Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia

Comparing Practice Intentions and Patterns of Family Physicians in Canada

BACKGROUND AND OBJECTIVES

In Canada, competency-based medical education prepares family medicine (FM) graduates to provide a broad scope of practice (SoP). We compared the practice intentions of FM residents at the end of training with actual practice patterns of early career family physicians (FPs) for SoP activities reflective of comprehensive family medicine.

METHODS

We collected self-reported data from cross-sectional family medicine longitudinal surveys for exiting FM residents in 2015 and 2016 and from a separate cohort of FPs who were 3 years into practice in 2018 and 2019 from 15 programs. We measured outcomes from exiting FM residents intending to participate in SoP activities and FPs participating in 15 SoP domains of family medicine.

RESULTS

A total of 1,409 exiting FM residents (58.2% response rate) and 523 early career FPs (21% response rate) responded to the surveys. A high correlation existed between the percentage of exiting residents who intended to participate in each SoP activity and the percentage of FPs who participated in those activities (r2=0.95). However, we found statistically significant declines in the percentage of FPs reporting involvement in the SoP activities compared to their reported practice intentions for 14 of the 15 domains. We saw the greatest declines in providing care in long-term care facilities, rural communities, emergency departments, intrapartum care, and care for Indigenous populations (P<.001).

CONCLUSIONS

While SoP patterns are highly correlated with practice intentions, early-career FPs are less likely to provide care as intended for all SoP activities. Further research is needed on the factors influencing practice patterns in specific areas to determine how FP graduates can be supported to provide comprehensive care.

Concordance between 8-1-1 HealthLink BC Emergency iDoctor-in-assistance (HEiDi) virtual physician advice and subsequent health service utilization for callers to a nurse-managed provincial health information telephone service

BACKGROUND

British Columbia 8-1-1 callers who are advised by a nurse to seek urgent medical care can be referred to virtual physicians (VPs) for supplemental assessment and advice. Prior research indicates callers' subsequent health service use may diverge from VP advice. We sought to 1) estimate concordance between VP advice and subsequent health service use, and 2) identify factors associated with concordance to understand potential drivers of discordant cases.

METHODS

We linked relevant provincial administrative databases to obtain inpatient, outpatient, and emergency service use by callers. We developed operational definitions of concordance collaboratively with researcher, patient, VP, and management perspectives. We used Kaplan-Meier curves to describe health service use post-VP consultation and Cox regression to estimate the association of caller factors (rurality, demography, attachment to primary care) and call factors (reason, triage level, time of day) with concordance as hazard ratios.

RESULTS

We analyzed 17,188 calls from November 16, 2020 to April 30, 2021. Callers advised to attend an emergency department (ED) immediately were the most concordant (73%) while concordance was lowest for those advised to seek Family Physician (FP) care either immediately (41%) or within 7 days (47%). Callers unattached to FPs were less likely to schedule an FP visit (hazard ratio = 0.76 [95%CI: 0.68-0.85]). Rural callers were less likely to attend an ED within 48 h when advised to go immediately (0.53 [95%CI:0.46-0.61]) compared to urban callers. Rural callers advised to see an FP, either immediately (1.28 [95%CI:1.01-1.62]) or within 7 days (1.23 [95%CI: 1.11-1.37]), were more likely to do so than urban callers.

INTERPRETATION

Concordance between VP advice and subsequent caller health service use varies substantially by category of advice and caller rurality. Concordance with advice to "Go to ED" is high overall but to access primary care is below 50%, suggesting potential issues with timely access to FP care. Future research from a patient/caller centered perspective may reveal additional barriers and facilitators to concordance.

Changes in comprehensiveness of services delivered by Canadian family physicians: Analysis of population-based linked data in 4 provinces

OBJECTIVE

To describe changes in the comprehensiveness of services delivered by family physicians across service settings and service areas in 4 Canadian provinces, to identify which settings and areas have changed the most, and to compare the magnitude of changes by physician characteristics.

DESIGN

Descriptive analysis of province-wide, population-based billing data linked to population and physician registries.

SETTING

British Columbia, Manitoba, Ontario, and Nova Scotia.

PARTICIPANTS

Family physicians registered to practise in the 1999-2000 and 2017-2018 fiscal years.

MAIN OUTCOME MEASURES

Comprehensiveness was measured across 7 service settings (home care, long-term care, emergency departments, hospitals, obstetric care, surgical assistance, anesthesiology) and in 7 service areas consistent with office-based practice (prenatal and postnatal care, Papanicolaou testing, mental health, substance use, cancer care, minor surgery, palliative home visits). The proportion of physicians with activity in each setting and area are reported and the average number of service settings and areas by physician characteristics is described (years in practice, sex, urban or rural practice setting, and location of medical degree training).

RESULTS

Declines in comprehensiveness were observed across all provinces studied. Declines were greater for comprehensiveness of settings than for areas consistent with office-based practice. Changes were observed across all physician characteristics. On average across provinces, declines in the number of service settings and service areas were highest among physicians in practice 20 years or longer, male physicians, and physicians practising in urban areas.

