How long does it take patients to find a new primary care physician when theirs retires: a population-based, longitudinal study.

BACKGROUND: The retirement of a family physician can represent a challenge in accessibility and continuity of care for patients. In this population-based, longitudinal cohort study, we assess whether and how long it takes for patients to find a new majority source of primary care (MSOC) when theirs retires, and we investigate the effect of demographic and clinical characteristics on this process. METHODS: We used provincial health insurance records to identify the complete cohort of patients whose majority source of care left clinical practice in either 2007/2008 or 2008/2009 and then calculated the number of days between their last visit with their original MSOC and their first visit with their new one. We compared the clinical and sociodemographic characteristics of patients who did and did not find a new MSOC in the three years following their original physician's retirement using Chi-square and Fisher's exact test. We also used Cox proportional hazards models to determine the adjusted association between patient age, sex, socioeconomic status, location and morbidity level (measured using Johns Hopkins' Aggregated Diagnostic Groupings), and time to finding a new primary care physician. We produce survival curves stratified by patient age, sex, income and morbidity. RESULTS: Fifty-four percent of patients found a new MSOC within the first 12 months following their physician's retirement. Six percent of patients still had not found a new physician after 36 months. Patients who were older and had higher levels of morbidity were more likely to find a new MSOC and found one faster than younger, healthier patients. Patients located in more urban regional health authorities also took longer to find a new MSOC compared to those in rural areas. CONCLUSIONS: Primary care physician retirements represent a potential threat to accessibility; patients followed in this study took more than a year on average to find a new MSOC after their physician retired. Providing programmatic support to retiring physicians and their patients, as well as addressing shortages of longitudinal primary care more broadly could help to ensure smoother retirement transitions.

Is attending birth dying out? Trends in obstetric care provision among primary care physicians in British Columbia.

OBJECTIVE: To examine trends in and sociodemographic predictors of the provision of obstetric care within the primary care context among physicians in British Columbia (BC). DESIGN: Population-based, longitudinal cohort study using administrative data. SETTING: British Columbia. PARTICIPANTS: All primary care physicians practising in BC between 2005-2006 and 2011-2012. MAIN OUTCOME MEASURES: Fee-for-service payment records were used to identify the provision of prenatal and postnatal care and deliveries. The proportions of physicians who attended deliveries and who included any obstetric care provision in their practices were examined over time using longitudinal mixed-effects log-linear models. RESULTS: The proportion of physicians attending deliveries or providing any obstetric care declined significantly over the study period (deliveries: odds ratio [OR] of 0.92, 95% CI 0.89-0.95; obstetric care: OR = 0.92, 95% CI 0.89-0.95), and obstetric care provision accounted for a smaller proportion of overall practice activity (OR = 0.96, 95% CI 0.94-0.99). Female physicians had higher odds of including obstetric care in their practices (OR = 1.46, 95% CI 1.27-1.69), and by 2011-2012 had significantly higher odds of attending deliveries (OR = 1.22, 95% CI 1.05-1.38). Older physicians and those located in metropolitan centres were less likely to provide obstetric care or attend deliveries. CONCLUSION: The provision of obstetric care by primary care physicians in BC declined over this period, suggesting the possibility of a growing access issue, particularly in rural and remote communities where family physicians are often the sole providers of obstetric services.

The Experience of Family Physicians and Home Health Staff Involved in an Intervention to Increase Patient-Related Collaboration.

