The impact of the COVID-19 pandemic on primary care physicians and nurses in Nova Scotia: a qualitative exploratory study.

BACKGROUND: The COVID-19 pandemic has brought immense disruption worldwide, dramatically altering the ways we live, work and learn on a day-to-day basis; however, few studies have investigated this from the perspective of primary care providers. In this study, we sought to explore the experiences of primary care providers in the province of Nova Scotia, with the intention of understanding the impact of the COVID-19 pandemic on primary care providers' ability to provide care, their information pathways, and the personal and professional impact of the pandemic. METHODS: We conducted an exploratory qualitative research study involving semistructured interviews conducted via Zoom videoconferencing or telephone with primary care providers (physicians, nurse practitioners and family practice nurses) who self-identified as working in primary health care in Nova Scotia from June 2020 to April 2021. We performed a thematic analysis involving coding and classifying data according to themes. Emergent themes were then interpreted by seeking commonalties, divergence, relationships and overarching patterns in the data. RESULTS: Twenty-four primary care providers were interviewed. Subsequent analysis identified 4 interrelated themes within the data: disruption to work-life balance, disruptions to "non-COVID-19" patient care, impact of provincial and centralized policies, and filtering and processing an influx of information. INTERPRETATION: Our findings showed that managing a crisis of this magnitude requires coordination and new ways of working, balancing professional and personal life, and adapting to already implemented changes (i.e., virtual care). A specific primary care pandemic response plan is essential to mitigate the impact of future health care crises.

Community pharmacists' expanding roles in supporting patients before and during COVID-19: An exploratory qualitative study.

BACKGROUND: Timely access and attachment to a primary healthcare provider is associated with better population health outcomes. In Canada, community pharmacists are highly accessible and patients struggling to access a family physician or nurse practitioner (i.e., "unattached") may seek care from a community pharmacist. Community pharmacists took on additional roles during the COVID-19 pandemic; however, little is known about how community pharmacists managed the needs of attached and unattached patients before and during the COVID-19 pandemic. AIM: To describe Nova Scotian community pharmacists' roles in caring for unattached patients before and during the COVID-19 pandemic and identifying barriers and facilitators to optimizing patient access. METHOD: Semi-structured interviews with community pharmacists (n = 11) across the province of Nova Scotia (Canada) were conducted. RESULTS: Five key themes were noted: (1) rising pressure on pharmacists to meet unique health needs of attached and unattached patients; (2) what pharmacists have to offer (e.g., accessibility, trustworthiness); (3) positioning pharmacists in the system (e.g., how pharmacists can address gaps in primary healthcare); (4) pharmacist wellbeing; and, (5) recommendations for practice post-pandemic (e.g., maintain some policy changes made during the COVID-19 pandemic). CONCLUSION: Before and during the pandemic, community pharmacists played a significant and increasing role providing care to patients, especially unattached patients. With growing numbers of unattached patients, it is vital that community pharmacists are supported to provide services to care for the health needs of patients.

Adverse Events Following Immunization with mRNA and Viral Vector Vaccines in Individuals with Previous SARS-CoV-2 Infection from the Canadian National Vaccine Safety Network.

BACKGROUND: Adults previously infected with SARS-CoV-2 develop short-term immunity and may have increased reactogenicity to COVID-19 vaccines. This prospective, multi-center active surveillance cohort study examined the short-term safety of COVID-19 vaccines in adults with a prior history of SARS-CoV-2. METHODS: Canadian adults vaccinated between December 22, 2020 and November 27, 2021 were sent an electronic questionnaire 7 days post dose 1, dose 2 and dose 3 vaccination. The main outcome was health events occurring in the first 7 days after each vaccination that prevented daily activities, resulted in work absenteeism or required a medical consultation, including hospitalization. RESULTS: Among 684,998 vaccinated individuals, 2.6% (18,127/684,998) reported a prior history of SARS-CoV-2 infection a median of 4 months (interquartile range 2-6 months) previously. After dose 1, individuals with moderate (bedridden) to severe (hospitalized) COVID-19 who received BNT162b2, mRNA1273 or ChAdox1-S vaccines had higher odds of a health event preventing daily activities, resulting in work absenteeism or requiring medical consultation; adjusted odds ratio (AOR) 3.96 (95% CI 3.67-4.28) for BNT162b2, 5.01 (4.57-5.50) for mRNA1273 and 1.84 (1.54-2.20) for ChAdox1-S compared to no infection. Following dose 2 and 3, the greater risk associated with previous infection was also present but attenuated compared to dose 1. For all doses, the association was lower or absent after mild or asymptomatic infection. CONCLUSION: Adults with moderate or severe previous SARS-CoV-2 infection were more likely to have a health event sufficient to impact routine activities or require medical assessment in the week following each vaccine doses.

