index and, to a lesser extent, health behaviors may be mediating factors in the association between overqualification and incident DM. Further research on the association of overqualification with DM is warranted.

BackgroundPopulation aging is a global phenomenon. Resultant healthcare workforce shortages are anticipated. To ensure access to comprehensive primary care, which correlates with improved health outcomes, equity, and costs, data to inform workforce planning are urgently needed.ObjectivesTo explore temporal trends in early career, mid-career, and near-retirement comprehensive primary care physician characteristics, the medical and social needs of their patients, and the workforce’s capacity to absorb patients of near-retirement physicians. Gender-based workforce trends and trends around alternative practice models were also explored.DesignA serial cross-sectional population-based study using health administrative data.SettingOntario, Canada, where most comprehensive primary care is delivered by family physicians (FPs) under universal insurance.ParticipantsAll insured Ontario residents at three time points: 2008 (12,936,360), 2013 (13,447,365), and 2019 (14,388,566) and all Ontario physicians who billed primary care services (2008: 11,566; 2013: 12,693; 2019: 15,054).Exposure(s)Changes in the comprehensive FP workforce over three time periods.Main Outcome(s) and Measure(s)The number and proportion of patients attached to near-retirement comprehensive FPs; the number and proportion of near-retirement comprehensive FPs; the characteristics of patients and their comprehensive FPs.ResultsPatient attachment to comprehensive FPs increased over time. The overall FP workforce grew, but the proportion practicing comprehensiveness declined from 77.2% (2008) to 70.7% (2019), with shifts into other/focused scopes of practice across all physician career stages. Over time, an increasing proportion of the comprehensive FP workforce was near retirement age. Correspondingly, an increasing proportion of patients were attached to near-retirement comprehensive FPs. By 2019, 13.9% of comprehensive FPs were 65 years or older, corresponding to 1,695,126 (14.8%) patients. Mean patient age increased, and near-retirement comprehensive FPs served markedly increasing numbers of medically and socially complex patients.Conclusions and RelevancePrimary care is foundational to high-performing health systems, but the sector faces capacity challenges as both patients and physicians age and fewer physicians choose to practice comprehensiveness. Nearly 15% (1.7 million) of Ontarians with a comprehensive FP may lose their physician to retirement by 2025. To serve a growing and increasingly complex patient population, innovative solutions that extend beyond simply growing the FP workforce are needed.

Background: This descriptive study reports the early career outcomes of postdoctoral fellows who completed a novel embedded fellowship training program, the Canadian Institutes of Health Research (CIHR) Health System Impact (HSI) Fellowship. The program was designed to support impact-oriented career paths of doctoral graduates, build research capacity within health system organizations, and help to advance learning health systems in Canada. Methods: Employment of fellowship alumni upon completion of the program were tracked using internet searches of publicly accessible online sources and complemented with program survey data. Results: Descriptive analyses show that all 87 eligible alumni included in the study are currently employed (100% of 87), with 92% employed in Canada. Their employment spans several sectors, including in academic (37%), public (29%), healthcare delivery (17%), and private (14%) sectors. Altogether, 32% of alumni held hybrid roles with an affiliation in academia and another sector. The most common position types were senior scientist (42%), professorships (18%), and director, manager or administrator roles (12%). Program reporting data indicate that these employment outcomes are generally consistent with the group’s career aspirations reported at the start of the fellowship program, and that the program receives high ratings from fellows in the extent it is believed to support their career preparedness and readiness (4.49 out of 5). Conclusion: We find that HSI Fellow alumni are employed mostly in research-related roles in a range of sectors including, but not limited to academia, that they positively perceive the program’s success in elevating their career readiness and potential to make an impact – suggesting that the program may help equip fellows with the skills, readiness and networks for a broad array of employment sectors and roles. The findings are a promising signal of the demand for research talent and the growing capacity for learning health systems in Canada.

We describe changes in the comprehensiveness of services delivered by family physicians in 4 Canadian provinces (British Columbia, Manitoba, Ontario, Nova Scotia) during the periods 1999-2000 and 2017-2018 and explore if changes differ by years in practice. We measured comprehensiveness using province-wide billing data across 7 settings (home, long-term care, emergency department, hospital, obstetrics, surgical assistance, anesthesiology) and 7 service areas (pre/postnatal care, Papanicolaou [Pap] testing, mental health, substance use, cancer care, minor surgery, palliative home visits). Comprehensiveness declined in all provinces, with greater changes in number of service settings than service areas. Decreases were no greater among new-to-practice physicians.

