Spontaneous Scaling of a Primary Care Innovation in Real-Life Conditions: Protocol for a Case Study.

BACKGROUND: Scaling effective primary care innovations to benefit more people is of interest to decision makers. However, we know little about how promising innovations are being scaled "spontaneously," that is, without deliberate guidance. OBJECTIVE: We aim to observe, document, and analyze how, in real-life conditions, 1 primary care innovation spontaneously scales up across Quebec, Canada. METHODS: We will conduct a participative study using a descriptive single-case study. It will be guided by the McLean and Gargani principles for scaling and reported according to the COREQ (Consolidated Criteria for Reporting Qualitative Research) guidelines. Informed by an integrated knowledge translation approach, our steering committee will include patient users throughout the project. Inspired by the Quebec College of Family Physician's "Dragons' Den" primary care program, we will identify a promising primary care innovation that is being or will be scaled spontaneously. We will interview the innovation team about their scaling experiences every month for 1 year. We will conduct interviews and focus groups with decision makers, health care providers, and end users in the innovation team and the target site about their experience of both scaling and receiving the scaled innovation and document meetings as nonparticipant observers. Interview transcripts and documentary data will be analyzed to (1) compare the spontaneous scaling plan and implementation with the McLean and Gargani principles for scaling and (2) determine how it was consistent with or diverged from the 4 McLean and Gargani guiding principles: justification, optimal scale, coordination, and dynamic evaluation. RESULTS: This study was funded in March 2020 by the Canadian Institutes of Health Research. Recruitment began in November 2023 and data collection began in December 2023. Results are expected to be published in the first quarter of 2024. CONCLUSIONS: Our study will advance the science of scaling by providing practical evidence-based material about scaling health and social care innovations in real-world settings using the 4 guiding principles of McLean and Gargani. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/54855.

Strategies used throughout the scaling-up process of eConsult - Multiple case study of four Canadian Provinces.

BACKGROUND: eConsult is a model of asynchronous communication connecting primary care providers to specialists to discuss patient care. This study aims to analyze the scaling-up process and identify strategies used to support scaling-up efforts in four provinces in Canada. METHODS: We conducted a multiple case study with four cases (ON, QC, MB, NL). Data collection methods included document review (n = 93), meeting observations (n = 65) and semi-structured interviews (n = 40). Each case was analyzed based on Milat's framework. RESULTS: The first scaling-up phase was marked by the rigorous evaluation of eConsult pilot projects and the publication of over 90 scientific papers. In the second phase, provinces implemented provincial multi-stakeholder committees, institutionalized the evaluation, and produced documents detailing the scaling-up plan. During the third phase, efforts were made to lead proofs of concept, obtain the endorsement of national and provincial organizations, and mobilize alternate sources of funding. The last phase was mainly observed in Ontario, where the creation of a provincial governance structure and strategies were put in place to monitor the service and manage changes. CONCLUSIONS: Various strategies need to be used throughout the scaling-up process. The process remains challenging and lengthy because health systems lack clear processes to support innovation scaling-up.

Evaluation of a Dragons' Den-inspired symposium to spread primary health care innovations in Quebec, Canada: a mixed-methods study using quality-improvement e-surveys.

BACKGROUND: On May 24, 2017, the Quebec College of Family Physicians held an innovation symposium inspired by the television show Dragons' Den, at which innovators pitched their innovations to Dragon-Facilitators (i.e., decision-makers) and academic family medicine clinical leads. We evaluated the effects of the symposium on the spread of primary health care innovations. METHODS: We conducted a mixed-methods evaluation of the symposium. We collected data related to Rogers' innovation-decision process using 3 quality-improvement e-surveys (distributed between May 2017 and February 2018). The first survey evaluated spread outputs (innovation discovery, intention to spread, improvements) and was sent to all participants immediately after the symposium. The second evaluated short-term spread outcomes (follow-ups, successes, barriers) and was sent to innovators 3 months after the symposium. The third evaluated medium-term spread outcomes (spread, perceived impact) and was sent to innovators and clinical leads 9 months after the symposium. We analyzed the data using descriptive statistics, content analysis and joint display. RESULTS: Fifty-one innovators, 66 clinical leads (representing 42 clinics) and 37 Dragon-Facilitators attended the symposium. The response rates for the surveys were 61% (82/134) for the immediate post-symposium survey of all participants; 68% (21/31) for the 3-month survey of innovators; and 49% (48/97) for the 9-month survey of clinical leads and innovators. Immediately after the symposium, clinical leads and Dragon-Facilitators reported a high likelihood of adopting an innovation (mean ± standard deviation 8.02 ± 1.63 on a 10-point Likert scale) and 87% (53/61) agreed that they had discovered innovations at the symposium. Nearly all innovators (95%, 20/21) intended to follow up with potential adopters. After 3 months, 62% (13/21) of innovators had followed up in some way. After 9 months, 72% of clinical leads (18/25) had implemented at least 1 innovation, and 52% of innovators (12/23) had spread or were in the process of spreading innovations. INTERPRETATION: The innovation symposium supported participants in achieving the early stages of spreading primary health care innovations. Replicating such symposia may help spread other health care innovations.