Increased self-reported pharmacist prescribing during the COVID-19 pandemic: Using the Theoretical Domains Framework to identify barriers and facilitators to prescribing.

BACKGROUND: Community pharmacists are positioned to improve access to medications through their ever-expanding role as prescribers, with this role becoming more pronounced during the COVID-19 pandemic. OBJECTIVES: Our research aimed to determine the extent of self-reported pharmacist prescribing pre-COVID-19 and during the COVID-19 pandemic, to identify barriers and facilitators to pharmacist prescribing, and to explore the relationship between these factors and self-reported prescribing activity. METHODS: A questionnaire based on the Theoretical Domains Framework (TDFv2) assessing self-reported prescribing was electronically distributed to all direct patient care pharmacists in NS (N = 1338) in July 2020. Wilcoxon signed-rank tests were used to examine temporal differences in self-reported prescribing activity. TDFv2 responses were descriptively reported as positive (agree/strongly agree), neutral (uncertain), and negative (strongly disagree/disagree) based on the 5-point Likert scale assessing barriers and facilitators to prescribing from March 2020 onward (i.e., 'during' COVID-19). Simple logistic regression was used to measure the relationship between TDFv2 domain responses and self-reported prescribing activity. RESULTS: A total of 190 pharmacists (14.2%) completed the survey. Over 98% of respondents reported prescribing at least once per month in any of the approved prescribing categories, with renewals being the most common activity reported. Since the pandemic, activity in several categories of prescribing significantly increased, including diagnosis supported by protocol (29.0% vs. 58.9%, p < 0.01), minor and common ailments (25.3% vs 34.7%, p = 0.03), preventative medicine (22.1% vs. 33.2%, p < 0.01). Amongst the TDFv2 domains, Beliefs about Consequences domain had the largest influence on prescribing activity (OR = 3.13, 95% CI 1.41-6.97, p < 0.01), with Social Influences (OR = 2.85, 95% CI 1.42-5.70, p < 0.01) being the next most influential. CONCLUSION: Self-reported prescribing by direct patient care community pharmacists in Nova Scotia increased during the COVID-19 pandemic, particularly for government-funded services. Key barriers to address, and facilitators to support pharmacist prescribing were identified and can be used to inform future interventions.

Safety of COVID-19 vaccines in pregnancy: a Canadian National Vaccine Safety (CANVAS) network cohort study.

BACKGROUND: Pregnant individuals have been receiving COVID-19 vaccines following pre-authorisation clinical trials in non-pregnant people. This study aimed to determine the frequency and nature of significant health events among pregnant females after COVID-19 vaccination, compared with unvaccinated pregnant controls and vaccinated non-pregnant individuals. METHODS: We did an observational cohort study, set in seven Canadian provinces and territories including Ontario, Quebec, British Columbia, Alberta, Nova Scotia, Yukon, and Prince Edward Island. Eligibility criteria for vaccinated individuals were a first dose of a COVID-19 vaccine within the previous 7 days; an active email address and telephone number; ability to communicate in English or French; and residence in the aforementioned provinces or territories. Study participants were pregnant and non-pregnant females aged 15-49 years. Individuals were able to participate as controls if they were unvaccinated and fulfilled the other criteria. Data were collected primarily by self-reported survey after both vaccine doses, with telephone follow-up for those reporting any medically attended event. Participants reported significant health events (new or worsening of a health event sufficient to cause work or school absenteeism, medical consultation, or prevent daily activities) occurring within 7 days of vaccination or within the past 7 days for unvaccinated individuals. We employed multivariable logistic regression to examine significant health events associated with mRNA vaccines, adjusting for age group, previous SARS-CoV-2 infection, and trimester, as appropriate. FINDINGS: As of Nov 4, 2021, 191 360 women aged 15-49 years with known pregnancy status had completed the first vaccine dose survey and 94 937 had completed the second dose survey. 180 388 received one dose and 94 262 received a second dose of an mRNA vaccine, with 5597 pregnant participants receiving dose one and 3108 receiving dose two, and 174 765 non-pregnant participants receiving dose one and 91 131 receiving dose two. Of 6179 included unvaccinated control participants, 339 were pregnant and 5840 were not pregnant. Overall, 226 (4·0%) of 5597 vaccinated pregnant females reported a significant health event after dose one of an mRNA vaccine, and 227 (7·3%) of 3108 after dose two, compared with 11 (3·2%) of 339 pregnant unvaccinated females. Pregnant vaccinated females had an increased odds of a significant health event within 7 days of the vaccine after dose two of mRNA-1273 (adjusted odds ratio [aOR] 4·4 [95% CI 2·4-8·3]) compared with pregnant unvaccinated controls within the past 7 days, but not after dose one of mRNA-1273 or any dose of BNT162b2. Pregnant vaccinated females had decreased odds of a significant health event compared with non-pregnant vaccinated females after both dose one (aOR 0·63 [95% CI 0·55-0·72]) and dose two (aOR 0·62 [0·54-0·71]) of any mRNA vaccination. There were no significant differences in any analyses when restricted to events which led to medical attention. INTERPRETATION: COVID-19 mRNA vaccines have a good safety profile in pregnancy. These data can be used to appropriately inform pregnant people regarding reactogenicity of COVID-19 vaccines during pregnancy, and should be considered alongside effectiveness and immunogenicity data to make appropriate recommendations about best use of COVID-19 vaccines in pregnancy. FUNDING: Canadian Institutes of Health Research, Public Health Agency of Canada.