Les médecins de famille (MF) et le personnel de soins de santé à domicile (PSD) canadiens rencontrent d'importants obstacles lorsqu'ils doivent collaborer pour la prestation de soins aux patients qu'ils ont en commun. Cette étude à méthodologie mixte visait à évaluer la qualité et la viabilité de l'utilisation de l'audioconférence sécurisée dans une optique d'amélioration de la planification des soins pour ces patients. Les données primaires incluaient les résultats d'un sondage réalisé avant et après l'intervention, ainsi que des entretiens semi-structurés et des groupes de discussion post-intervention. Des méthodes statistiques non paramétriques ont été utilisées pour analyser les résultats du sondage, et les données qualitatives ont fait l'objet d'une analyse thématique de contenu. Les résultats des analyses quantitatives et qualitatives ont ensuite été intégrés afin de faire ressortir les inférences reflétant les approches des MF et du PSD relatives aux obstacles et aux avantages de la planification interdisciplinaire des soins. Les MF et le PSD ont montré que des obstacles structurels limitent leur capacité à collaborer. Le PSD et les MF ont également convenu que les rencontres entre les intervenants des deux services étaient bénéfiques pour les patients et que l'utilisation de l'audioconférence constituait une méthode efficiente de planification collaborative des soins. Les limites comprenaient la petite taille de l'échantillon et la courte période d'intervention, compte tenu de l'ampleur des changements attendus.Canadian family physicians (FPs) and home health staff (HHS) experience significant barriers to patient-related collaboration about patients they share. This mixed-methods study sought to determine the quality and sustainability of secure audio conferencing as a way to increase care planning about shared patients. Primary data sources included pre-and post-study administration of a published survey and post-study semi-structured interviews and focus groups. Non-parametric statistical procedures were used to analyze survey results and thematic content analysis was undertaken for qualitative data. Results from both quantitative and qualitative analysis were integrated into the overall analysis, in order to draw inferences reflecting both approaches to barriers and benefits of collaborative care planning for FPs and HHS. Both FPs and HHS provided evidence that structural barriers impede their ability to collaborate. HHS and FPs also agreed that joint conferences were beneficial for patients, and that the use of audio conferencing provided an efficient method of collaborative care planning. Limitations included a small sample size and short timeline for the intervention period, given the magnitude of the expected change.

Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia.

PURPOSE: Providing care in alternative (non-office) locations and outside office hours are important elements of access and comprehensiveness of primary care. We examined the trends in and determinants of the services provided in a cohort of primary care physicians in British Columbia, Canada. METHODS: We used physician-level payments for all primary care physicians practicing in British Columbia from 2006-2007 through 2011-2012. We examined the association between physician demographics and practice characteristics and payment for care in alternative locations and after hours across rural, urban, and metropolitan areas using longitudinal mixed-effects models. RESULTS: The proportion of physicians who provided care in alternative locations and after hours declined significantly during the period, in rural, urban, and metropolitan practices. Declines ranged from 5% for long-term care facility visits to 22% for after-hours care. Female physicians, and those in the oldest age category, had lower odds of providing care at alternative locations and for urgent after-hours care. Compared with those practicing in metropolitan centers, physicians working in rural areas had significantly higher odds of providing care both in alternative locations and after hours. CONCLUSION: Care provided in non-office locations and after office hours declined significantly during the study period. Jurisdictions where providing these services are not mandated, and where similar workforce demographic shifts are occurring, may experience similar accessibility challenges.

The impact of the 2008/2009 financial crisis on specialist physician activity in Canada.

Fee-for-service physicians are responsible for planning for their retirements, and there is no mandated retirement age. Changes in financial markets may influence how long they remain in practice and how much they choose to work. The 2008 crisis provides a natural experiment to analyze elasticity in physician service supply in response to dramatic financial market changes. We examined quarterly fee-for-service data for specialist physicians over the period from 1999/2000 to 2013/2014 in Canada. We used segmented regression to estimate changes in the number of physicians receiving payments, per-physician service counts, and per-physician payments following the 2008 financial crisis and explored whether patterns differed by physician age. The number of specialist physicians increased more rapidly in the period since 2008 than in earlier years, but increases were largest within the youngest age group, and we observed no evidence of delayed retirement among older physicians. Where changes in service volume and payments were observed, they occurred across all ages and not immediately following the 2008 financial crisis. We conclude that any response to the financial crisis was small compared with demographic shifts in the physician population and changes in payments per service over the same time period.

