Measuring equity in per capita primary care investment in Ontario: Challenges for data linkage and analysis

Introduction Fifteen years ago almost all primary care physicians (PCPs) were paid fee-for-service. Now, many physicians receive other payments as well, including capitation payments, incentives and bonuses and funding for other health professionals. It is challenging to track these changes in primary care payment and understand how they relate to individual patients. Objectives and Approach The objectives of this study were to assess changes in PCP payments from 2002/03 to 2011/12 and examine differences in per capita investment by urban-rural status, recent arrival (proxy for immigrant status) and income quintile. This required a three-step approach: assigning payments to physicians, assigning patients to physicians and then apportioning the payments by patient. Payments were apportioned based on the type of payment and how the data were captured. For example, capitation payments were paid monthly, but without any detail as to which patients they were for, so all capitation payments were summed and apportioned among all rostered patients. Results All PCPs for whom we had payment data and to whom patients could be assigned were included. Three types of physician-patient 'relationships' were identified: the patient was on the physician's formal roster; the patient was 'virtually' rostered to the physician who provided the plurality of their care; or the patient was part of the physician's overall panel, which includes all patients seen during the year, rostered and not. The type of relationship determined which payment were allocated to each patient. When the $3.5B in payments were apportioned and different populations compared, we found inequities in new primary care investment by income, immigrant status and rurality. For example, we found a disproportionate investment in interdisciplinary teams for non-immigrant Ontarians living in more well-off suburban areas. Conclusion/Implications Estimating per capita primary care investment is a challenging but worthwhile undertaking. The results of this study suggest that the Government of Ontario should facilitate increased participation in new primary care models by immigrants and people living in major urban centres

Effectiveness of registered nurses on system outcomes in primary care: a systematic review

Background Internationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of registered nurses (RNs) within primary care teams. Although existing literature provides some information regarding RN contributions, further evidence on the impact of RNs towards quality and cost of care is necessary to demonstrate the contribution of this role on health system outcomes. In this study we synthesize international evidence on the effectiveness of RNs on care delivery and system-level outcomes in primary care. Methods A systematic review was conducted in accordance with Joanna Briggs Institute methodology. Searches were conducted in CINAHL, MEDLINE Complete, PsycINFO, and Embase for published literature and ProQuest Dissertations and Theses and MedNar for unpublished literature between 2019 and 2022 using relevant subject headings and keywords. Additional literature was identified through Google Scholar, websites, and reference lists of included articles. Studies were included if they measured effectiveness of a RN-led intervention (i.e., any care/activity performed by a primary care RN within the context of an independent or interdependent role) and reported outcomes of these interventions. Included studies were published in English; no date or location restrictions were applied. Risk of bias was assessed using the Integrated Quality Criteria for Review of Multiple Study Designs tool. Due to the heterogeneity of included studies, a narrative synthesis was undertaken. Results Seventeen articles were eligible for inclusion, with 11 examining system outcomes (e.g., cost, workload) and 15 reporting on outcomes related to care delivery (e.g., illness management, quality of smoking cessation support). The studies suggest that RN-led care may have an impact on outcomes, specifically in relation to the provision of medication management, patient triage, chronic disease management, sexual health, routine preventative care, health promotion/education, and self-management interventions (e.g. smoking cessation support). Conclusions The findings suggest that primary care RNs impact the delivery of quality primary care, and that RN-led care may complement and potentially enhance primary care delivered by other primary care providers. Ongoing evaluation in this area is important to further refine nursing scope of practice policy, determine the impact of RN-led care on outcomes, and inform improvements to primary care infrastructure and systems management to meet care needs. Protocol registration ID PROSPERO: International prospective register of systematic reviews. 2018. ID= CRD42018090767

Nutritional support during labour, a randomized clinical trial of patient-controlled oral intake during labour

grantor: University of Toronto'Objective'. The purpose of this trial was to determine if a policy of unrestricted access to foods and fluids during labor was effective in reducing the incidence of dystocia, and in low risk milliparous, women. 'Study design'. A randomized clinical trial was conducted at a teaching hospital in southeastern Ontario. Three hundred and thirty low risk nulliparous women were randomized between 30-40 weeks gestation to either an intervention or usual cam group. Women in the intervention group received, prenatally, an information booklet containing guidelines about food and fluid intake during labor and were encouraged to eat and drink, as they pleased, and as was comfortable for them throughout labor. The oral protocol was discontinued if women received epidural analgesia or complications developed such that they were at risk for a caesarean section birth. Women in the usual care group were restricted to ice chips and water during labor. 'Results'. Three hundred and twenty eight women were randomized to either the control group (n = 165) or intervention group (n = 163). Of these women 78% (257/328) returned completed postpartum questionnaires. Women in the intervention group reported a significantly different pattern of oral intake, during early labor in the hospital ([chi]2 = 40.7, p < 001). Most women regulated their intake in response to feelings of nausea or discomfort. The incidence of dystocia was 36% (n = 58) in the intervention group and 44% (n = 72) in the usual care group and was not significantly different (OR = .71, 95% CI .46, 1.1). There were no significant differences in the other secondary outcomes measured or in the incidence of adverse maternal or neonatal complications. 'Conclusion'. Patient controlled oral intake during labor did not decrease the incidence of dystocia, was not associated with any adverse maternal or neonatal outcome and was enjoyed by women in labor. In the absence of benefit or harm women should be informed about the results of this trial in order to make their own decisions with regards to oral intake during labour. Further research is warranted to determine if a more prescriptive pattern of oral fluid intake during established labor is beneficial.Ph.D