Impact of the Connected Medicine collaborative in improving access to specialist care: a cross-sectional analysis.

BACKGROUND: In 2017, the Canadian Foundation for Healthcare Improvement launched the Connected Medicine collaborative to support the implementation, spread and adaptation of 2 innovative remote consult solutions - the Champlain Building Access to Specialists through eConsultation (BASE) eConsult service and the Rapid Access to Consultative Expertise (RACE) service - across Canada. We evaluated the impact of the programs implemented through the collaborative. METHODS: We conducted a cross-sectional analysis of data from provincial teams that participated in the Connected Medicine collaborative, which took place between June 2017 and December 2018 in 7 provinces across Canada (British Columbia, Alberta, Saskatchewan, Manitoba, Quebec, New Brunswick, Newfoundland and Labrador). Data included utilization data collected automatically by the BASE and RACE services and, where available, responses to surveys completed by primary care providers at the end of each case. We assessed programs on the following outcomes: usage (i.e., number of cases completed, average specialist response time), number of specialties available, impact on primary care provider's decision to refer and impact on emergency department visits. We performed descriptive analyses. RESULTS: Ten provincial teams participated in the collaborative and implemented or adapted either the RACE service (4 teams), the BASE service (5 teams) or a combination of the 2 services (1 team). Average monthly case volume per team ranged from 14.7 to 424.5. All programs offered multispecialty access, with specialists from 5 to 37 specialty groups available. Specialists responded to eConsults within 7 days in 80% (n = 294/368) to 93% (n = 164/176) of cases. Six programs provided survey data on avoidance of referrals, which occurred in 48% (n = 667/1389) to 76% (n = 302/398) of cases. Two programs reported on the avoidance of potential emergency department visits, noting that originally considered referrals were avoided in 28% (n = 138/492) and 74% (n = 127/171) of cases, respectively. INTERPRETATION: The 2 innovative virtual care solutions implemented through the Connected Medicine collaborative received widespread usage and affected primary care providers' decisions to refer patients to specialists. The impact of these models of care in multiple settings shows that they are an effective means to move beyond the pilot stage and achieve spread and scale.

Scaling up eConsult for access to specialists in primary healthcare across four Canadian provinces: study protocol of a multiple case study.

BACKGROUND: Canada has been referred to as the land of 'perpetual pilot projects'. Effective innovations often remain small in scale, with limited impact on health systems. Several innovations have been developed in Canada to tackle important challenges such as poor access to services and excessive wait times - one of the most promising innovations that has been piloted is eConsult, which is a model of asynchronous communication that allows primary care providers to electronically consult with specialists regarding their patients' medical issues. eConsult pilot projects have been shown to reduce wait times for specialist care, prevent unnecessary referrals and reduce health system costs. eConsult has been spread throughout Ontario as well as to certain regions in Manitoba, Quebec, and Newfoundland and Labrador. Our aim is to understand and support the scale-up process of eConsult in Ontario, Quebec, Manitoba, and Newfoundland and Labrador. Our specific objectives are to (1) describe the main components of eConsult relevant to the scale-up process in each province; (2) understand the eConsult scale-up process in each province and compare across provinces; (3) identify policy issues and strategies to scaling up eConsult in each province; and (4) foster cross-level and cross-jurisdictional learning on scaling up eConsult. METHODS: We will conduct a qualitative multiple case study to investigate the scaling up of eConsult in four Canadian provinces using a grey literature review, key stakeholder interviews (10 interviews/province), non-participant observations, focus groups and deliberative dialogues. We will identify the main components of eConsult to be scaled up using logic models (obj. 1). Scaling up processes will be analysed using strategies adapted from process research (obj. 2). Policy issues and strategies to scale-up eConsult will be analysed thematically (obj. 3). Finally, a symposium will foster pan-Canadian learning on the process of scaling up eConsult (obj. 4). DISCUSSION: This study will likely increase learning and support evidence-based policy-making across participating provinces and may improve the capacity for a pan-Canadian scale-up of eConsult, including in provinces where eConsult has not yet been implemented. This work is essential to inform how similar innovations can reshape our health systems in the evolving information age.

Improving the Referral Process, Timeliness, Effectiveness, and Equity of Access to Specialist Medical Services Through Electronic Consultation: Pilot Study.