Health Services Research Spending and Healthcare System Impact Comment on "Public Spending on Health Service and Policy Research in Canada, the United Kingdom, and the United States: A Modest Proposal".

The challenges associated with translating health services and policy research (HSPR) evidence into practice are many and long-standing. Indeed, those challenges have themselves spawned new areas of research, including knowledge translation and implementation science. These sub-disciplines have increased our understanding of the critical success factors associated with the uptake of research evidence into (system) practice. Engaging those for whom research evidence is likely to help solve implementation and/or policy problems, and ensuring that they are key partners throughout the research life-cycle, appear to us (based on current evidence) to be the most direct and effective paths to improved knowledge translation. In that regard, building on Canada's recent Strategy for Patient Oriented Research (SPOR) would seem to offer considerable promise. The "modest" proposals offered by Thakkar and Sullivan seem less likely to bear fruit.

Will the Real Physician Retirees Please Stand Up?

Policy makers and health workforce planners rely on counts of practice licences as a measure of the size of the active physician workforce. We use a population-based approach to correlate estimates of retirement from clinical care based on these data with those produced using physician payment data. We find that licensure data generates per-capita estimates of physician supply in British Columbia that are substantially higher than activity-based estimates. Licensure data are unlikely to produce reliable estimates of the timing and extent of physician retirement and therefore should not be used as the primary basis for estimating current or future physician supply.

Patterns of physician retirement and pre-retirement activity: a population-based cohort study.

BACKGROUND: Knowing when physicians retire and how they practise in the pre-retirement years is important information for health human resource planning. We identified patterns of retirement for physicians in British Columbia and the determinants of when and how physicians retire. METHODS: For this population-based retrospective cohort study, we used administrative data to examine activity levels and to identify retirements among BC's practising physicians. We included all physicians who were at least 50 years of age as of March 2006 and who had received payments for clinical services in at least 1 year between 2005/06 and 2011/12. We defined retirement as a permanent drop in monthly payments to less than $1667/month ($20 000/yr). We examined the patterns and timing of retirement by age, sex, specialty and location using linear and logistic regression models. RESULTS: Of the 4572 physicians who met the inclusion criteria, 1717 (37.6%) retired during the study period. The average age at retirement was 65.1 (standard deviation 7.8) years. Controlling for other demographic and practice characteristics, we found that women and physicians working in rural areas retired earlier, by 4.1 (95% confidence interval [CI] -4.9 to -3.2) years and 2.3 (95% CI -3.4 to -1.1) years, respectively. We found no difference in retirement age by specialty. We identified 4 patterns of pre-retirement activity: slow decline, rapid decline, maintenance and increasing activity. About 40% of physicians (440/1107) reduced their activity levels by at least 10% in the 3 years preceding retirement. INTERPRETATION: During the study period, physicians in BC - particularly women and those in rural areas - retired earlier than indicated by licensure and survey data. Many physicians reduced their practice activity in the pre-retirement years. These trends indicate that forecasts relying on licensure "head counts" are likely overestimating current and future physician supply.

In British Columbia, The Supply Of Primary Care Physicians Grew, But Their Rate Of Clinical Activity Declined.

Reports of a primary care shortage are ubiquitous in Canada and the United States. We used a population-based, retrospective cohort study to examine the extent to which the feminization and aging of the primary care physician workforce and secular trends may contribute to changes in the availability of primary care services. We used billing data for all primary care physicians in British Columbia for the period 2005-12. We used multivariate linear mixed-effects models to study physician remuneration and activity levels. We found limited change in per physician remuneration over the study period. However, numbers of patient contacts and practice sizes (numbers of unique patients) declined by 14 percent and 10 percent, respectively. Although the feminization of the workforce-and, to a lesser extent, its aging-contributed to this decline, the primary driver appears to be a broad trend toward reduced clinical activity over time. To the extent that similar trends are occurring in the United States, the implications of our study for the availability of primary care services beyond Canada are potentially significant.

Examining regional variation in health care spending in British Columbia, Canada.