Barriers and Facilitators Related to Delivery of Hospital Pharmacy Services to Women, Children, and Their Families during a Pandemic: A Qualitative Study.

Background: When the COVID-19 pandemic was declared in March 2020, health care professionals were challenged to adapt quickly and efficiently to change their work practices. However, an evidence-informed approach has not yet been used to systematically gather data on barriers and facilitators related to delivery of hospital pharmacy services in Canada. Objectives: The primary objective was to identify and describe barriers and facilitators related to the delivery of hospital pharmacy services to women, children, and their families during the COVID-19 pandemic. The secondary objective was to provide recommendations for improvement in delivery of pharmacy services to enhance patient care during pandemics. Methods: This qualitative study involved semistructured virtual interviews with pharmacists who worked in direct or nondirect patient care throughout the pandemic (since March 2020) at women's and/or children's hospitals in Canada. Individual interviews were completed virtually using conferencing software. An interview guide mapped to the Theoretical Domains Framework version 2 (TDFV2) was used to facilitate the interviews. Interviews were audio-recorded and transcribed verbatim by the principal investigator. Transcribed interviews were coded, mapped to the TDFV2, and analyzed using thematic analysis. Results: Interviews were completed with 21 pharmacists in 7 provinces across Canada. Barriers and facilitators coded to the TDFV2 were grouped into 4 main themes: communication and collaboration, adaptability, health and well-being, and preparedness. Conclusions: Participants highlighted a significant number of barriers that they experienced during the COVID-19 pandemic; overall, however, participants reported that they felt prepared for subsequent waves of the COVID-19 pandemic and future pandemics.

Contexte: Lors de la déclaration de la pandémie de COVID-19 en mars 2020, les professionnels de la santé ont été mis au défi de s'adapter rapidement et efficacement à la situation en changeant leurs pratiques professionnelles. Cependant, une approche fondée sur des données probantes pour recueillir systématiquement des données sur les obstacles à la prestation des services de pharmacie hospitalière au Canada et les éléments facilitant celle-ci n'a pas encore été utilisée de manière systématique. Objectifs: L'objectif principal consistait à identifier et à décrire les obstacles à la prestation de services de pharmacie hospitalière aux femmes, aux enfants et à leur famille et les éléments facilitant celle-ci pendant la pandémie de COVID-19. L'objectif secondaire consistait, quant à lui, à fournir des recommandations pour améliorer la prestation de services de pharmacie afin d'améliorer les soins aux patients pendant une pandémie. Méthodes: Cette étude qualitative comprenait des entrevues virtuelles semi-structurées avec des pharmaciens ayant travaillé dans le domaine des soins directs ou non directs aux patients tout au long de la pandémie (depuis mars 2020) dans des hôpitaux pour femmes et/ou enfants au Canada. Les entretiens individuels ont été réalisés virtuellement à l'aide d'un logiciel de conférence. Un guide d'entretien adapté de la 2e version du cadre des domaines théoriques (TDFV2) [Theoretical Domains Framework] a été utilisé pour faciliter les entretiens. Ceux-ci ont été enregistrés sur bande audio et retranscrits textuellement par le chercheur principal. Les entretiens ainsi retranscrits ont été codés, reportés sur le TDFV2 et analysés par thème. Résultats: Des entrevues ont été réalisées auprès de 21 pharmaciens dans 7 provinces du Canada. Les obstacles et les éléments facilitateurs codés selon le TDFV2 ont été regroupés en 4 grands thèmes: communication et collaboration; adaptabilité; santé et bien-être; et état de préparation. Conclusions: Les participants ont mentionné un nombre important d'obstacles qu'ils ont rencontrés pendant la pandémie de COVID-19; dans l'ensemble, cependant, les participants ont déclaré qu'ils se sentaient préparés aux vagues ultérieures de la pandémie de COVID-19 et aux futures pandémies.