Background and Objectives: The primary goal of family medicine residency training is for graduates to provide high-quality, safe, and effective patient care for the population they serve when they enter practice. This study explores (a) the practice profiles, 5 years into practice, of residents who completed family medicine training in Ontario, Canada; and (b) relationships between performance on the College of Family Physicians of Canada’s (CFPC) Certification Examination in Family Medicine and quality of care provided 5 years into practice. Methods: We performed a retrospective study with secondary data analysis. We merged CFPC examination data sets with the ICES (Institute for Clinical Evaluative Sciences) administrative database. We included physicians who passed the examination between the years 2000 and 2010 and practiced in Ontario after graduation. Practice profile indicators included practice type, continuity and comprehensiveness of care, patient rostering and panel size, and rurality index. We explored 11 indicators related to management of diabetes and cancer screening. Results: We included a total of 1,983 physicians in the analyses. Five years after the examinations, 74.3% of the physicians were working in major urban centers, and 67.3% of the physicians were providing comprehensive primary care. We noted significant differences across the six medical schools in multiple practice profile indicators, and three indicators showed significant differences across the examination score quintiles. Conclusions: Graduates of Ontario family medicine residency programs were providing care to a broad spectrum of the population 5 years after passing the examination, and they performed similarly across quality-of-care indicators regardless of examination scores.

In this concluding article, Healthcare Excellence Canada and the Canadian Institutes of Health Research reflect upon and respond to the lessons learned from the contributing articles in the special issue and summarize key takeaways for the next steps in evidence-informed pandemic preparedness in long-term care in Canada. The implications of their cross-organizational partnership for achieving collective impact now and in the future are also discussed.

ObjectivesTo determine the clinical and economic impact of a community-based, hybrid model of in-person and virtual care by comparing health-system performance of the rural jurisdiction where this model was implemented with neighbouring jurisdictions without such a model and the broader regional health system.DesignA cross-sectional comparative study.SettingOntario, Canada, with a focus on three largely rural public health units from April 1, 2018, until March 31, 2021.ParticipantsAll residents of Ontario, Canada under the age of 105 eligible for the Ontario Health Insurance Plan (OHIP) during the study period.InterventionsAn innovative, community-based, hybrid model of in-person and virtual care, the Virtual Triage and Assessment Centre (VTAC), was implemented in Renfrew County, Ontario on March 27, 2020.Main outcome measuresPrimary outcome was change in emergency department (ED) visits anywhere in Ontario, secondary outcomes included changes in hospitalizations and health-system costs, using percent changes in mean monthly values of linked health-system administrative data for two years pre-implementation and one year post-implementation.ResultsRenfrew County saw larger declines in ED visits (−34.4%, 95% confidence interval -41.9% to -26.0%) and hospitalizations (−11.1%, 95% confidence interval -19.7% to -1.5%), and slower growth in health-system costs than other rural regions studied. VTAC patients’ low-acuity ED visits decreased by -32.9%, high-acuity visits increased by 8.2%, and hospitalizations increased by 30.0%.ConclusionAfter implementing VTAC, Renfrew County saw reduced ED visits and hospitalizations and slower health-system cost growth compared to neighbouring rural jurisdictions. VTAC patients experienced reduced unnecessary ED visits and increased appropriate care. Community-based, hybrid models of in-person and virtual care may reduce the burden on emergency and hospital services in rural, remote and underserved regions. Further study is required to evaluate potential for scale and spread.Trial registrationNot applicable.STRENGTHS AND LIMITATIONS OF THE STUDYThis study uses population-level health administrative data to investigate the empirical effects of a community-based, hybrid model of in-person and virtual care in rural, remote, and underserved communities, where access to comprehensive primary care is insufficient.Population-level data from administrative datasets were linked using unique encoded identifiers and analyzed at ICES, Ontario’s population health data steward.The intervention jurisdiction is compared with two similar adjoining jurisdictions and with the whole Province.Because of the relatively short time period studied — two years before the intervention and one year post — it remains to be seen whether the observed differences will persist over time.This study’s design does not allow firm inferences about causality; however, the observed changes are in the right temporal sequence and benefit from local comparisons of similar jurisdictions.

Background and Objectives: In family medicine, leadership is critical for health care delivery, advancing curricula, research, and quality improvement. Systematic reviews of leadership development programs in health care identify limitations, calling for innovative designs and rigorous assessment. Our objective was to evaluate the impact of applying master class principles to leadership development in academic family medicine. Methods: We used mixed methods to assess the impact of an innovative master class program on 15 emerging leaders in a large academic department of family medicine. The program consisted of five sessions where family physician masters shared their wisdom, techniques, and feedback with promising leaders. Quantitative evaluation involved participants’ ratings of each session’s content and delivery using a 5-point Likert scale. We assessed postcourse semistructured interviews with participants qualitatively using descriptive thematic content analysis. Results: Individual sessions were highly evaluated, with a combined mean of 4.82/5. Qualitative thematic analysis identified self-perceived increased effectiveness in leadership activities; increased confidence as a leader; increased motivation to be a leader; and perceptions of value from the program, contributing to what participants described as unexpected potential change within themselves. Themes related to effectiveness of the program were practical advice; networking; diverse topics; accessible speakers sharing personal stories; and small-group, informal, early-evening format. Conclusions: Master class concepts can be adapted to leadership development in academic family medicine, with evidence of early positive impact on participants’ self-perception of leadership skills and confidence. Further research is warranted to assess organizational impact and applicability to other settings.