CONCLUSION

Declining comprehensiveness was observed across all physician characteristics, pointing to changes in the practice and policy contexts in which all family physicians work.

Are early career family physicians prepared for practice in Canada? A qualitative study

BACKGROUND

In Canada, the College of Family Physicians of Canada (CFPC) introduced Competency Based Medical Education to prepare and train family medicine residents to be competent to enter and adapt to the independent practice of comprehensive family medicine. Despite its implementation, the scope of practice is narrowing. This study aims to understand the degree to which early career Family Physicians (FPs) are prepared for independent practice.

METHOD

A qualitative design was used for this study. A survey and focus groups were conducted with early-career FPs who completed residency training in Canada. The survey and focus groups examined the degree of preparedness of early career FPs in relation to 37 core professional activities identified by the CFPC's Residency Training Profile. Descriptive statistics and qualitative content analysis were conducted.

RESULTS

Seventy-five participants from across Canada participated in the survey, and 59 participated in the focus groups. Early career FPs reported being well prepared to provide continuous and coordinated care for patients with common presentations and deliver various services to different populations. FPs were also well prepared to manage the electronic medical record, participate in team-based care, provide regular and after-hours coverage, and assume leadership and teaching roles. However, FPs reported being less prepared for virtual care, business management, providing culturally safe care, delivering specific services in emergency care hospitals, obstetrics, self-care, engaging with the local communities, and conducting research activities.

CONCLUSIONS

Early career FPs do not feel fully prepared for practice in all 37 core activities in the Residency Training Profile. As part of the introduction of the three-year program by the CFPC, the postgraduate family medicine training should consider providing more exposure to learning opportunities and developing curricula in the areas where FPs are unprepared for practice. These changes could facilitate the production of a FP workforce better prepared to manage the dynamic and complex challenges and dilemmas faced in independent practice.

Characteristics and practice patterns of family physicians who provide home visits in Ontario, Canada: a cross-sectional study

BACKGROUND

Physician home visits are essential for populations who cannot easily access office-based primary care. The objective of this study was to describe the characteristics, practice patterns and physician-level patient characteristics of Ontario physicians who provide home visits.

METHODS

This was a retrospective cross-sectional study, based on health administrative data, of Ontario physicians who provided home visits and their patients, between Jan. 1, 2019, and Dec. 31, 2019. We selected family physicians who had at least 1 home visit in 2019. Physician demographic characteristics, practice patterns and aggregated patient characteristics were compared between high-volume home visit physicians (the top 5%) and low-volume home visit physicians (bottom 95%).

RESULTS

A total of 6572 family physicians had at least 1 home visit in 2019. The top 5% of home visit physicians (n = 330) performed 58.6% of all home visits (n = 227 321 out of 387 139). Compared with low-volume home visit physicians (n = 6242), the top 5% were more likely to be male and practise in large urban areas, and rarely saw patients who were enrolled to them (median 4% v. 87.5%, standardized mean difference 1.12). High-volume physicians' home visit patients were younger, had greater levels of health care resource utilization, resided in lower-income and large urban neighbourhoods, and were less likely to have a medical home.

INTERPRETATION

A small subset of home visit physicians provided a large proportion of home visits in Ontario. These home visits may be addressing a gap in access to primary care for certain patients, but could be contributing to lower continuity of care.

Development and pilot evaluation of an educational session to support sparing opioid prescriptions to opioid naïve patients in a Canadian primary care setting

BACKGROUND

Prescribing rates of some analgesics decreased during the public health crisis. Yet, up to a quarter of opioid-naïve persons prescribed opioids for noncancer pain develop prescription opioid use disorder. We, therefore, sought to evaluate a pilot educational session to support primary care-based sparing of opioid analgesics for noncancer pain among opioid-naïve patients in British Columbia (BC).

METHODS

Therapeutics Initiative in BC has launched an audit and feedback intervention. Individual prescribing portraits were mailed to opioid prescribers, followed by academic detailing webinars. The webinars' learning outcomes included defining the terms opioid naïve and opioid sparing, and educating attendees on the (lack of) evidence for opioid analgesics to treat noncancer pain. The primary outcome was change in knowledge measured by four multiple-choice questions at the outset and conclusion of the webinar.

RESULTS

Two hundred participants attended four webinars; 124 (62%) responded to the knowledge questions. Community-based primary care professionals (80/65%) from mostly urban settings (77/62%) self-identified as family physicians (46/37%), residents (22/18%), nurse practitioners (24/19%), and others (32/26%). Twelve participants (10%) recalled receiving the individualized portraits. While the correct identification of opioid naïve definitions increased by 23%, the correct identification of opioid sparing declined by 7%. Knowledge of the gaps in high-quality evidence supporting opioid analgesics and risk tools increased by 26% and 35%, respectively.

CONCLUSION

The educational session outlined in this pilot yielded mixed results but appeared acceptable to learners and may need further refinement to become a feasible way to train professionals to help tackle the current toxic drugs crisis.

