Using positive deviance to improve timely access in primary care.

BACKGROUND: Improving timely access in primary care is a continued challenge in many countries. We used positive deviance to try and identify best practices for achieving timely access in our primary care organisation in Toronto, Canada. METHODS: Semistructured interviews were used to identify practice strategies used by physicians who successfully maintained a low third next available appointment (TNA) (positive deviants, n=6). We then conducted a cross-sectional survey to understand the prevalence of identified promising practices among all physicians (n=70) in the practice. We used χ2 testing to understand whether uptake of promising practices among survey respondents was different for those with a median TNA of 7 days or less vs a median TNA over 7 days. RESULTS: We identified seven promising practice strategies used by positive deviants: adjusting the appointment template based on demand; reviewing the appointment schedule in advance; max-packing of visits; using phone, email and secure messaging; customising care for complex patients; managing planned absences; and involving the interprofessional team. 65 of 70 physicians responded to the survey on promising practices. Uptake of the promising practices was variable among survey respondents. In general, we found no association between uptake of promising practices and median TNA. One exception was that those with a median TNA of 7 or less were more likely to review the schedule in advance to potentially mitigate a visit using phone/email (62% vs 31%, p=0.0159). CONCLUSION: Promising practices used by a small group of physicians ('positive deviants') to maintain good access were generally not associated with timely access among a larger sample of physicians in the practice. Our findings highlight the difficulty of untangling physician practice style and its contribution to timely access in primary care.

Understanding disparities in primary care patient experience.

OBJECTIVE: To understand disparities in primary care patient experience. DESIGN: A serial cross-sectional study was conducted to understand disparities in patient experience at 2 time points (2014 and 2016). Disparities related to age, gender, neighbourhood income, and self-rated health were explored using 3 analytic approaches: stratification, logistic regression, and relative comparison across multiple demographic variables. SETTING: A multisite family health team in Toronto, Ont. PARTICIPANTS: Patients in the family medicine practice who completed e-mail surveys in 2014 (n = 1171, 19% response rate) and 2016 (n = 1823, 15% response rate). MAIN OUTCOME MEASURES: Patient-reported access (timely access when sick, access after hours) and patient-centredness (opportunity to ask questions, involvement in care decisions, enough time with provider). RESULTS: Performance for all measures improved between 2014 and 2016, with the greatest absolute improvement seen in access after hours (61% in 2014; 75% in 2016). Patients residing in low-income neighbourhoods reported worse patient experiences than those in high-income neighbourhoods did, as did patients with poor versus excellent self-rated health, even after adjustment for other variables. For example, in 2016, 60% of patients residing in low-income neighbourhoods reported timely access when sick versus 70% in high-income neighbourhoods (adjusted odds ratio of 0.67, 95% CI 0.47 to 0.95); 60% of patients with poor or fair self-rated health reported timely access when sick versus 72% with excellent self-rated health (adjusted odds ratio of 0.54, 95% CI 0.35 to 0.84). Comparing across demographic groups, patients with excellent self-rated health and poor or fair self-rated health reported the best and worst experiences, respectively, for all measures. In 2016, the average disparity between subgroups was largest for access after hours. CONCLUSION: In this setting, patient experience was worse for patients in lower-income neighbourhoods and those with poor or fair self-rated health. Access after hours demonstrated the greatest overall absolute improvement but also the greatest widening of disparities.

Partnering with patients to improve access to primary care.

Continuity and timely access are hallmarks of high-quality primary care and are important considerations for urgent concerns that present both during the day and after-hours. It can be especially difficult to ensure continuity of primary care after-hours in urban settings where walk-in clinics offer patients easy and convenient access. Patients of our large, multisite primary care practice in inner-city Toronto, Canada were reporting that they were not easily able to access after-hours care from their team without having to use outside services. In partnership with patients, we combined the Model for Improvement with Experience-Based Design methodology to address the issue of poor access to after-hours care. We did a root cause analysis to isolate the causes of the local problem, using a variety of capture tools designed to incorporate the patient voice. Then, patients and providers codesigned two Plan-Do-Study-Act (PDSA) cycles aimed to increase the ease of accessing after-hours care. Key actions included a redesign of our after-hours advertisement and communication of the material in multiple formats. Following these PDSA cycles, the team saw a 26%, 23% and 17% increase in awareness of weekday evening clinics, weekend clinics and after-hours phone services, respectively, and a 16% increase in the proportion of patients reporting that it was very or somewhat easy to get care during the evening, on the weekend or on a holiday from their care team. Measures continued to improve and improvements have been sustained 3 years later. Our success highlights the effectiveness of partnering with patients to improve access to primary care.

Cancer screening rates among transgender adults: Cross-sectional analysis of primary care data.