Examining regional variation in health care spending may reveal opportunities for improved efficiency. Previous research has found that health care spending and service use vary substantially from place to place, and this is often not explained by differences in the health status of populations or by better outcomes in higher-spending regions, but rather by differences in intensity of service provision. Much of this research comes from the United States. Whether similar patterns are observed in other high-income countries is not clear. We use administrative data on health care use, covering the entire population of the Canadian province of British Columbia, to examine how and why health care spending varies among health regions. Pricing and insurance coverage are constant across the population, and we adjust for patient-level age, sex, and recorded diagnoses. Without adjusting for differences in population characteristics, per-capita spending is 50% higher in the highest-spending region than in the lowest. Adjusting for population characteristics as well as the very different environments for health service delivery that exist among metropolitan, non-metropolitan, and remote regions of the province, this falls to 20%. Despite modest variation in total spending, there are marked differences in mortality. In this context, it appears that policy reforms aimed at system-wide quality and efficiency improvement, rather than targeted at high-spending regions, will likely prove most promising.

Classifying physician practice style: a new approach using administrative data in British Columbia.

BACKGROUND: Primary medical care is changing-more female providers, desire for better work-life balance, and increasing availability of walk-in clinics have altered service delivery. There is no uniform physician practice style, and understanding service availability and delivery requires analysis of family physicians' practice patterns, rather than just physician counts. METHODS: This paper offers a new approach for describing the practice habits of primary care physicians. We use administrative data to identify activities associated with acting as "most responsible" physicians. We used British Columbia's administrative health care data from 2007/2008 to 2011/2012 to derive information regarding physicians, patients, and service delivery. We developed 5 variables to describe practice style: referrals, oversight, screening, initial prescribing for long-term medications, and repeat visits. Cluster analysis revealed 3 distinct groups of physicians. RESULTS: Only 24% of the primary care physicians were assigned to the high-responsibility group, whereas 36% and 39% were in the low-responsibility and mixed-practice groups, respectively. All cluster variables follow a similar pattern, with the high-responsibility and low-responsibility physicians many multiples apart on the means and the mixed group falling in between. Several forms of sensitivity analysis confirmed the robustness of these results. CONCLUSIONS: Physician practice patterns influence the effective supply of primary care. The fact that more than one third of British Columbia physicians are identified as "low responsibility" has implications for the delivery of primary care, both in ensuring that people have access to regular care and in insuring high-quality and comprehensive care.

Two wings and a prayer: should Canada make it easier for Canadian doctors trained abroad to enter practice here?

About 3,600 Canadians are currently studying medicine abroad (CSMAs). Most hope to return to practise in Canada. But the road back is not easy. These graduates must complete postgraduate residency training in Canada and alas, there are less openings than there are aspirants. One might have thought, amid the endless rhetoric of "physician shortages," that an obvious solution would be to increase the number of residency positions. But provincial governments are well aware, even if the media are not, that Canada is in the early stages of a dramatic expansion in physician supply fuelled by increased domestic training capacity. Last time the physician supply outpaced population growth, as it is doing today, governments choked off the entry of international graduates. It could happen again.

The implications of the feminization of the primary care physician workforce on service supply: a systematic review.

