Evaluation of the implementation of single points of access for unattached patients in primary care and their effects: a study protocol

INTRODUCTION

Attachment to a primary care provider is an important component of primary care as it facilitates access. In Québec, Canada, attachment to a family physician is a concern. To address unattached patients' barriers to accessing primary care, the Ministry of Health and Social Services mandated Québec's 18 administrative regions to implement single points of access for unattached patients (Guichets d'accès première ligne (GAPs)) that aim to better orient patients towards the most appropriate services to meet their needs. The objectives of this study are to (1) analyse the implementation of GAPs, (2) measure the effects of GAPs on performance indicators and (3) assess unattached patients' experiences of navigation, access and service utilisation.

METHODS AND ANALYSIS

A longitudinal mixed-methods case study design will be conducted. Objective 1. Implementation will be analysed through semistructured interviews with key stakeholders, observations of key meetings and document analysis. Objective 2. GAP effects on indicators will be measured using performance dashboards produced using clinical and administrative data. Objective 3. Unattached patients' experiences will be assessed using a self-administered electronic questionnaire. Findings for each case will be interpreted and presented using a joint display, a visual tool for integrating qualitative and quantitative data. Intercase analyses will be conducted highlighting the similarities and differences across cases.

ETHICS AND DISSEMINATION

This study is funded by the Canadian Institutes of Health Research (# 475314) and the Fonds de Soutien à l'innovation en santé et en services sociaux (# 5-2-01) and was approved by the CISSS de la Montérégie-Centre Ethics Committee (MP-04-2023-716).

Perceptions on barriers, facilitators, and recommendations related to mental health service delivery during the COVID-19 pandemic in Quebec, Canada: a qualitative descriptive study

Background

There was an increase in self-reported mental health needs during the COVID-19 pandemic in Canada, with research showing reduced access to mental health services in comparison to pre-pandemic levels. This paper explores 1) barriers and facilitating factors associated with mental health service delivery via primary care settings during the first two pandemic waves in Quebec, Canada, and 2) recommendations to addressing these barriers.

Methods

A qualitative descriptive study design was used. Semi-structured interviews with 20 participants (health managers, family physicians, mental health clinicians) were conducted and coded using a thematic analysis approach.

Results

Barriers and facilitating factors were organized according to Chaudoir et al. (2013)‘s framework of structural, organizational, provider- and patient-related, as well as innovation (technological modalities for service delivery) categories. Barriers included relocation of mental health staff to non-mental health related COVID-19 tasks (structural); mental health service interruption (organizational); mental health staff on preventive/medical leave (provider); the pandemic’s effect on consultations (i.e., perceptions of increased demand) (patients); and challenges with the use of technological modalities (innovation). Facilitating factors included reinforcements to mental health care teams (structural); perceptions of reductions in wait times for mental health evaluations during the second wave due to diminished FP referrals in the first wave, as well as supports (i.e., management, private sector, mental health trained staff) for mental health service delivery (organizational); staff’s mental health consultation practices (provider); and advantages in increasing the use of technological modalities in practice (innovation).

Conclusions

To our knowledge, this is the first study to explore barriers and facilitating factors to mental health service delivery during the pandemic in Quebec, Canada. Some barriers identified were caused by the pandemic, such as the relocation of staff to non-mental health services and mental health service interruption. Offering services virtually seemed to facilitate mental health service delivery only for certain population groups. Recommendations related to building and strengthening human and technological capacity during the pandemic can inform mental health practices and policies to improve mental health service delivery in primary care settings and access to mental health services via access points.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01634-w.

Exploring the implementation and underlying mechanisms of centralized referral systems to access specialized health services in Quebec

BACKGROUND

In 2016, Quebec, a Canadian province, implemented a program to improve access to specialized health services (Accès priorisé aux services spécialisés (APSS)), which includes single regional access points for processing requests to such services via primary care (Centre de répartition des demandes de services (CRDS)). Family physicians fill out and submit requests for initial consultations with specialists using a standardized form with predefined prioritization levels according to listed reasons for consultations, which is then sent to the centralized referral system (the CRDS) where consultations with specialists are assigned. We 1) described the APSS-CRDS program in three Quebec regions using logic models; 2) compared similarities and differences in the components and processes of the APSS-CRDS models; and 3) explored contextual factors influencing the models' similarities and differences.

METHODS

We relied on a qualitative study to develop logic models of the implemented APSS-CRDS program in three regions. Semi-structured interviews with health administrators (n = 9) were conducted. The interviews were analysed using a framework analysis approach according to the APSS-CRDS's components included in the initially designed program, Mitchell and Lewis (2003)'s logic model framework, and Chaudoir and colleagues (2013)'s framework on contextual factors' influence on an innovation's implementation.

