Disparities in access to primary care are growing wider in Canada

COVID-19 vaccine acceptance and preference for future delivery among language minority, newcomer, and racialized peoples in Canada: a national cross-sectional and longitudinal study

BACKGROUND

Despite high COVID-19 vaccine coverage in Canada, vaccine acceptance and preferred delivery among newcomers, racialized persons, and those who primarily speak minority languages are not well understood. This national study explores COVID-19 vaccine acceptance, access to vaccines, and delivery preferences among ethnoculturally diverse population groups.

METHODS

We conducted two national cross-sectional surveys during the pandemic (Dec 2020 and Oct-Nov 2021). Binary logistic regression analysis investigated the association between newcomer, language, and racialized minority respondents' perceptions and acceptance of COVID-19 vaccines, experiences of discrimination when accessing health services, and sociodemographic characteristics. McNemar-Bowker tests were used to assess changes in responses collected at two time points.

RESULTS

Among 1630 respondents, 30.8% arrived in Canada within the last five years, 87.4% self-identified as a racialized minority, and 37.2% primarily spoke languages other than English or French. Although single dose COVID-19 vaccine uptake was at 92.7% among respondents, 14.8% experienced difficulty accessing vaccines, citing a need for translated resources or multi-lingual personnel. In longitudinal analysis, respondents were increasingly motivated over time to overcome barriers to accessing vaccines (61.4% to 69.6%, p = <.001). Fifty-nine percent (59.9%) of respondents would accept annual vaccination and over half would accept co-administration with routine (56.2%) or influenza (52.3%) vaccines. Experiences of racism/discrimination upon health service access were reported by 12.3% of respondents, who recommended increasing culturally safe practices and community involvement at vaccination sites.

CONCLUSIONS

Understanding how newcomers, racialized peoples, and minority language speakers perceive and access COVID-19 vaccines will support vaccination campaigns to optimize equitable access.

Interprofessional collaboration in pharmacist-led primary care clinics

Background

Pharmacists are essential to team-based care, contributing knowledge and expertise that positively impact patient care. However, it is less clear how interprofessional collaboration is enacted by pharmacists in single-disciplinary outpatient practice environments.

Methods

We recruited pharmacists from 3 university-affiliated, pharmacist-led primary care clinics in Canada. Employing a social network analysis approach, the data collection encounter explored the nature and composition of collaboration in patient care. We conducted semistructured interviews, including participant drawings (sociograms), to illustrate their network experiences caring for specific patients. Transcripts from the data collection encounters were systematically coded and analyzed in an iterative process. Initial codes were generated inductively and broader categories refined through constant comparison and finalized by author discussion.

Results

Eleven (78%) pharmacists were interviewed and drew 28 sociograms. Pharmacist networks encompassed a wide array of health professionals and patient family members. Despite the physical distribution of interprofessional members, pharmacists formed and maintained relationships to support patient care through conscientious communication and medication management decision-making. Network relationships and system factors influenced collaboration and patient care, often resulting in practice paralysis and/or the need to re-emphasize patient self-advocacy.

Interpretation and conclusion

Our findings underscore the dynamic nature of pharmacist networks and how they are navigated to support pharmacist-led medication management. Primary care pharmacists attempt to overcome encountered barriers to implementing patient care plans through various strategies, including leveraging new and existing network relationships. System obstacles impeding effective and efficient patient care could in part be overcome through pharmacist scope of practice expansion.

Examining experiences and system impacts of publicly funded episodic virtual care: protocol for a cross-provincial mixed methods study

INTRODUCTION

Health systems are under pressure as one in five Canadians have no regular place for primary care, with many experiencing substantial travel times and delays in accessing care. In the context of these urgent needs, platforms for virtual care offer immediate access to care in 'walk-in' style format, with limited continuity for ongoing health needs or coordination with other health services. We refer to these services as episodic virtual care (EVC), to distinguish them from virtual services offered in longitudinal primary care. The governments of Nova Scotia (NS) and New Brunswick (NB) both offer publicly funded EVC and offer a unique opportunity for research.The overarching goal of this work is to learn from the implementation of EVC in NS and NB to understand experiences and system impacts, includingWhat are patient perceptions and experiences of EVC and how do these differ by patient characteristics?What are the characteristics of patients who use EVC and of clinicians who deliver it?What are the system impacts of EVC?

