Understanding and addressing changing administrative workload in primary care in Canada: protocol for a mixed-method study.

INTRODUCTION: Many Canadians struggle to access the primary care they need while at the same time primary care providers report record levels of stress and overwork. There is an urgent need to understand factors contributing to the gap between a growing per-capita supply of primary care providers and declines in the availability of primary care services. The assumption of responsibility by primary care teams for services previously delivered on an in-patient basis, along with a rise in administrative responsibilities may be factors influencing reduced access to care. METHODS AND ANALYSIS: In this mixed-methods study, our first objective is to determine how the volume of services requiring primary care coordination has changed over time in the Canadian provinces of Nova Scotia and New Brunswick. We will collect quantitative administrative data to investigate how services have shifted in ways that may impact administrative workload in primary care. Our second objective is to use qualitative interviews with family physicians, nurse practitioners and administrative team members providing primary care to understand how administrative workload has changed over time. We will then identify priority issues and practical response strategies using two deliberative dialogue events convened with primary care providers, clinical and system leaders, and policy-makers.We will analyse changes in service use data between 2001/2002 and 2021/2022 using annual total counts, rates per capita, rates per primary care provider and per primary care service. We will conduct reflexive thematic analysis to develop themes and to compare and contrast participant responses reflecting differences across disciplines, payment and practice models, and practice settings. Areas of concern and potential solutions raised during interviews will inform deliberative dialogue events. ETHICS AND DISSEMINATION: We received research ethics approval from Nova Scotia Health (#1028815). Knowledge translation will occur through dialogue events, academic papers and presentations at national and international conferences.

Factors influencing practice choices of early-career family physicians in Canada: a qualitative interview study.

BACKGROUND: Comprehensiveness of primary care has been declining, and much of the blame has been placed on early-career family physicians and their practice choices. To better understand early-career family physicians' practice choices in Canada, we sought to identify the factors that most influence their decisions about how to practice. METHODS: We conducted a qualitative study using framework analysis. Family physicians in their first 10 years of practice were recruited from three Canadian provinces: British Columbia, Ontario, and Nova Scotia. Interview data were coded inductively and then charted onto a matrix in which each participant's data were summarized by code. RESULTS: Of the 63 participants that were interviewed, 24 worked solely in community-based practice, 7 worked solely in focused practice, and 32 worked in both settings. We identified four practice characteristics that were influenced (scope of practice, practice type and model, location of practice, and practice schedule and work volume) and three categories of influential factors (training, professional, and personal). CONCLUSIONS: This study demonstrates the complex set of factors that influence practice choices by early-career physicians, some of which may be modifiable by policymakers (e.g., policies and regulations) while others are less so (e.g., family responsibilities). Participants described individual influences from family considerations to payment models to meeting community needs. These findings have implications for both educators and policymakers who seek to support and expand comprehensive care.

Engaging the collective voice of physicians: Optimizing participation in research and policy development in the context of COVID-19 and physician burnout.

Physicians and governments work collaboratively to determine optimal healthcare policy options. Physicians are also engaged by health researchers to participate in studies. Physician engagement can be impeded by limits on physician time and remuneration for engagement, and the impact of physician burnout (exacerbated by COVID-19). Doctors Nova Scotia engaged physicians on various research and policy items throughout the pandemic. Strategies included integrating physicians into research teams, remunerating engagement activities, and leveraging existing tools and networks. Health researchers and policy-makers can improve physician engagement through physician champions, reduction of research duplication, valuing of physician contributions, and integrating networks.

For health or for profit? Understanding how private financing and for-profit delivery operate within Canadian healthcare (4H|4P): protocol for a multimethod knowledge mobilisation research project.

INTRODUCTION: Privatisation through the expansion of private payment and investor-owned corporate healthcare delivery in Canada raises potential conflicts with equity principles on which Medicare (Canadian public health insurance) is founded. Some cases of privatisation are widely recognised, while others are evolving and more hidden, and their extent differs across provinces and territories likely due in part to variability in policies governing private payment (out-of-pocket payments and private insurance) and delivery. METHODS AND ANALYSIS: This pan-Canadian knowledge mobilisation project will collect, classify, analyse and interpret data about investor-owned privatisation of healthcare financing and delivery systems in Canada. Learnings from the project will be used to develop, test and refine a new conceptual framework that will describe public-private interfaces operating within Canada's healthcare system. In Phase I, we will conduct an environmental scan to: (1) document core policies that underpin public-private interfaces; and (2) describe new or emerging forms of investor-owned privatisation ('cases'). We will analyse data from the scan and use inductive content analysis with a pragmatic approach. In Phase II, we will convene a virtual policy workshop with subject matter experts to refine the findings from the environmental scan and, using an adapted James Lind Alliance Delphi process, prioritise health system sectors and/or services in need of in-depth research on the impacts of private financing and investor-owned delivery. ETHICS AND DISSEMINATION: We have obtained approval from the research ethics boards at Simon Fraser University, University of British Columbia and University of Victoria through Research Ethics British Columbia (H23-00612). Participants will provide written informed consent. In addition to traditional academic publications, study results will be summarised in a policy report and a series of targeted policy briefs distributed to workshop participants and decision/policymaking organisations across Canada. The prioritised list of cases will form the basis for future research projects that will investigate the impacts of investor-owned privatisation.