RESULTS

Findings show the APSS-CRDS program's regional variability in the implementation of its components, including its structure (centralized/decentralized), human resources involved in implementation and operation, processes to obtain specialists' availability and assess/relay requests, as well as monitoring methods. Variability may be explained by contextual factors' influence, like ministerial and medical associations' involvement, collaborations, the context's implementation readiness, physician practice characteristics, and the program's adaptability.

INTERPRETATION

Findings are useful to inform decision-makers on the design of programs like the APSS-CRDS, which aim to improve access to specialists, the essential components for the design of these types of interventions, and how contextual factors may influence program implementation. Variability in program design is important to consider as it may influence anticipated effects, a next step for the research team. Results may also inform stakeholders should they wish to implement similar programs to increase access to specialized health services via primary care.

[Naso-ethmoido-maxillary protrusion (NEMP): a specific dysmorphosis]

Naso-ethmoido-maxillary protrusion (NEMP) is a rare dental and facial dysmorphosis, with excessive growth of basicranium, ethmoid, maxillary, and nasal bones. The clinical presentation includes nasal and upper lip protrusion, telecanthus, a class 2 malocclusion with maxillary protrusion and exoclusion. The craniofacial field is increased in Delaire's analysis. Contrary to isolated maxillary protrusion secondary to membranous ossification dysfunction, NEMP is a constitutional anomaly resulting from an excessive primary growth of the chondrocranium. The therapeutic management of NEMP should take into account these specificities.

Resistance of trichostrongyles to benzimidazoles in Italy: a first report in a goat farm with multiple and repeated introductions

Anthelmintic resistance is widely distributed in small ruminants throughout the world. The extension of resistance seems lower in southern European countries and has not been reported previously in Italy. In the present study, resistance to benzimidazoles, levamisole and ivermectin was evaluated in a multi-breed goat farm of southern Italy. The farm had a history of repeated goat introductions from other flocks and a moderate regimen of anthelmintic treatments using alternatively the three above-mentioned drugs. Resistance of gastrointestinal strongyles was studied on the basis of faecal egg counts, egg hatch assay and necropsies. Resistance to anthelmintics was evidenced for benzimidazoles only, and Trichostrongylus colubriformis was the only resistant strongyle species. Single drug and single species resistance suggest that resistance is on its beginning and that measures for reducing the spread of resistance are of interest and should be promoted.

Evolution of nematode community in grazing sheep selected for resistance and susceptibility to Teladorsagia circumcincta and Trichostrongylus colubriformis: a 4-year experiment

Field trials were undertaken to compare nematode population dynamics in two experimental flocks of rams selected for high and for low faecal egg counts (FECs) following two doses with 20000 infective larvae, 12000 Teladorsagia circumcincta (Tcirc) and 8000 Trichostrongylus colubriformis (Tcol) separated by a treatment. The selection was done by dosing 200 ram lambs (INRA 401 breed) and FECs proceeded with egg identification on days 28 and 35 post-each-infection. The 30 lambs with the lowest FECs constituted the group of permanent resistant rams (R), the 30 with the highest values the group of susceptible ones (S). Each group grazed separated pastures from April to November, this during 4 consecutive years. The contamination (number of eggs deposited) was estimated every 3 weeks on each pasture. The larval populations was measured by successive groups of tracer lambs. The infection of the permanent rams was done by slaughtering eight R and S rams on mid and end of each grazing season. Each autumn, new R and S ram lambs were selected to complete the R and S groups before turning out in spring. On third year, a third species (Haemonchus contortus, Hcon) was added to compare its behaviour with the two others. The regulation of parasite populations were studied by comparing what happens in R rams and pasture to S ones. The selected R ram lambs had a FEC of Tcirc 50% lower than S ones. This induced a similar lowered pasture contamination, a 25% decrease of infective larval population in years 2 and 3, and the worm burdens in R rams were the half of that in S rams after 2 years. The FEC of Tcol was 75% lower at the selection and induced similar difference in pasture contamination, but 65 and 96% reduction in L3 population, respectively, after 1 and 2 years. The worm burden was reduced by 99%. Adding Hcon species during the third year, in year 4, the L3 population was half in R pasture compared with S one, and R rams had 60% less worms of this species than S ones. This selection without any drench prevent outbreaks observed in young tracer lambs on S pasture. The comparison of selected resistant rams to selected susceptible ones and not to unselected controls gave more rapid information about the tendency of the regulation of the communities of nematode parasites.