ImportanceThe COVID-19 pandemic has resulted in increased use of virtual care, however, few studies have looked at the association between virtual primary care visits and other healthcare use.ObjectiveTo determine whether there was an association between a high proportion of virtual visits in primary care and more emergency department visitsDesignA cross-sectional study, using routinely collected dataSettingOntario, CanadaParticipantsOntario residents alive on March 31st 2021 and family physicians with at least 1 visit claim between February and October 2021.ExposureFamily physicians stratified by the percentage of total visits that were virtual (phone or video) between February and October 2021Main outcome(s) and measure(s)We calculated the emergency department visit rate for each stratum of family physician virtual care use. We used multivariable logistic regression models to understand the relative rate of patient emergency department use after stratifying for rurality and adjusting first for patient characteristics and then the 2019 emergency department visit rate.ResultsWe analyzed data for 15,155 family physicians and 12,951,063 Ontarians attached to these physicians. The mean number of emergency department visits was highest among patients whose physicians provided only in-person care (470.3 ± 1918.8 per 1,000) and was lowest among physicians who provided >80 to 20% of visits delivered virtually had lower rates of emergency department visits compared to patients of physicians who provided >0%-20% virtually (e.g. >80 to 0%-20% virtual visits in Big Cities, Relative Rate (RR) 0.80 [95%CI 0.76-0.83]). This trend held across all rurality strata and after adjustment for 2019 emergency department visit rates. In urban areas, there was a gradient whereby physicians providing the highest level of virtual care had the lowest emergency department visit rates.Conclusions and RelevancePhysicians who provided a high proportion of care virtually did not have higher emergency department visits than those who provided the lowest levels of virtual care. Our findings refute hypotheses that emergency department use is being driven by family physicians providing more care virtually.Key pointsQuestionDo family physicians who provide more care virtually have higher emergency department visit rates among their patient panel?FindingsIn this cross-sectional study from Ontario, Canada, we examined data from February to October 2021 for 12,951,063 patients attached to 15,155 family doctors and found that physicians who provided a high proportion of virtual care did not have higher emergency department visits than those who provided the lowest levels of virtual care. This finding remained true after adjusting for patient characteristics.MeaningOur findings refute hypotheses that emergency department use is being driven by family physicians providing more care virtually.

BACKGROUND Resettled refugees land in Canada through 3 sponsorship models with similar health insurance and financial supports but differences in how resettlement is facilitated. We examined whether health system utilization, costs, and aggregate 1-year morbidity differed by resettlement model. METHODS Population-based matched cohort study in Ontario, 2008 to 2018, including pediatric (0–17 years) resettled refugees and matched Ontario-born peers and categorized refugees by resettlement model: (1) private sponsorship (PSRs), (2) Blended Visa Office-Referred program (BVORs), and (3) government-assisted refugee (GAR). Primary outcomes were health system utilization and costs in year 1 in Canada. Multivariable logistic regression was used to test the associations between sponsorship model and major illnesses. RESULTS We included 23 287 resettled refugees (13 360 GARs, 1544 BVORs, 8383 PSRs) and 93 148 matched Ontario-born. Primary care visits were highest among GARs and lowest in PSRs (median visits [interquartile range], GARs 4[2–6]; BVORs 3[2–5]; PSRs 3[2–5]; P CONCLUSIONS Health care use and morbidity of PSRs suggests they are healthier and less costly than GARs and BVOR model refugees. Despite a greater intensity of health care utilization than Ontario-born, overall excess demand on the health system for all resettled refugee children is low.

ObjectivesTo determine the clinical and economic impact of a community-based, hybrid model of in-person and virtual care by comparing health-system performance of the rural jurisdiction where this model was implemented with neighbouring jurisdictions without such a model and the broader regional health system.DesignA cross-sectional comparative study.SettingOntario, Canada, with a focus on three largely rural public health units from 1 April 2018 until 31 March 2021.ParticipantsAll residents of Ontario, Canada under the age of 105 eligible for the Ontario Health Insurance Plan during the study period.InterventionsAn innovative, community-based, hybrid model of in-person and virtual care, the Virtual Triage and Assessment Centre (VTAC), was implemented in Renfrew County, Ontario on 27 March 2020.Main outcome measuresPrimary outcome was a change in emergency department (ED) visits anywhere in Ontario, secondary outcomes included changes in hospitalisations and health-system costs, using per cent changes in mean monthly values of linked health-system administrative data for 2 years preimplementation and 1 year postimplementation.ResultsRenfrew County saw larger declines in ED visits (−34.4%, 95% CI −41.9% to −26.0%) and hospitalisations (−11.1%, 95% CI −19.7% to −1.5%) and slower growth in health-system costs than other rural regions studied. VTAC patients’ low-acuity ED visits decreased by −32.9%, high-acuity visits increased by 8.2%, and hospitalisations increased by 30.0%.ConclusionAfter implementing VTAC, Renfrew County saw reduced ED visits and hospitalisations and slower health-system cost growth compared with neighbouring rural jurisdictions. VTAC patients experienced reduced unnecessary ED visits and increased appropriate care. Community-based, hybrid models of in-person and virtual care may reduce the burden on emergency and hospital services in rural, remote and underserved regions. Further study is required to evaluate potential for scale and spread.