Finding Primary Care—Repurposing Physician Registration Data to Generate a Regionally Accurate List of Primary Care Clinics: Development and Validation of an Open-Source Algorithm

Background

Some Canadians have limited access to longitudinal primary care, despite its known advantages for population health. Current initiatives to transform primary care aim to increase access to team-based primary care clinics. However, many regions lack a reliable method to enumerate clinics, limiting estimates of clinical capacity and ongoing access gaps. A region-based complete clinic list is needed to effectively describe clinic characteristics and to compare primary care outcomes at the clinic level.

Objective

The objective of this study is to show how publicly available data sources, including the provincial physician license registry, can be used to generate a verifiable, region-wide list of primary care clinics in British Columbia, Canada, using a process named the Clinic List Algorithm (CLA).

Methods

The CLA has 10 steps: (1) collect data sets, (2) develop clinic inclusion and exclusion criteria, (3) process data sets, (4) consolidate data sets, (5) transform from list of physicians to initial list of clinics, (6) add additional metadata, (7) create working lists, (8) verify working lists, (9) consolidate working lists, and (10) adjust processing steps based on learnings.

Results

The College of Physicians and Surgeons of British Columbia Registry contained 13,726 physicians, at 2915 unique addresses, 6942 (50.58%) of whom were family physicians (FPs) licensed to practice in British Columbia. The CLA identified 1239 addresses where primary care was delivered by 4262 (61.39%) FPs. Of the included addresses, 84.50% (n=1047) were in urban locations, and there was a median of 2 (IQR 2-4, range 1-23) FPs at each unique address.

Conclusions

The CLA provides a region-wide description of primary care clinics that improves on simple counts of primary care providers or self-report lists. It identifies the number and location of primary care clinics and excludes primary care providers who are likely not providing community-based primary care. Such information may be useful for estimates of capacity of primary care, as well as for policy planning and research in regions engaged in primary care evaluation or transformation.

Influence of rurality on general practitioner registrars' participation in their practice's after-hours roster: A cross-sectional study

Objective

To investigate whether practice rurality and rural training pathway are associated with general practitioner registrars' participation in their practice's after‐hours care roster.

Design

A cross‐sectional analysis of data (2017‐2019) from the Registrar Clinical Encounters in Training study, an ongoing inception cohort study of Australian general practitioner registrars. The principal analyses used logistic regression.

Setting

Three national general practitioner regional training organisations across 3 Australian states.

Participants

General practitioner registrars in training within regional training organisations.

Main outcome measure

Involvement in practice after‐hours care was indicated by a dichotomous response on a 6‐monthly Registrar Clinical Encounters in Training study questionnaire item.

Results

1576 registrars provided 3158 observations (response rate 90.3%). Of these, 1574 (48.6% [95% confidence interval: 46.8‐50.3]) involved registrars contributing to their practice's after‐hours roster. In major cities, 40% of registrar terms involved contribution to their practice's after‐hours roster; in regional and remote practices, 62% contributed to the after‐hours roster. On multivariable analysis, both level of rurality of practice (odds ratio(OR) 1.75, P = .007; and OR 1.74, P = .026 for inner regional and outer regional/remote locations, respectively, versus major city) and rural training pathway of registrar (OR 1.65, P = .008) were significantly associated with more after‐hours roster contribution. Other associations were registrars' later training stage, larger practices and practices not routinely bulk billing. Significant regional variability in after‐hours care was identified (after adjusting for rurality).

Conclusion

These findings suggest that registrars working rurally and those training on the rural pathway are more often participating in practice after‐hours rosters. This has workforce implications, and implications for the educational richness of registrars' training environment.

Modern work patterns of "classic" versus millennial family doctors and their effect on workforce planning for community-based primary care: a cross-sectional survey

BACKGROUND

There are ongoing accessibility challenges in primary care in British Columbia, Canada, with 17% of the population not having a regular source of care. Anecdotal evidence suggests that physicians are moving away from a community-based comprehensive practice model, which could contribute to shortages. Thus, we aimed to identify and describe how family physicians are currently organizing their primary care practices in a large health region in British Columbia and to examine differences between newer graduates and more established physicians.

METHODS

Data for this cross-sectional study were drawn from an annual physician privileging survey. N = 1017 physicians were invited to participate. We categorized practice style into five distinct groupings and compared features across respondent groups, including personal and practice location characteristics, hospital and teaching work, payment and appointment characteristics, and scope of practice. We discuss the implications of styles of practice and associated characteristics on health workforce policy and planning.

RESULTS

We received responses from 525 (51.6%) physicians. Of these, 355 (67.6%) reported doing at least some community-based primary care. However, only 112 (21.3%) provided this care full time. Most respondents supplemented community-based work with part-time hours in focused practice, hospitals, or inpatient facilities. We found diversity in the scope and style of practice across practice models. Compared to established physicians, new graduates (in practice less than 10 years) work more weekly hours (more patient care, and paperwork in particular). However, we found no difference between new and established physicians in the odds of providing any or full-time community-based primary care.

CONCLUSIONS

Despite a lack of formalized structural reform in British Columbia's primary care system, most physicians are finding alternative ways to model their practice and shifting away from work at single-location, community-based clinics. This shift challenges assumptions that are relied on for workplace planning that is intended to ensure adequate access to longitudinal, community-based family medicine.