Acute pericarditis with transient constriction

Transient constrictive pericarditis is a rare entity. It is characterized by clinical and echocardiographic features similar to constrictive pericarditis, but is distinguished by its transient nature. This feature is important to recognize for avoiding unnecessary pericardectomy. The case of a patient who presented with acute myopericarditis and typical echocardiographic features of constriction is described. Within weeks, all signs of constriction disappeared spontaneously.

Relationship between helminth species diversity, intensity of infection and breeding management in dairy goats

Helminth infection, species diversity (proportion of each species in the community), species number, intensity of infection and anthelmintic resistance were investigated in 16 dairy-goat farms of south-western France. The aim of the study was to estimate which breeding management factors may affect diversity and intensity of infection. Anthelmintic resistance was investigated because this factor may modify composition of nematode communities. Farm history and breeding management were recorded by means of a questionnaire. Natural and experimental infections were compared to determine which strategy was the best to estimate diversity index and number of species from nematode community of a whole herd. A total of 17 species of helminths, among which 14 nematodes, one cestode (Moniezia spp.) and two trematodes (Paramphistomum daubneyi and Dicrocoelium lanceolatum) were recovered in the 26 necropsied culled goats. One culled goat worm burden represented conveniently species number but not species diversity (Shannon index) of parasite community harboured in the whole herd. Experimental sheep infection with larvae from pooled faeces of 15 goats was the best strategy to estimate species diversity in farms. Diversity could be predicted from the number of farms from which goats originated at constitution of the herd, the duration of goat winter withdrawal from pastures, and intensity of infection. Anthelmintic resistance was correlated with the number of farms of origin, area of permanent pastures and intensity of infection. The strategy adopted for the herd constitution was a critical step as species diversity and risk of anthelmintic resistance increased with the number of farms of origin. Intensity of infection was negatively correlated with species diversity. This suggested that more diverse communities were better controlled by the host, in agreement with the widespread statement that diversity would beget stability.

Segmental myocardial contractility versus perfusion in Kawasaki disease with coronary arterial aneurysm

The impact of Kawasaki-related coronary injury on the myocardium was evaluated in 13 patients with persistent coronary aneurysm after a follow-up period of 7.92+/-3.97 years (range 1.8 to 14.3). Myocardial segmental perfusion and contractility integrity were assessed by resting and exercise echocardiography and technetium-99 (Tc-99m) sestamibi scan. Eight patients (61.5%) had giant aneurysms (> or = 8 mm) and 9 had multivessel involvement; the mean diameter of the largest aneurysm was 8.6+/-2.5 mm (range 5 to 14). During the acute phase, myocardial infarction occurred in 1 patient and coronary thrombosis in another. At the latest echocardiographic evaluation, the mean aneurysm diameter was 6.8+/-2.4 mm (range 4.5 to 12), there was persistent giant aneurysms in 5 of 8 patients, and 3 of 9 patients had multivessel involvement. Coronary angiography demonstrated stenosis in 7 of 10 patients, with multiple levels in 2. At sestamibi scan, all 13 patients had perfusion anomalies at rest, whereas only 7 had detectable hypokinesia on echocardiography. With exercise, perfusion returned to near normal in 3 patients, improved in 3, remained unchanged in 4, and worsened in 3 patients. Segmental contractility similarly deteriorated in the latter 3 patients but also in 2 patients whose perfusion scan had improved with exercise. Three patients, normal at rest, developed segmental hypokinesia during exercise. When present, the location of observed changes in contractility on stress echocardiography corresponded to that of perfusion defect. In conclusion, abnormal myocardial perfusion is present long term after complicated Kawasaki disease, the worst anomalies accompanying persistent giant aneurysms. Unfavorable perfusion response was coupled with abnormal contractility; however, enhanced perfusion with exercise correlated poorly with segmental contractility response.

Mitral valve repair: Intermediate to long-term echocardiographic follow-up

OBJECTIVE

To review intermediate to long term echocardiographic follow-up after mitral valve repair for mitral regurgitation.

DESIGN

Nonrandomized, retrospective and prospective observational study.

SETTING

Sacré-Coeur Hospital, University of Montreal, Montreal, Quebec.

PATIENTS

Echocardiographic findings in 37 patients (mean age 62.1 +/- 10 years) three to 197 months (median 45) after mitral valve repair were reviewed.

INTERVENTIONS

Preoperative data were collated from hospital records. Between October 1994 and March 1995, all patients had a clinical evaluation and a complete transthoracic echocardiogram done by a cardiologist.