Barriers and supports for development of a clinician scientist role in cerebrovascular nursing: A position paper

This position paper will: 1. Provide an update on relevant current developments in the education, training and positioning of clinician nurse scientists; 2. Provide and promote a rational argument for the development of the clinician nurse scientist role, and; 3. Discuss issues related to capacity building in clinical research in neuroscience nursing, with specific reference to and support for the cerebrovascular (stroke) specialty nursing area

The 2000 Helene Hudson Memorial Lecture: Decisional role in seriously ill hospitalized patients near the end of life: The patient's and provider's perspective

Decisions about whether or not to implement life-sustaining therapies are complex and are becoming more so as the ability to prolong life with advanced technologies and care increases. The objectives of this study were: (1) to determine seriously ill hospitalized patients' preferences for decisional role with respect to decisions about life-sustaining treatments, and (2) to determine if providers were aware of patients' preferences. This prospective, descriptive pilot study was conducted at an Ontario teaching hospital. One hundred and seventeen seriously ill adult patients admitted with cancer and non-cancerous conditions participated in a structured interview. Fifty-three nurses and 63 physicians responsible for the care of the participating patients also participated. Patients and providers were asked similar questions about end-of-life discussions and preference for decisional responsibility for life-sustaining treatments. Most patients (n=89, 77%) had thought about end-of-life issues and nwere willing to discuss these with their physicians and nurses, but few (n=37, 37%) reported such discussions. Preferences for decisional role varied; most indicated a preference for a shared role (n=80, 80%) and there were no differences in patients with or without cancer. Generally, both physicians and nurses were not aware of or did not determine accurately patient preferences for decisional role. The findings from this study show that seriously ill hospitalized patients have thought about and are willing to share in discussions about end-of-life care with their providers, yet many have not

Conférence à la mémoire de Helene Hudson 2000 : Le rôle décisionnel chez les patients hospitalisés gravement malades en fin de vie : la perspective du patient et celle du soignant

Les décisions concernant la mise en œuvre ou non de traitements de survie sont complexes et le deviennent toujours davantage à mesure que la médecine est de plus en plus capable de prolonger la vie en faisant appel à des technologies et des soins de pointe. Cette étude avait pour objectifs : (1) de déterminer les préférences des patients hospitalisés gravement malades en matière de rôle décisionnel lié à l'utilisation de traitements de survie, (2) de déterminer si les soignants connaissaient les préférences de leurs patients. Cette étude pilote prospective et descriptive s'est déroulée dans un hôpital d'enseignement de l'Ontario. Cent dix-sept adultes gravement malades et hospitalisés à la suite de cancer et d'autres maladies ont participé à une entrevue structurée. Cinquante-trois infirmières et 63 médecins qui étaient chargés des soins aux répondants ont également participé à l'étude. On posait des questions semblabes aux patients et aux soignants sur les discussions relatives à la fin de vie et sur leur préférence quant à la responsabilité décisionnelle visant les traitements de survie. La plupart des patients (n=89, 77 %) avaient déjà réfléchi à des questions relatives à la fin de vie et étaient prêts à en discuter avec leurs médecins et infirmières, mais ils étaient peu nombreux (n=37, 37 %) à signaler de telles discussions. En ce qui concerne le rôle décisionnel, les préférences variaient, la majorité des reepondants indiquant une préférence pour un partage de la prise de décision (n=80, 80%) tandis que l'on n'observait aucune différence entre les réponses des patients atteints de cancer et les autres. En général, ni les médecins ni les infirmières n'étaient au courant des préférences de leurs patients en la matière, out étaient dans l'impossibilité de les déterminer correctement. Les résultats de cette étude montrent que les patients hospitalisés gravement malades ont réfléchi aux soins en fin de vie et qu'ils sont prêts à en discuter avec leurs soignants, mais que, dans bien des cas, ces discussions n'ont jamais lieu