ImportanceThe COVID-19 pandemic has played a role in increased use of virtual care in primary care. However, few studies have examined the association between virtual primary care visits and other health care use.ObjectiveTo evaluate the association between the percentage of virtual visits in primary care and the rate of emergency department (ED) visits.Design, Setting, and ParticipantsThis cross-sectional study used routinely collected administrative data and was conducted in Ontario, Canada. The sample comprised family physicians with at least 1 primary care visit claim between February 1 and October 31, 2021, and permanent Ontario residents who were alive as of March 31, 2021. All residents were assigned to physicians according to enrollment and billing data.ExposureFamily physicians’ virtual visit rate was the exposure. Physicians were stratified by the percentage of total visits that they delivered virtually (via telephone or video) during the study period (0% [100% in person], >0%-20%, >20%-40%, >40%-60%, >60%-80%, >80% to Main Outcomes and MeasuresPopulation-level ED visit rate was calculated for each stratum of virtual care use. Multivariable regression models were used to understand the relative rate of patient ED use after adjusting for rurality of practice, patient characteristics, and 2019 ED visit rates.ResultsData were analyzed for a total of 13 820 family physicians (7114 males [51.5%]; mean [SD] age, 50 [13.1] years) with 12 951 063 patients (6 714 150 females [51.8%]; mean [SD] age, 42.6 [22.9] years) who were attached to these physicians. Most physicians provided between 40% and 80% of care virtually. A higher percentage of the physicians who provided more than 80% of care virtually were 65 years or older, female individuals, and practiced in big cities. Patient comorbidity and morbidity were similar across strata of virtual care use. The mean (SD) number of ED visits was highest among patients whose physicians provided only in-person care (470.3 [1918.8] per 1000 patients) and was lowest among patients of physicians who provided more than 80% to less than 100% of care virtually (242.0 [800.3] per 1000 patients). After adjustment for patient characteristics, patients of physicians with more than 20% of visits delivered virtually had lower rates of ED visits compared with patients of physicians who provided more than 0% to 20% of care virtually (eg, >80% to 0%-20% virtual visits in big cities: relative rate, 0.77%; 95% CI, 0.74%-0.81%). This pattern was unchanged across all rurality of practice strata and after adjustment for 2019 ED visit rates. In urban areas, there was a gradient whereby patients of physicians providing the highest level of virtual care had the lowest ED visit rates.Conclusions and RelevanceFindings of this study show that patients of physicians who provided a higher percentage of virtual care did not have higher ED visit rates compared with patients of physicians who provided the lowest levels of virtual care. The findings refute the hypothesis that family physicians providing more care virtually during the pandemic resulted in higher ED use.

ObjectivesThis study aimed to: (1) examine the experience of nine global jurisdictions that engaged primary care providers (PCPs) to administer COVID-19 vaccines during the pandemic; (2) describe how vaccine hesitancy and principles of equity were incorporated in the COVID-19 vaccine roll-out strategies and (3) identify the barriers and facilitators to the vaccine roll-out.DesignRapid scoping review.Data sourcesSearches took place in MEDLINE, CINAHL, Embase, the Cochrane Library, SCOPUS and PsycINFO, Google, and the websites of national health departments. Searches and analyses took place from May 2021 to July 2021.ResultsSixty-two documents met the inclusion criteria (35=grey literature; 56% and 27=peer reviewed; 44%). This review found that the vaccine distribution approach started at hospitals in almost all jurisdictions. In some jurisdictions, PCPs were engaged at the beginning, and the majority included PCPs over time. In many jurisdictions, equity was considered in the prioritisation policies for various marginalised communities. However, vaccine hesitancy was not explicitly considered in the design of vaccine distribution approaches. The barriers to the roll-out of vaccines included personal, organisational and contextual factors. The vaccine roll-out strategy was facilitated by establishing policies and processes for pandemic preparedness, well-established and coordinated information systems, primary care interventions, adequate supply of providers, education and training of providers, and effective communications strategy.ConclusionsEmpirical evidence is lacking on the impact of a primary care-led vaccine distribution approach on vaccine hesitancy, adoption and equity. Future vaccine distribution approaches need to be informed by further research evaluating vaccine distribution approaches and their impact on patient and population outcomes.