COVID-19 - an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada).

BACKGROUND: COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes during the first 18 months of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. METHODS: We conducted a multiple case study based on 63 semi-structured interviews (n = 33 in Quebec, n = 30 in Nova Scotia) conducted between October 2020 and May 2021 and 71 documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policy-makers, decision-makers, family physicians, nurses) involved in reorganizing primary care during the COVID-19 pandemic using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. RESULTS: We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, interim primary care clinics for unattached patients, and a community connector to health and social services for older adults - pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID-dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors, such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. CONCLUSION: COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after the pandemic. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.

The Canadian National Vaccine Safety Network: surveillance of adverse events following immunisation among individuals immunised with the COVID-19 vaccine, a cohort study in Canada.

INTRODUCTION: COVID-19 vaccines require enhanced safety monitoring after emergency approval. The Canadian National Vaccine Safety Network monitors the safety of COVID-19 vaccines and provides enhanced monitoring for healthy, auto-immune, immunocompromised, pregnant and breastfeeding populations and allows for the detection of safety signals. METHODS AND ANALYSIS: Online participant reporting of health events in vaccinated and unvaccinated individuals 12 years of age and older is captured in three surveys: 1 week after dose 1, 1 week after dose 2 and 7 months after dose 1. Medically attended events are followed up by telephone. The number, percentage, rate per 10 000 and incident rate ratios with 95% CIs are calculated by health event, vaccine type, sex and in 10-year age groups. ETHICS AND DISSEMINATION: Each study site has Research Ethics Board approvals for the project (UBC Children's & Women's, CIUSSS de l'Estrie-CHUS, Health PEI, Conjoint Health Research Ethics Board, University of Calgary and Alberta Health Services, IWK Health, Unity Health Toronto and CHU de Québec-Université Laval Research Ethics Boards). Individuals are invited to participate in this active surveillance and electronic consent is given before proceeding to each survey. Weekly reports are shared with public health and posted on the study website. At least one peer-reviewed manuscript is produced.

Problems in Coordinating and Accessing Primary Care for Attached and Unattached Patients Exacerbated During the COVID-19 Pandemic Year (the PUPPY Study): Protocol for a Longitudinal Mixed Methods Study.

BACKGROUND: The COVID-19 pandemic has significantly disrupted primary care in Canada, with many walk-in clinics and family practices initially closing or being perceived as inaccessible; pharmacies remaining open with restrictions on patient interactions; rapid uptake of virtual care; and reduced referrals for lab tests, diagnostics, and specialist care. OBJECTIVE: The PUPPY Study (Problems in Coordinating and Accessing Primary Care for Attached and Unattached Patients Exacerbated During the COVID-19 Pandemic Year) seeks to understand the impact of the COVID-19 pandemic across the quadruple aims of primary care, with particular focus on the effects on patients without attachment to a regular provider and those with chronic health conditions. METHODS: The PUPPY study builds on an existing research program exploring patients' access and attachment to a primary care practice, pivoted to adapt to the emerging COVID-19 context. We intend to undertake a longitudinal mixed methods study to understand critical gaps in primary care access and coordination, as well as compare prepandemic and postpandemic data across 3 Canadian provinces (Quebec, Ontario, and Nova Scotia). Multiple data sources will be used such as a policy review; qualitative interviews with primary care policymakers, providers (ie, family physicians, nurse practitioners, and pharmacists), and patients (N=120); and medication prescriptions and health care billing data. RESULTS: This study has received funding by the Canadian Institutes of Health Research COVID-19 Rapid Funding Opportunity Grant. Ethical approval to conduct this study was granted in Ontario (Queens Health Sciences & Affiliated Teaching Hospitals Research Ethics Board, file 6028052; Western University Health Sciences Research Ethics Board, project 116591; University of Toronto Health Sciences Research Ethics Board, protocol 40335) in November 2020, Québec (Centre intégré universitaire de santé et de services sociaux de l'Estrie, project 2020-3446) in December 2020, and Nova Scotia (Nova Scotia Health Research Ethics Board, file 1024979) in August 2020. CONCLUSIONS: To our knowledge, this is the first study of its kind to explore the effects of the COVID-19 pandemic on primary care systems, with particular focus on the issues of patient's attachment and access to primary care. Through a multistakeholder, cross-jurisdictional approach, the findings of the PUPPY study will inform the strengthening of primary care during and beyond the COVID-19 pandemic, as well as have implications for future policy and practice. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/29984.