An analysis of policies supporting the roles of family physicians in four regions in Canada during the COVID-19 pandemic.

Policy supports are needed to ensure that Family Physicians (FPs) can carry out pandemic-related roles. We conducted a document analysis in four regions in Canada to identify regulation, expenditure, and public ownership policies during the COVID-19 pandemic to support FP pandemic roles. Policies supported FP roles in five areas: FP leadership, Infection Prevention and Control (IPAC), provision of primary care services, COVID-19 vaccination, and redeployment. Public ownership polices were used to operate assessment, testing and vaccination, and influenza-like illness clinics and facilitate access to personal protective equipment. Expenditure policies were used to remunerate FPs for virtual care and carrying out COVID-19-related tasks. Regulatory policies were region-specific and used to enact and facilitate virtual care, build surge capacity, and enforce IPAC requirements. By matching FP roles to policy supports, the findings highlight different policy approaches for FPs in carrying out pandemic roles and will help to inform future pandemic preparedness.

"There's nothing like a good crisis for innovation": a qualitative study of family physicians' experiences with virtual care during the COVID-19 pandemic.

BACKGROUND: Prior to the pandemic, Canada lagged behind other Organisation for Economic Cooperation and Development countries in the uptake of virtual care. The onset of COVID-19, however, resulted in a near-universal shift to virtual primary care to minimise exposure risks. As jurisdictions enter a pandemic recovery phase, the balance between virtual and in-person visits is reverting, though it is unlikely to return to pre-pandemic levels. Our objective was to explore Canadian family physicians' perspectives on the rapid move to virtual care during the COVID-19 pandemic, to inform both future pandemic planning for primary care and the optimal integration of virtual care into the broader primary care context beyond the pandemic. METHODS: We conducted semi-structured interviews with 68 family physicians from four regions in Canada between October 2020 and June 2021. We used a purposeful, maximum variation sampling approach, continuing recruitment in each region until we reached saturation. Interviews with family physicians explored their roles and experiences during the pandemic, and the facilitators and barriers they encountered in continuing to support their patients through the pandemic. Interviews were audio-recorded, transcribed, and thematically analysed for recurrent themes. RESULTS: We identified three prominent themes throughout participants' reflections on implementing virtual care: implementation and evolution of virtual modalities during the pandemic; facilitators and barriers to implementing virtual care; and virtual care in the future. While some family physicians had prior experience conducting remote assessments, most had to implement and adapt to virtual care abruptly as provinces limited in-person visits to essential and urgent care. As the pandemic progressed, initial forays into video-based consultations were frequently replaced by phone-based visits, while physicians also rebalanced the ratio of virtual to in-person visits. Medical record systems with integrated capacity for virtual visits, billing codes, supportive clinic teams, and longitudinal relationships with patients were facilitators in this rapid transition for family physicians, while the absence of these factors often posed barriers. CONCLUSION: Despite varied experiences and preferences related to virtual primary care, physicians felt that virtual visits should continue to be available beyond the pandemic but require clearer regulation and guidelines for its appropriate future use.

The roles of family physicians during a pandemic.

Family physicians play important roles throughout all stages of a pandemic response; however, actionable descriptions outlining these roles are absent from current pandemic plans. Using a multiple case study design, we conducted a document analysis and interviewed 68 family physicians in four Canadian regions. We identified roles performed by family physicians in five distinct stages of pandemic response: pre-pandemic, phased closure and re-opening, acute care crisis, vaccination, and pandemic recovery. In addition to adopting public health guidance to ensure continued access to primary care services, family physicians were often expected to operationalize public health roles (eg, staffing assessment centres), modulate access to secondary/tertiary services, help provide surge capacity in acute care facilities, and enhance supports and outreach to vulnerable populations. Future pandemic plans should include family physicians in planning, explicitly incorporate family physician roles, and ensure needed resources are available to allow for an effective primary care response.