METHODS AND ANALYSIS

We will use a cross-sectional survey conducted through an online questionnaire to explore patient perceptions and experiences with EVC. We will also examine how these differ based on the type of care needed, age, gender, residence (urban or rural), immigration and language preference. We will use linked administrative data and quasi-experimental analysis to assess the impacts of EVC on visits to community-based primary care (including in-person walk-in clinics), emergency department visits, prescriptions and referrals for other health services like laboratory testing, imaging and consulting specialist physicians.

ETHICS AND DISSEMINATION

This proposal has been reviewed and received approval from the Nova Scotia Health Research Ethics Board. Findings will identify the impacts and trade-offs in the deployment of EVC, which will inform primary care planning. In addition to traditional academic publications and information provided to primary care patients/the public, this study will inform decision-makers across multiple jurisdictions as they contend with the challenge of meeting patients' immediate care needs for access to primary care, while seeking to improve coordination and integration of systems as a whole.

Patterns of outpatient antibiotic prescribing in older adults by social determinants of healthcare access: a population-based retrospective cohort study

OBJECTIVES

Strategies to improve antibiotic use may exacerbate health inequities if they do not consider existing barriers to healthcare access. We examined associations between social determinants of healthcare access (SDOH) and antibiotic prescribing and variations in these associations pre- and post-COVID-19 emergence.

METHODS

We conducted a retrospective cohort study of community-dwelling adults aged ≥66 years in Ontario, Canada, between March 2018 and March 2020 (pre-pandemic period) and March 2020 and March 2022 (pandemic period). Multivariable Fine-Gray subdistribution hazard models were used to examine associations between three SDOH variables (neighbourhood-level income and proportion racialized, and individual-level recent immigration) and incident antibiotic prescriptions, accounting for mortality as a competing risk. We assessed for potential effect modification by the pandemic period.

RESULTS

The pre-pandemic (n = 2 567 382) and pandemic (n = 2 744 337) cohorts were similar in average age (75 years). Antibiotic prescribing was slightly higher among residents in the highest income neighbourhoods in pre-pandemic (subdistribution hazard ratio [sHR], 1.03 [95% CI, 1.02-1.04], compared with lowest income) and pandemic (sHR, 1.02 [1.01-1.03]) periods. Prescribing was higher among recent immigrants (vs. long-term residents) in both periods, with a more pronounced difference observed during the pandemic (sHR, 1.21 [1.18-1.25]) than pre-pandemic (sHR, 1.12 [1.09-1.16]) period. Prescribing was lower among residents living in the most diverse neighbourhoods (vs. least diverse) in both periods, with a more pronounced difference during the pandemic (sHR, 0.81 [0.80-0.82]) than pre-pandemic (sHR, 0.92 [0.91-0.93]) period.

DISCUSSION

SDOH variables are associated with antibiotic prescribing patterns over time among older outpatients, and the COVID-19 pandemic further modified some of these associations.

Addressing unmet need for primary care in Canada

Primary care is the key health system strategy for improving health, enhancing patient and clinician experience, saving money, and promoting equity. Once a pioneer in primary care, Canada now fails to provide access to millions of people. This crisis is widely recognized, but policy responses are varied and mostly incremental and piecemeal. The goal of providing primary care to everyone seems unrealistic and elusive in Canada, yet it has long been attained in many other countries. Without an explicit policy goal of primary care for all, most likely on a geographic basis, Canada will continue to underinvest and underperform in primary care, with ramifications that include rapidly escalating costs, emergency department and hospital overcrowding and a growing and inequitable burden of preventable suffering. A commitment to work towards this goal is needed now to ensure that Canadians have access to high-quality well-organized care for everyone.