OBJECTIVE: To compare rates of cervical, breast, and colorectal cancer screening between patients who are transgender and those who are cisgender (ie, nontransgender). DESIGN: Cross-sectional study. SETTING: A multisite academic family health team in Toronto, Ont, serving more than 45 000 enrolled patients. PARTICIPANTS: All patients enrolled in the family health team who were eligible for cervical, breast, or colorectal cancer screening. Patients were identified as transgender using an automated search of the practice electronic medical record followed by manual audit. MAIN OUTCOME MEASURES: Screening rates for cervical, breast, and colorectal cancer calculated using data from the electronic medical record and provincial cancer screening registry. Screening rates among the transgender and cisgender populations were compared using 2 tests, and logistic regression modeling was used to understand differences in screening after adjustment for age, neighbourhood income quintile, and number of primary care visits. RESULTS: A total of 120 transgender patients were identified as eligible for cancer screening. More than 85% of transgender patients eligible for breast cancer screening were assigned male at birth. Transgender patients were less likely than cisgender patients (n = 20 514) were to be screened for cervical (56% vs 72%, P = .001; adjusted odds ratio [OR] of 0.39; 95% CI 0.25 to 0.62), breast (33% vs 65%, P < .001; adjusted OR = 0.27; 95% CI 0.12 to 0.59), and colorectal cancer (55% vs 70%, P = .046; adjusted OR = 0.50; 95% CI 0.26 to 0.99). CONCLUSION: In this setting, transgender patients were less likely to receive recommended cancer screening compared with the cisgender population. Future research and quality improvement activities should aim to understand and address potential patient, provider, and system factors.

Mailed Letter Versus Phone Call to Increase Uptake of Cancer Screening: A Pragmatic, Randomized Trial.

BACKGROUND: There is good evidence that cancer-specific patient outreach improves rates of cervical, breast, and colorectal cancer screening. However, it is unclear how primary care practices should implement integrated outreach for all 3 types of cancer screening. We aimed to understand whether integrated outreach using mailed letters or phone calls were more effective at increasing screening uptake in a primary care organization. METHOD: We conducted a pragmatic randomized trial comparing outreach by mailed letter or personalized phone call for patients overdue for cervical, breast, or colorectal cancer screening. The study was conducted at 6 clinics within an academic primary care organization in Toronto, Canada. Our primary outcome was an uptake of at least 1 screening test for which the patient was overdue. Our primary analysis was an intention-to-treat, unadjusted comparison of proportions, using a χ2 test. We also compared costs per additional patient screened. All analyses were stratified by sex. RESULTS: A total of 3733 females and 1537 males were randomized to receive 1 of the interventions. Among women, 33.0% allocated to receive a reminder letter and 41.2% allocated to receive a reminder phone call received at least 1 screening test for which they were due (absolute difference, 8.1%; 95% CI, 5.1%-11.2%, P < .001). Among men, 24.8% allocated to receive a reminder letter and 28.8% allocated to a reminder phone call received screening for colorectal cancer (absolute difference, 4.1%; 95% CI, -0.4% to 8.5%, P = .073). For women and men, the letters cost approximately CaD $5.07 and CaD $7.16, respectively, for each completed screening test compared with CaD $8.71 and CaD $12.00 for the phone calls. CONCLUSIONS: Phone calls were more effective than mailed letters at increasing uptake for cervical, breast, and colorectal cancer screening among women. However, phone calls were more expensive than letters. Primary care practices should consider integrating phone call reminders into their practice, possibly as part of a targeted or staged approach to outreach for cancer screening.

Measuring and improving cervical, breast, and colorectal cancer screening rates in a multi-site urban practice in Toronto, Canada.

Our Family Health Team is located in Toronto, Canada and provides care to over 35 000 patients. Like many practices in Canada, we took an opportunistic approach to cervical, breast, and colorectal cancer screening. We wanted to shift to a proactive, population-based approach but were unable to systematically identify patients overdue for screening or calculate baseline screening rates. Our initiative had two goals: (1) to develop a method for systematically identifying patients eligible for screening and whether they were overdue and (2) to increase screening rates for cervical, breast, and colorectal cancer. Using external government data in combination with our practice's electronic medical record, we developed a process to identify patients eligible and overdue for cancer screening. After generating baseline data, we implemented an evidence-based, multifaceted intervention to improve cancer screening rates. We sent a personalized reminder letter to overdue patients, provided physicians with practice-level audit and feedback, and improved our electronic reminder function by updating charts with accurate data on the Fecal Occult Blood Test (FOBT). Following our initial intervention, we sought to maintain and further improve our screening rates by experimenting with alternative recall methods and collecting patient feedback. Screening rates significantly improved for all three cancers. Between March 2014 and December 2016, the cervical cancer screening rate increased from 60% to 71% (p<0.05), the breast cancer screening rate increased from 56% to 65% (p<0.05), and the overall colorectal screening rate increased from 59% to 70% (p<0.05). The increase in colorectal screening rates was largely due to an increase in FOBT screening from 18% to 25%, while colonoscopy screening remained relatively unchanged, shifting from 45% to 46%. We also found that patients living in low income neighbourhoods were less likely to be screened. Following our intervention, this equity gap narrowed modestly for breast and colorectal cancer but did not change for cervical cancer screening. Our future improvement efforts will be focused on reducing the gap in screening between patients living in low-income and high-income neighbourhoods while maintaining overall gains.