There is a widespread perception that the increasing proportion of female physicians in most developed countries is contributing to a primary care service shortage because females work less and provide less patient care compared with their male counterparts. There has, however, been no comprehensive investigation of the effects of primary care physician (PCP) workforce feminization on service supply. We undertook a systematic review to examine the current evidence that quantifies the effect of feminization on time spent working, intensity and scope of work, and practice characteristics. We searched Medline, Embase, and Web of Science from 1991 to 2013 using variations of the terms 'primary care', 'women', 'manpower', and 'supply and distribution'; screened the abstracts of all articles; and entered those meeting our inclusion criteria into a data abstraction tool. Original research comparing male to female PCPs on measures of years of practice, time spent working, intensity of work, scope of work, or practice characteristics was included. We screened 1,271 unique abstracts and selected 74 studies for full-text review. Of these, 34 met the inclusion criteria. Years of practice, hours of work, intensity of work, scope of work, and practice characteristics featured in 12%, 53%, 42%, 50%, and 21% of studies respectively. Female PCPs self-report fewer hours of work than male PCPs, have fewer patient encounters, and deliver fewer services, but spend longer with their patients during a contact and deal with more separate presenting problems in one visit. They write fewer prescriptions but refer to diagnostic services and specialist physicians more often. The studies included in this review suggest that the feminization of the workforce is likely to have a small negative impact on the availability of primary health care services, and that the drivers of observed differences between male and female PCPs are complex and nuanced. The true scale of the impact of these findings on future effective physician supply is difficult to determine with currently available evidence, given that few studies looked at trends over time, and results from those that did are inconsistent. Additional research examining gender differences in practice patterns and scope of work is warranted.

Health care services use in assisted living: a time series analysis.

This article describes British Columbia's regulatory model for assisted living and used time series analysis to examine individuals' use of health care services before and after moving to assisted living. The 4,219 assisted living residents studied were older and predominantly female, with 73 per cent having one or more major chronic conditions. Use of health care services tended to increase before the move to assisted living, drop at the time of the move (most notably for general practitioners, medical specialists, and acute care), and remain low for the 12-month follow-up period. These apparent positive effects are not trivial; the cohort of 1,894 assisted living residents used 18,000 fewer acute care days in the year after, compared to the year before, their move. Future research should address whether and how assisted living affects longer-term pathways of care for older adults and ultimately their function and quality of life.

Designation, diligence and drift: understanding laboratory expenditure increases in British Columbia, 1996/97 to 2005/06.

BACKGROUND: Laboratory testing is one of the fastest growing areas of health services spending in Canada. We examine the extent to which increases in laboratory expenditures might be explained by testing that is consistent with guidelines for the management of chronic conditions, by analyzing fee-for-service physician payment data in British Columbia from 1996/97 and 2005/06. METHOD: We used direct standardization to quantify the effect on laboratory expenditures from changes in: fee levels; population growth; population aging; treatment prevalence; expenditure on recommended tests for those conditions; and expenditure on other tests. The chronic conditions selected were those with guidelines containing laboratory recommendations developed by the BC Guidelines and Protocol Advisory Committee: diabetes, hypertension, congestive heart failure, renal failure, liver disease, rheumatoid arthritis, osteoarthritis and dementia. RESULT: Laboratory service expenditures increased by $98 million in 2005/06 compared to 1996/97, or 3.6% per year after controlling for population growth and aging. Testing consistent with guideline-recommended care for chronic conditions explained one-third (1.2% per year) of this growth. Changes in treatment prevalence were just as important, contributing 1.5% per year. Hypertension was the most common condition, but renal failure and dementia showed the largest changes in prevalence over time. Changes in other laboratory expenditure including for those without chronic conditions accounted for the remaining 0.9% growth per year. CONCLUSION: Increases in treatment prevalence were the largest driver of laboratory cost increases between 1996/97 and 2005/06. There are several possible contributors to increasing treatment prevalence, all of which can be expected to continue to put pressure on health care expenditures.

British Columbia hospitals: examination and assessment of payment reform (B-CHeaPR).