Resilient health care performance in the real world: fixing problems that never happened

BACKGROUND

Staff in health systems everywhere have exhibited flexibility and a capacity for improvisations during, and in response to, the COVID-19 pandemic. Looking to other examples of such resilient behaviours outside of those induced by the pandemic is instructive for those involved with researching or understanding change, or making health systems improvements.

METHODS

Here, we synthesise and then assess the value of eight case studies of in situ resilient performance from Canada, Sweden, Japan, Belgium, the United Kingdom, Norway, the United States and Brazil. The cases are divided into four categories: responsiveness to a crisis; adaptiveness over time; local adoption in accommodating to a top down, national policy change; and the consequential outcomes of an intervention.

RESULTS

The cases illuminate the resourcefulness of translational and social researchers in examining such behaviours and practices. More than that, they also foreground the ingenuity and adaptive capacity of staff on-the-ground who continually anticipate, respond and adapt to make systems work and provide continuous care in the face of many challenges, including resource deficiencies, policy misalignments, and new technologies, policies and procedures that need to be integrated into local workflows. Front line clinicians make care systems work, pre-empting issues and sorting out problems before they occur or as they arise.

CONCLUSIONS

A key lesson amongst a range of findings is that, rather than focusing on shiny new tools of change (checklists, frameworks, policy mandates), it is much more insightful and satisfying to deeply apprehend care at the sharp end, where clinicians deliver care to patients, understanding how everyday work is executed. This, rather than the Health Ministry, the Boardroom, or the Management Consultant's office, is where and how change is being enabled, and where street level actors solve problems, thwart issues in advance, and constantly avoid pitfalls.

Organizational innovations related to Primary Care Access Points (GAP) for unattached patients in Quebec: a multi-case qualitative study

BACKGROUND

Being attached to a primary care (PC) provider is at the core of a strong primary health care system. Centralized waiting lists (CWL) for unattached patients have been implemented in eight provinces of Canada to support the attachment process. In Quebec, the Ministry of Health mandated the implementation of Primary Care Access Points (GAP) across the province to help unattached patients navigate the health system while awaiting attachment through the CWL. Several local health territories developed complementary innovations to the GAP to respond to local population needs. This paper aims to describe five organizational innovations implemented locally.

METHODS

This multi-case qualitative study was conducted in four local health territories in the province of Quebec. Fifty-two semi-structured interviews with healthcare managers, nurses, physicians, other health professionals and administrative staff were conducted between April 2023 and April 2024. An interview guide was developed based on existing frameworks on the implementation of innovations and the evaluation of the GAP. Thematic analysis was conducted using NVivo software. Inductive and deductive approaches were used to develop relevant codes and themes. Logic models were built to describe the organizational innovations.

RESULTS

Five organizational innovations are described. First, a multidisciplinary clinic aimed at responding to patients with mental health issues was implemented. Second, a nurse clinic was implemented to provide temporary care for patients with unstable chronic illnesses. The third innovation is a mobile proximity clinic where unattached GAP patients are first evaluated by a paramedic before receiving care from a nurse. Fourth, a pharmacist trajectory was implemented to increase engagement of community pharmacists to respond to GAP patients. The last innovation is a decentralized GAP offering in-person nursing care to unattached GAP patients.

CONCLUSIONS

Descriptions of these five innovations are key to inform other territories and provinces on ways to improve access for unattached patients while they are waiting to be attached. The introduction of the GAP and the organizational innovations, suggests a transition where access to PC services does not rely solely on attachment status.

"What got you here, won't get you there": Students as leaders of the change we need

Lack of access, system inequities, and inefficiencies plague our current healthcare system. With a challenge this complex, no one intervention is sufficient; all will be necessary. The primary care system needs a strong health workforce prepared in bold new ways. Students represent an important voice, given their role as future leaders of health education and healthcare. For students to lead, educators must leverage education paradigms that position current students as leaders of transformation. Yet, in current health education systems, students are often seen as passive recipients of knowledge and skill. Transformative education seeks to foster critical reflection (an ongoing process of questioning unhelpful assumptions and power relations) and informed action in students to enable them to challenge and change norms and change practices, structures, and society. This article highlights the value of transformative education in cultivating thoughtful change agents and provides one tangible example of a new education/practice model that puts this paradigm into action.