Family physician leadership during the COVID-19 pandemic: roles, functions and key supports.

PURPOSE: Strong leadership in primary care is necessary to coordinate an effective pandemic response; however, descriptions of leadership roles for family physicians are absent from previous pandemic plans. This study aims to describe the leadership roles and functions family physicians played during the COVID-19 pandemic in Canada and identify supports and barriers to formalizing these roles in future pandemic plans. DESIGN/METHODOLOGY/APPROACH: This study conducted semi-structured qualitative interviews with family physicians across four regions in Canada as part of a multiple case study. During the interviews, participants were asked about their roles during each pandemic stage and the facilitators and barriers they experienced. Interviews were transcribed and a thematic analysis approach was used to identify recurring themes. FINDINGS: Sixty-eight family physicians completed interviews. Three key functions of family physician leadership during the pandemic were identified: conveying knowledge, developing and adapting protocols for primary care practices and advocacy. Each function involved curating and synthesizing information, tailoring communications based on individual needs and building upon established relationships. PRACTICAL IMPLICATIONS: Findings demonstrate the need for future pandemic plans to incorporate formal family physician leadership appointments, as well as supports such as training, communication aides and compensation to allow family physicians to enact these key roles. ORIGINALITY/VALUE: The COVID-19 pandemic presents a unique opportunity to examine the leadership roles of family physicians, which have been largely overlooked in past pandemic plans. This study's findings highlight the importance of these roles toward delivering an effective and coordinated pandemic response with uninterrupted and safe access to primary care.

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.

Government policies targeting primary care physician practice from 1998-2018 in three Canadian provinces: A jurisdictional scan.

Primary care is the foundation of health care systems around the world. Physician autonomy means that governments rely on a limited selection of levers to implement reforms in primary care delivery, and these policies may impact the practice choices, intentions, and patterns of primary care physicians. Using a systematic search strategy to capture publicly available policy documents, we conducted a scan of such policies from 1998 to 2018 in three Canadian provinces: British Columbia, Nova Scotia, and Ontario. We reviewed 388 documents and extracted 170 policies from their texts, followed by analysis of the policies' instruments, actors, and topic areas. Policy reforms across the three provinces were primarily focused on physician payment, with governments relying on both targeted incentives and reformed payment models. Policies also employed various instruments to target priority areas of practice: 24/7 access to care, team-based primary care, unattached patients, eHealth, and rural/Northern recruitment of physicians. Across the three provinces and the 20-year timespan, reform priorities and instruments were largely uniform, with Ontario's policies tending to be the most diverse. Physicians helped shape reforms through the agreements negotiated between provincial governments and medical associations, influencing the topics and timing of reforms. Future research should evaluate impacts on the delivery of primary care and explore opportunities for policy innovation.

Practice patterns among early-career primary care (ECPC) physicians and workforce planning implications: protocol for a mixed methods study.

INTRODUCTION: Canadians report persistent problems accessing primary care despite an increasing per-capita supply of primary care physicians (PCPs). There is speculation that PCPs, especially those early in their careers, may now be working less and/or choosing to practice in focused clinical areas rather than comprehensive family medicine, but little evidence to support or refute this. The goal of this study is to inform primary care planning by: (1) identifying values and preferences shaping the practice intentions and choices of family medicine residents and early career PCPs, (2) comparing practice patterns of early-career and established PCPs to determine if changes over time reflect cohort effects (attributes unique to the most recent cohort of PCPs) or period effects (changes over time across all PCPs) and (3) integrating findings to understand the dynamics among practice intentions, practice choices and practice patterns and to identify policy implications. METHODS AND ANALYSIS: We plan a mixed-methods study in the Canadian provinces of British Columbia, Ontario and Nova Scotia. We will conduct semi-structured in-depth interviews with family medicine residents and early-career PCPs and analyse survey data collected by the College of Family Physicians of Canada. We will also analyse linked administrative health data within each province. Mixed methods integration both within the study and as an end-of-study step will inform how practice intentions, choices and patterns are interrelated and inform policy recommendations. ETHICS AND DISSEMINATION: This study was approved by the Simon Fraser University Research Ethics Board with harmonised approval from partner institutions. This study will produce a framework to understand practice choices, new measures for comparing practice patterns across jurisdictions and information necessary for planners to ensure adequate provider supply and patient access to primary care.