BACKGROUND: Accounting for 36% of public spending on health care in Canada, hospitals are a major target for cost reductions through various efficiency initiatives. Some provinces are considering payment reform as a vehicle to achieve this goal. With few exceptions, Canadian provinces have generally relied on global and line-item budgets to contain hospital costs. There is growing interest amongst policy-makers for using activity based funding (ABF) as means of creating financial incentives for hospitals to increase the 'volume' of care, reduce cost, discourage unnecessary activity, and encourage competition. British Columbia (B.C.) is the first province in Canada to implement ABF for partial reimbursement of acute hospitalization. To date, there have been no formal examinations of the effects of ABF policies in Canada. This study proposal addresses two research questions designed to determine whether ABF policies affect health system costs, access and hospital quality. The first question examines the impact of the hospital funding policy change on internal hospital activity based on expenditures and quality. The second question examines the impact of the change on non-hospital care, including readmission rates, amount of home care provided, and physician expenditures. METHODS/DESIGN: A longitudinal study design will be used, incorporating comprehensive population-based datasets of all B.C. residents; hospital, continuing care and physician services datasets will also be used. Data will be linked across sources using anonymized linking variables. Analytic datasets will be created for the period between 2005/2006 and 2012/2013. DISCUSSION: With Canadian hospitals unaccustomed to detailed scrutiny of what services are provided, to whom, and with what results, the move toward ABF is significant. This proposed study will provide evidence on the impacts of ABF, including changes in the type, volume, cost, and quality of services provided. Policy- and decision-makers in B.C. and elsewhere in Canada will be able to use this evidence as a basis for policy adaptations and modifications. The significance of this proposed study derives from the fact that the change in hospital funding policy has the potential to affect health system costs, residents' access to care and care quality.

The redistributive effect of the move from age-based to income-based prescription drug coverage in British Columbia, Canada.

OBJECTIVES: To explore the redistributive impact of two different pharmaceutical financing policies (age-based versus income-based pharmacare) on the distribution of income in British Columbia (B.C.), Canada. METHODS: Using household-level data on all payments that are used to finance prescription drugs in B.C. (including taxation and private payments), we performed a redistributive analysis to indicate how much income inequality in the province changed as a result of payments made for prescription drugs. We also illustrated changes in vertical equity (different treatment according to ability-to-pay) and horizontal equity (equals, according to ability-to-pay, being treated equally) between the two years separately through a pre-post policy examination. RESULTS: We found that payments made to finance prescription drugs increased overall income inequality in the province. This negative impact was larger after the move to income-based pharmacare. Our results also show increasing horizontal inequity after the policy change, and suggest that the increased reliance on out-of-pocket payments was a major source of the negative impact on the B.C.'s overall income distribution. We also show that the consequences of the move to income-based pharmacare would have been less severe had the level of public financing not decreased substantially between the two years. CONCLUSIONS: The increase in income inequality in B.C. following the policy change was an unintended consequence of the move to income-based pharmacare. This finding is worth consideration as countries and jurisdictions weigh pharmaceutical policy alternatives.

Will paying the piper change the tune?

Most provincial governments are considering or introducing changes to hospital funding. Ten years of rapidly increasing expenditures have left them still facing complaints of waiting lists and waiting times. Activity-based funding (ABF) would supplement traditional negotiated global budgets, reimbursing a predetermined amount for each case treated - essentially, a "fee schedule" - thus providing incentives and resources to increase throughput of certain "hot button" procedures and services and to improve efficiency.Maybe. ABF-type systems in other countries date back over 20 years; the results are very mixed. What is clear is that information and reporting requirements are substantial. A host of perverse incentives lurk in ABF. Most Canadian hospitals and provincial governments do not now have the necessary data systems, so are wise to proceed cautiously.

Diagnosing senescence: contributions to physician expenditure increases in british columbia, 1996/97 to 2005/06.

Conventional wisdom holds that Canada suffers from a physician shortage, yet expenditures for physicians' services continue to increase rapidly. We address this apparent paradox, analyzing fee-for-service payments to physicians in British Columbia in 1996/97 and 2005/06. Age-specific per capita expenditures (adjusted for fee changes) rose 1% per year over this period, adding $174 million to 2005/06 expenditures. We partition these increases into changes in the proportion of the population seeing a physician; the number of unique physicians seen; the number of visits per physician; and the average expenditure per visit. Expenditures on laboratory and imaging services, particularly for the elderly and very elderly, have increased dramatically. By contrast, primary care services for the non-elderly appear to have declined. The causes and health consequences of these large changes deserve serious attention.