RESULT

There was a significant reduction in the dimensions of the left-sided cavities compared with preoperative data. Left atrial diameter decreased from from 50.9 +/- 7.7 to 46.3 +/- 8.1 mm (P = 0.01), left ventricular end-diastolic diameter from 59.6 +/- 7.1 to 51.2 +/- 6.3 mm (P < 0.001) and left ventricular end-systolic diameter from 35.3 +/- 7.9 to 32.8 +/- 7.8 mm (P = 0.07). On colour Doppler echocardiography, nine patients had no mitral regurgitation, 25 had mitral regurgitation grade I to II/IV, and three had grade III/IV. The mean mitral valve gradient was 4.2 +/- 1.8 mmHg and the pressure half-time 121.9 +/- 48 ms. There was no difference in gradient, mitral valve area and mitral regurgitation in patients with degenerative (29) compared with rheumatic (five) mitral valve disease.

CONCLUSIONS

Mitral valve repair is highly effective in reducing mitral regurgitation in the long term and is associated with a reduction in the dimensions of the left atrium and the left ventricle. However, it leaves a mild degree of mitral valve obstruction.

Salmonella endocarditis of a ventricular aneurysm: a case report and review of the literature

A 63-year-old man with salmonella endocarditis of a ventricular aneurysm is presented. The patient had a documented apical aneurysm with mural thrombus and left ventricular dysfunction following a previous myocardial infarction. His condition was unresponsive to maximal medical therapy and was cured by surgery. A review of the English-language literature revealed that only two other published cases of nonvalvular salmonella endocarditis resulted in patient survival. This report underscores the importance of suspecting a cardiovascular origin in cases of salmonella bacteremia to avoid delay in diagnosis and surgical intervention in this deadly condition.

Host, season and year do not play an important role on genetic variability in a trichostrongyle nematode as assessed from allozymes

The isolates of the trichostrongyle nematode Teladorsagia circumcincta in sheep may vary from one site to another as assessed from allozyme studies. This genetic variability could be host (on the parasitic stages) or/and environmentally (on the free-living stages) induced. In the present study the role of host (susceptible to the establishment of the parasite and partly resistant ones) and environmental changes expressed by season (Autumn versus Spring) or year of sampling (1990 or 1992) were investigated. Five polymorphic enzymes were studied: glucose-phosphate-isomerase (GPI), lactate dehydrogenase (LDH), malate dehydrogenase (MHD), mannose-phosphate isomerase (MPI), and phosphoglucomutase (PGM). No significant difference in allelic frequencies was recorded between 4 susceptible lambs from a flock grazed in 1990 as well as in 3 lambs selected on their susceptibility or resistance to natural infection in a flock grazed in 1992. The mode of infection (natural--frequently repeated small infections, versus experimental--3 repeated large infections) did not modify the allelic frequencies of the nematodes. The allelic frequencies remained stable along the seasons and during the 2 years investigated. The largest distance of Rogers (0.07) and Fst (0.012) were recorded between worms originating from susceptible and resistant lambs or in Autumn versus Spring populations of worms (0.08 and Fst 0.010). A deficiency in heterozygotes of the same magnitude was recorded in the worm populations obtained from the different infections. The stability of allelic frequencies and genetic structure are surprising when one considers the evolution of the same parasite in several generations of laboratory conditions. This stability could be related to the fact that levels of disturbance on parasitic and free-living stages are neither too low (as in laboratory conditions) nor too high (as in farms when anthelmintic treatment are used regularly and destroy the adult stages).

Studies on multispecific resistance of gastrointestinal nematodes to benzimidazoles on dairy-goat farms

Multispecific resistance to benzimidazoles was studied in three selected farms. These farms had bred dairy goats for more than 15 years. The helminths were introduced with the goats at the establishment of the farms which afterwards remained isolated. Nematode resistance could then be related to their own management practices. Faecal egg count tests and egg hatch assays were performed to assess intensity of resistance. The generic (infective larvae in faecal cultures) and specific richness (adult worms) were assessed. The resistant species were Trichostrongylus colubriformis, Teladorsagia circumcincta, Haemonchus contortus and Oesophagostomum venulosum. Faecal egg count reduction tests and egg-hatch assays did not match exactly. Faecal larval counts after treatments gave a distorted picture of multispecific resistance: Haemonchus and Oesophagostomum were very largely over represented. The number of species found in the three farms was relatively low compared with other reports in goat farms of the area. This reduction of diversity might also be due in part to characteristics of breeding management and history (use of permanent pasture and introduction of goats at the establishment of farm).