BACKGROUND: Access to specialty care remains a major challenge in the Canadian health care system. Electronic consultation (eConsult) services allow primary care providers to seek specialist advice often without needing the patient to go for a face-to-face consultation. It improves overall access to specialists and the referral process using an electronic care consultation service in urban and rural primary care clinics. This study describes the preliminary results of a pilot study with an eConsult service across 3 regions in the province of Quebec, Canada. OBJECTIVE: The main objective of this study was to provide a 1-year snapshot of the implementation of the eConsult Quebec Service in rural and urban primary care clinics to improve access to care and the specialty referral process for primary care providers (PCPs). METHODS: We established an eConsult service that covers urban and rural communities in 3 regions of Quebec. We conducted a quantitative analysis of all eConsult cases submitted from July 4, 2017, to December 8, 2018. RESULTS: For over a year, 1016 eConsults have been generated during the course of this study. A total of 97 PCPs submitted requests to 22 specialty groups and were answered by 40 different specialists. The most popular specialty was internal medicine (224/1016, 22%). Overall, 63% (640/1016) of completed cases did not require a face-to-face visit. PCPs rated the service as being of high or very high value for themselves in 98% (996/1016) of cases. CONCLUSIONS: The preliminary data highlight the success of the implementation of the eConsult Quebec Service across 6 primary care clinics. The eConsult platform proves to be effective, efficient, and well received by both patients and physicians. If used more widely, eConsult could help reducing wait times significantly. Recently, the Ministry of Health and Social Services of Quebec has identified developing a strategic plan to scale eConsults throughout other regions of the province as a top priority.

Preventable obstetrical interventions: how many caesarean sections can be prevented in Canada?

Public health authorities have been alarmed by the progressive rise in rates of Caesarean section in Canada, approaching one birth in three in several provinces. We aimed therefore to consider what were preventable obstetrical interventions in women with a low-risk pregnancy and to propose an analytic framework for the reduction of the rate of CS. We obtained statistical variations of CS rates over time, across regions, and within professional practices from MED-ÉCHO, the Quebec hospitalization database, from 1969 to 2009. Data were extracted from a recent systematic review of the cascade of obstetrical interventions to calculate the population-attributable fractions for each intervention associated with an increased probability of CS. We thereby identified expectant management (as an alternative to labour induction) and planned vaginal birth after CS as the leading strategies for potentially reducing rates of CS in women at low risk. For vaginal birth after CS, an increase to its 1995 level could lower the current CS rate of 23.2% (2009 to 2010) to 21.0%. Other alternatives to obstetrical interventions with a potential for lowering CS rates included non-pharmacological pain control methods (such as continuous support during childbirth) in addition to usual care, intermittent auscultation of the fetal heart (instead of electronic fetal monitoring), and multidisciplinary internal quality assessment audits. We believe, therefore, that the concept of preventable CS is supported by empirical evidence, and we identified realistic strategies to maintain a CS rate in Quebec near 20%.

Les autorités en matière de santé publique ont été alarmées par la hausse graduelle des taux de césarienne (CS) au Canada (près d'une naissance sur trois dans plusieurs provinces). Nous avons donc cherché à identifier les interventions obstétricales qui pouvaient être évitées chez les femmes qui connaissent une grossesse les exposant à de faibles risques, ainsi qu'à proposer un cadre analytique pour la réduction du taux de CS. Les variations statistiques, entre 1969 et 2009, des taux de CS avec le temps, d'une région à l'autre et en fonction des pratiques professionnelles ont été tirées de MED-ÉCHO (la base de données sur l'hospitalisation au Québec). Des données ont été tirées d'une récente analyse systématique de la cascade d'interventions obstétricales en vue de calculer les fractions étiologiques du risque pour chacune des interventions associées à une probabilité accrue de CS. Nous avons ainsi identifié la prise en charge non interventionniste (à titre de solution de rechange au déclenchement du travail) et l'accouchement vaginal planifié après CS comme étant les principales stratégies pouvant permettre la réduction des taux de CS chez les femmes exposées à de faibles risques. Pour ce qui est de l'accouchement vaginal après CS, une hausse jusqu'à son niveau de 1995 pourrait faire passer le taux actuel de CS de 23,2 % (de 2009 à 2010) à 21,0 %. Parmi les solutions de rechange aux interventions obstétricales qui présentent le potentiel d'abaisser les taux de CS, on trouvait les méthodes non pharmacologiques de maîtrise de la douleur (comme l'offre d'un soutien continu pendant l'accouchement) s'ajoutant aux soins habituels, l'auscultation intermittente du cœur fœtal (plutôt que le monitorage électronique du fœtus) et les audits internes multidisciplinaires de la qualité. Nous estimons donc que le concept de la CS évitable est soutenu par des données empiriques et nous avons identifié des stratégies réalistes permettant d'assurer le maintien, au Québec, d'un taux de CS se situant près de 20 %.