The Canadian Institutes of Health Research - Institute of Health Services and Policy Research's (IHSPR's) Strategic Plan 2021-2026: Accelerate Health Care System Transformation through Research to Achieve the Quadruple Aim and Health Equity for All (CIHR IHSPR 2021) outlines the Institute's key priority areas for investment and activity over the next five years. IHSPR used an evidence-informed strategic planning process that was pan-Canadian in scope and designed to elicit the health services and policy research priorities of decision makers, providers, researchers, patients, communities and the public. This paper outlines IHSPR's four key strategic priorities for supporting and optimizing research in transforming Canada's healthcare delivery systems over the next five years.

To determine the population-level predictors for being unscreened for diabetic retinopathy (DR) among individuals with diabetes in a developed country.A retrospective population-based repeated-cross-sectional study.All individuals with diabetes (types 1 and 2) aged ≥20 years in the universal health care system in Ontario were identified in the 2011-2013 and 2017-2019 time periods.The Mantel-Haenszel test was used for the relative risk (RR) comparison of subcategories stratified by the 2 cross-sectional time periods.A total of 1 145 645 and 1 346 578 individuals with diabetes were identified in 2011-2013 and 2017-2019, respectively. The proportion of patients unscreened for DR declined very slightly from 35% (n = 405 967) in 2011-2013 to 34% (n = 455 027) in 2017-2019 of the population with diabetes (RR = 0.967; 95% CI, 0.964-0.9693; p0.0001). Young adults aged 20-39 years of age had the highest proportion of unscreened patients (62% and 58% in 2011-2013 and 2017-2019, respectively). Additionally, those who had a lower income quintile (RR = 1.039; 95% CI, 1.036-1.044; p0.0001), were recent immigrants (RR = 1.286; 95% CI, 1.280-1.293; p0.0001), lived in urban areas (RR = 1.149; 95% CI, 1.145-1.154; p0.0001), had a mental health history (RR = 1.117; 95% CI, 1.112-1.122; p0.0001), or lacked a connection to a primary care provider (RR = 1.656; 95% CI, 1.644-1.668; p0.0001) had a higher risk of being unscreened.This population-based study suggests that over 1 decade, 33% of individuals with diabetes are unscreened for DR, and young age, low income, immigration, residing in a large city, mental health illness, and no primary care access are the main predictors.

Introduction This study examines the separate and combined relationships between occupational physical activity (characterized by nonaerobic activities such as heavy lifting and prolonged standing) and leisure time physical activity on future diabetes incidence. Methods Data from Ontario respondents aged 35–74 years from the 2003 Canadian Community Health Survey (N=40,507) were prospectively linked to the Ontario Diabetes Database for diabetes cases until 2017, with statistical analysis performed in 2019. Leisure time physical activity was self-reported and occupational physical activity estimated from occupation titles. The analytical sample consisted of 7,026 employed people without previous diabetes diagnoses, with 846 diabetes cases recorded. Cox proportional hazard models were constructed to evaluate relationships over a median follow-up time of 13.7 years. Results No relationships were observed between occupational physical activity and diabetes. High leisure time physical activity was associated with lower diabetes risk for low occupational physical activity and stationary jobs (hazard ratio=0.63, 95% CI=0.47, 0.85). No association was found for high leisure time physical activity on diabetes risk for high occupational physical activity (hazard ratio=1.07, 95% CI=0.73, 1.56) or low occupational physical activity with movement (hazard ratio=0.92, 95% CI=0.55, 1.55). Conclusions This study suggests that physical activity recommendations exclusively recommending increased physical activity may only be effective for the sedentary part of the working population in reducing diabetes risk. Findings await confirmation in comparable prospective studies in other populations.

Background Some jurisdictions restrict primary care physicians’ daily patient volume to safeguard quality of care for complex patients. Our objective was to determine whether people with dementia receive lower-quality care if their primary care physician sees many patients daily. Methods Population-based retrospective cohort study using health administrative data from 100,256 community-living adults with dementia aged 66 years or older, and the 8,368 primary care physicians who cared for them in Ontario, Canada. Multivariable Poisson GEE regression models tested whether physicians’ daily patient volume was associated with the adjusted likelihood of people with dementia receiving vaccinations, prescriptions for cholinesterase inhibitors, benzodiazepines, and antipsychotics from their primary care physician. Results People with dementia whose primary care physicians saw ≥ 30 patients daily were 32% (95% CI: 23% to 41%, p p p = 0.02) less likely to receive influenza vaccination and 8% (95% CI: 4% to 13%, p = 0.0001) more likely to be prescribed cholinesterase inhibitors if their primary care physician saw ≥ 30 versus Conclusions People with dementia were more likely to receive both potentially harmful and potentially beneficial medications, and slightly less likely to be vaccinated by high-volume primary care physicians.