Changes in Primary Care Health Services During the COVID-19 Pandemic: A Longitudinal Analysis of Data From Ontario

The COVID-19 pandemic significantly impacted primary care, but its effect on quality of care is not well understood. We used health administrative data to understand the changes in quality-of-care measures for primary care between October 2018 and April 2022. We examined the following domains: cancer screening, chronic disease (diabetes) management, high-risk prescribing, continuity of care and capacity of primary care services. Colorectal and breast cancer screenings declined after the pandemic and had not returned to baseline by study end. In patients living with diabetes, in-person visits and up-to-date retinopathy screening rates declined after the pandemic declaration and did not return to baseline by study end, while statin prescribing remained stable. High-risk opioid prescribing decreased over time and was not affected by the pandemic. Physician continuity remained stable, though new patient enrollments decreased over the pandemic but returned to baseline by study end. Existing disparities in colorectal cancer screening by income and recent registration widened during the pandemic. In summary, COVID-19 had a variable impact on primary care, with the strongest influence on preventive and chronic disease care that was dependent on in-person visits.

Evaluating engagement with equity in Canadian provincial and territorial primary care policies: Results of a jurisdictional scan

Equitable access to primary care is essential to achieving more equitable health outcomes, yet evidence suggests that structurally marginalized populations are less likely to have benefited from varied primary care reforms in Canada. Our objective is to determine how equity is incorporated in public primary care policy and strategy documents across Canada. We conducted string term and snowball searches for provincial/territorial primary care policy documents published between 01 January 2018 and 30 June 2022, extracted the policy objective, and applied a rubric to evaluate each document's engagement with equity. We performed content analysis of the documents which acknowledged inequities and articulated a related policy response. Of the 224 identified documents that discussed primary care policy: 63 (28 %) identified one or more structurally marginalized group(s) experiencing inequities related to primary care, 64 (29 %) identified a structurally marginalized group and articulated a policy response, and 16 (7 %) articulated a detailed policy response to address inequities. Even where policy responses were articulated, in most cases these did not directly address the acknowledged inequities. The absence of measurable goals, meaningful community consultation, and tenuous connections between the policy response and inequities mentioned may help explain persistent inequities in primary care across Canada.

Neighbourhood-level socioeconomic status and prevalence of teacher-reported health disorders among Canadian kindergarten children

Background

The evidence on the association between neighborhood-level socioeconomic status (SES) and health disorders in young children is scarce. This study examined the prevalence of health disorders in Canadian kindergarten (5-6 years old) children in relation to neighborhood SES in 12/13 Canadian jurisdictions.

Methods

Data on child development at school entry for an eligible 1,372,980 children out of the total population of 1,435,428 children from 2004 to 2020, collected using the Early Development Instrument (EDI), were linked with neighborhood sociodemographic data from the 2006 Canadian Census and the 2005 Taxfiler for 2,058 neighborhoods. We examined the relationship using linear regressions. Children's HD included special needs, functional impairments limiting a child's ability to participate in classroom activities, and diagnosed conditions.

Results

The neighborhood prevalence of health disorders across Canada ranged from 1.8 to 46.6%, with a national average of 17.3%. The combined prevalence of health disorders was 16.4%, as 225,711 children were identified as having at least one health disorder. Results of an unadjusted linear regression showed a significant association between neighborhood-level SES and prevalence of health disorders (F(1, 2051) = 433.28, p < 0.001), with an R2 of 0.17. When province was added to the model, the R2 increased to 0.40 (F(12, 2040) = 115.26, p < 0.001). The association was strongest in Newfoundland & Labrador and weakest in Ontario.

Conclusion

Our study demonstrated that the prevalence of health disorders among kindergarten children was higher in lower SES neighborhoods and varied by jurisdiction in Canada, which has implications for practice and resource allocation.