BACKGROUND: Globally, primary care changed dramatically as a result of the coronavirus disease 2019 (COVID-19) pandemic. We aimed to understand the degree to which office and virtual primary care changed, and for which patients and physicians, during the initial months of the pandemic in Ontario, Canada. METHODS: This population-based study compared comprehensive, linked primary care physician billing data from Jan. 1 to July 28, 2020, with the same period in 2019. We identified Ontario residents with at least 1 office or virtual (telephone or video) visit during the study period. We compared trends in total physician visits, office visits and virtual visits before COVID-19 with trends after pandemic-related public health measures changed the delivery of care, according to various patient and physician characteristics. We used interrupted time series analysis to compare trends in the early and later halves of the COVID-19 period. RESULTS: Compared with 2019, total primary care visits between March and July 2020 decreased by 28.0%, from 7.66 to 5.51 per 1000 people/day. The smallest declines were among patients with the highest expected health care use (8.3%), those who could not be attributed to a primary care physician (10.2%), and older adults (19.1%). In contrast, total visits in rural areas increased by 6.4%. Office visits declined by 79.1% and virtual care increased 56-fold, comprising 71.1% of primary care physician visits. The lowest uptake of virtual care was among children (57.6%), rural residents (60.6%) and physicians with panels of ≥ 2500 patients (66.0%). INTERPRETATION: Primary care in Ontario saw large shifts from office to virtual care over the first 4 months of the COVID-19 pandemic. Total visits declined least among those with higher health care needs. The determinants and consequences of these major shifts in care require further study.

Breast, cervical, and colorectal cancers are cancers that can be detected early through screening. Despite organized cancer screening programs in Ontario, Canada participation remains low among marginalized populations. Although extensive research has been done about factors contributing to under-screening by cancer site, the predictors of under/never screened conjointly for all three types of cancer remain unknown. Using provincial-level linked administrative data sets, we examined Ontario women who were screen-eligible for all three types of cancer over a 36-month period (i.e., April 2014–March 2017) and determined how many were up to date on 0, 1, 2, and all three types of screenings. Multivariate logistic regression was utilized to examine individual and structural predictors of screening with the group overdue for all screening being the reference group. Of the 1,204,551 screen-eligible women, 15% were overdue for all. Living in the lowest income neighborhoods (AOR 0.46 [95% CI 0.45–0.47]), being recent immigrants (AOR 0.54 [95% CI 0.53–0.55]), having no primary care provider (AOR 0.17 [95% CI 0.16–0.17]), and having no contact with health care services (AOR 0.09 [95% CI 0.09–0.09]) significantly increased the likelihood of being overdue for all versus no screening type. Considering that more than 15% of screen-eligible women in Ontario were overdue for all types of cancer screening, it is imperative to address structural barriers such as lack of a primary care provider. Innovative interventions like “one-stop shopping” where screening for different cancers can be offered at the same time could promote screening uptake.

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.

OBJECTIVE The American Diabetes Association recently called for research on social and environmental determinants of diabetes to intensify primary prevention. Recent epidemiological evidence suggests that frequent and modifiable psychosocial stressors at work might contribute to the development of diabetes, but more prospective studies are needed. We evaluated the relationship between job strain and diabetes incidence in 12,896 workers followed up over a 13-year period in Ontario, Canada. We also examined the modifying effect of body mass index in this relationship. METHODS Data from Ontario respondents (35-74 years of age) to the 2000-2001, 2002, and 2003 cycles of the Canadian Community Health Survey were prospectively linked to the Ontario Health Insurance Plan database for physician services and the Canadian Institute for Health Information Discharge Abstract Database for hospital admissions. The sample consisted of actively employed participants with no previous diagnosis for diabetes. Cox proportional hazard regression models were performed to evaluate the relationship between job strain, obesity, and the incidence of diabetes. RESULTS Overall, job strain was not associated with the incidence of diabetes (hazard ratio [HR] = 1.05; 95% confidence interval [CI] = 0.83-1.34). Among women, job strain was associated with an elevated risk of diabetes, although this finding did not reach statistical significance (HR = 1.36; 95% CI = 0.94-1.96). Among men, no association was observed (HR = 0.89; 95% CI = 0.65-1.22). Also, job strain increased the risk of diabetes among women with obesity (HR = 1.88; 95% CI = 1.14-3.08), whereas these stressors reduced the risk among men with obesity (HR = 0.58; 95% CI = 0.36-0.95). CONCLUSIONS The current study suggests that lowering job strain might be an effective strategy for preventing diabetes among women, especially the high-risk group comprising women with obesity.

ImportanceVirtual walk-in clinics have proliferated since the onset of COVID-19. Yet, little is known about those who participate in this care model, and how virtual walk-in clinics contribute to care continuity and patient healthcare utilization.ObjectivesTo describe the characteristics and healthcare use of patients using virtual walk-in clinics compared to the general population, and a subset that received any virtual family physician visit.DesignThis was a retrospective, population-based, cross-sectional study.SettingOntario, Canada’s most populous province.ParticipantsPatients who had received at least one family physician visit at one of 13 virtual walk-in clinics from April 1st to December 31st, 2020. They were compared to Ontario residents who had any virtual family physician visit in the same time period.Main Outcome(s) and Measure(s)Patient characteristics and 30-day post-visit healthcare utilization.ResultsVirtual walk-in patients (N=132,168) had fewer comorbidities and lower previous healthcare utilization than Ontarians with any virtual visit. Less than 0.1% of virtual walk-in visits were with a patient’s own family physician. Compared to Ontarians having any virtual family physician visit, virtual walk-in patients were significantly less likely to have a subsequent in-person visit with the same physician (0.2% vs. 11.0%, SMD = 0.48), more likely to have a subsequent virtual visit (30.3% vs. 21.9%, SMD = 0.19), and twice as likely to have an emergency department visit within 30 days (8.3% vs. 4.1%, SMD = 0.18), an effect that persisted after adjustment and across rurality groups: large urban (aOR 2.26; 95% CI 2.08-2.45), small urban (aOR 2.08; 95% CI 1.99-2.18), and rural (aOR 1.87; 95% CI 1.69-2.07).Conclusions and RelevanceCompared to Ontarians attending any family physician virtual visit, virtual walk-in patients were less likely to have a subsequent in-person physician visit, but were more likely to visit the emergency department. Low continuity and the lack of physical examination may be contributing to increased emergency department utilization for virtual walk-in clinic patients.

To inform Canada's research response to COVID-19, the Canadian Institutes of Health Research's Institute of Health Services and Policy Research (IHSPR) conducted a rapid-cycle priority identification process. Seven COVID-19 priorities for health services and policy research were identified: system adaptation and organization of care; resource allocation decision-making and ethics; rapid synthesis and comparative policy analysis of the COVID-19 response and outcomes; healthcare workforce; virtual care; long-term consequences of the pandemic; and public and patient engagement. Three additional cross-cutting themes were identified: supporting the health of Indigenous Peoples and vulnerable populations, data and digital infrastructure, and learning health systems and knowledge platforms. IHSPR hopes these research priorities will contribute to the broader ecosystem for collective research investment and action.

To examine the relationship between job strain and incident myocardial infarction and congestive heart failure in a representative population of men and women in Ontario, Canada, over a 15-year period.A total of 14,508 respondents having provided responses to either the 2000/2001, 2002, or 2003 cycles of the Canadian Community Health Survey (CCHS) were aged 35 and older at the time and working. After removing respondents with pre-existing heart disease and missing data, our sample totaled 13,291 respondents. Responses were linked to administrative health care and hospitalization data to capture incident cases of myocardial infarction and congestive heart failure up to March 31, 2017. Job control and psychological demands were assessed using 5 items and 2 items respectively. A series of time-to-event regression models were run, adjusting sequentially for socio-demographic variables and health, other psychosocial work exposures, and health behaviours and body mass index.Over the study period, there were 199,583 person-years of follow-up (median follow-up: 15 years, 233 days). Higher incidence rates were observed for men (6.69 per 100 persons) than for women (2.77 per 100 persons). No clear relationship was observed for demand-control exposures and incidence of myocardial infarction and congestive heart failure in either men or women. After adjustment for socio-demographic factors, pre-existing health conditions, and other psychosocial exposures, the hazard ratio for high strain exposure (compared with low strain exposure) was 0.92 (0.46-1.84) for women and 0.75 (0.44-1.27) for men.In this large prospective cohort in Canada, we observed no relationship between components of the demand-control model and incident myocardial infarction and congestive heart failure over a 15-year period.RéSUMé: OBJECTIFS: Examiner la relation entre les stresseurs psychosociaux au travail (job strain) et la survenue de l’infarctus du myocarde ainsi que de l’insuffisance cardiaque sur une période de 15 ans, dans une population représentative des hommes et des femmes de l’Ontario, Canada. MéTHODES: Au total, 14 508 participants ayant répondu aux cycles de 2000-2001, de 2002 ou de 2003 de l’Enquête sur la santé dans les collectivités canadiennes (ESCC) étaient des travailleurs âgés de 35 ans et plus. Après avoir exclus les répondants ayant une maladie coronarienne préexistante ou des données manquantes, notre échantillon totalisait 13 291 participants. Les réponses de ces participants ont été liées à leur données administratives sur les soins de santé et l’hospitalisation pour identifier les cas incidents d’infarctus du myocarde et d’insuffisance cardiaque jusqu’au 31 mars 2017. Les stresseurs psychosociaux au travail, soit la latitude décisionnelle et la demande psychologique, ont été évalués à l’aide de cinq et de deux items, respectivement. Une série de modèles de régression temporelle a été réalisée, en ajustant séquentiellement pour les variables sociodémographiques et la santé, d’autres expositions psychosociales au travail, les comportements de santé et l’indice de masse corporelle. RéSULTATS: Au cours de la période d’étude, 199 583 personnes-années ont été recensées (suivi médian : 15 ans et 233 jours). Des taux d’incidence plus élevés ont été observés chez les hommes (6,69 pour 100 personnes) par rapport aux femmes (2,77 pour 100 personnes). Aucune relation n’a été observée entre la latitude décisionnelle, la demande psychologique et l’incidence d’infarctus du myocarde et de l’insuffisance cardiaque chez les hommes ou les femmes. Après ajustement pour les variables sociodémographiques, les conditions de santé préexistantes et les autres expositions psychosociales, le rapport de risque pour une exposition au job strain (combinaison d’une latitude faible et d’une demande élevée) était de 0,92 (0,46 - 1,84) pour les femmes et de 0,75 (0,44 - 1,27) pour les hommes. CONCLUSION: Dans cette vaste cohorte prospective canadienne, aucune relation n’a été observée entre les stresseurs psychosociaux au travail du modèle demande-latitude et la survenue de l’infarctus du myocarde et de l’insuffisance cardiaque sur une période de 15 ans.

BACKGROUND: In 2004, Ontario delisted routine eye examinations for people aged 20–64 years, potentially encouraging patients seeking eye care to visit government-insured primary care providers (PCPs) rather than optometrists whose services had been deinsured. We investigated if utilization of PCP services for nonrefractive eye conditions increased after 2004 among Ontarians who were affected by the delisting. METHODS: We conducted a comparative analysis of the utilization of PCP services for nonrefractive eye conditions in Ontario using administrative data from 2000 to 2014. We included participants without a visit to government-insured optometrists or ophthalmologists in the year before the study year; we excluded participants with existing diabetes. Changes in utilization before and after delisting were statistically assessed using segmented regression analysis in subgroups stratified by age, sex, rurality and neighbourhood income. RESULTS: A significant increase in utilization of PCP services for nonrefractive ocular diagnoses after 2004 was documented among people affected by the delisting: 17.8% (95% confidence interval [CI] 17.0% to 18.7%) for people aged 20–39 years and 11.6% (95% CI 10.6% to 12.5%) for people aged 40–64 years. This corresponds to an increase in the number of patients who visited PCPs for nonrefractive ocular diagnoses of 10 690 (95% CI 321 to 21 059) for people aged 20–39 years and 20 682 (95% CI −94 to 41 457) for people aged 40–64 years. Among people aged 65 years and older (an age group not affected by the delisting), utilization of PCP services for nonrefractive ocular diagnoses was stable (p = 0.95) throughout the study period. Changes in utilization of PCP services for nonocular diagnoses were nonsignificant among people aged 0–19, 40–64 and 65 years and older. INTERPRETATION: After delisting, utilization of the services of government-funded PCPs for nonrefractive ocular diagnoses significantly increased among Ontarians affected by the delisting. The impact on ocular outcomes and the cost-effectiveness of increased use of PCPs for ocular management warrants further investigation and policy-makers’ consideration.

Objective: Mental health issues in late life are a growing public health challenge as the population aged 65 and older rapidly increases worldwide. An updated understanding of the causes of mood disorders and their consequences in late life could guide interventions for this underrecognized and undertreated problem. We undertook a population-based analysis to quantify the prevalence of mood disorders in late life in Ontario, Canada, and to identify potential risk factors and consequences. Method: Individuals aged 65 or older participating in 4 cycles of a nationally representative survey were included. Self-report of a diagnosed mood disorder was used as the outcome measure. Using linked administrative data, we quantified associations between mood disorder and potential risk factors such as demographic/socioeconomic factors, substance use, and comorbidity. We also determined associations between mood disorders and 5-year outcomes including health service utilization and mortality. Results: The prevalence of mood disorders was 6.1% (4.9% among males, 7.1% among females). Statistically significant associations with mood disorders included younger age, female sex, food insecurity, chronic opioid use, smoking, and morbidity. Individuals with mood disorders had increased odds of all consequences examined, including placement in long-term care (adjusted odds ratio [OR] =2.28; 95% confidence interval [CI], 1.71 to 3.02) and death (adjusted OR = 1.35; 95% CI, 1.13 to 1.63). Conclusions: Mood disorders in late life were strongly correlated with demographic and social/behavioral factors, health care use, institutionalization, and mortality. Understanding these relationships provides a basis for potential interventions to reduce the occurrence of mood disorders in late life and their consequences.