Evaluation of the effects of centralized waiting lists for unattached patients on access to a family physician in Quebec

L’accès à un médecin de famille, basée sur une continuité de la relation patient-médecin, est associé à moins d’utilisation de l’urgence. Au Québec, 21% de la population est sans médecin de famille, la plus grande proportion de patients « orphelins » parmi des pays industrialisés. Pour améliorer l’accès, le Québec a mis en place l’inscription à un médecin de famille : une politique répandue à l’international qui demeure peu étudiée. Les guichets d’accès pour la clientèle orpheline (GACOs) offrent une occasion unique d’évaluer les effets de l’inscription des patients orphelins sur l’accès à un médecin de famille. Objectifs. Évaluer les effets des GACOs sur l’accès à un médecin de famille. Spécifiquement : 1) examiner les caractéristiques des patients associées à la probabilité et au délai d’inscription à un médecin de famille via les GACOs, 2) évaluer les effets de l’inscription à un médecin de famille via les GACOs sur le nombre de visites médicales en première ligne et la continuité (concentration) de ces visites, et 3) sur le nombre de visites à l’urgence. Méthodologie. 1) Étude transversale : données administratives de cinq GACOs de Montréal et de la Montérégie entre 2013 et 2015 (n=74 859). 2) Étude longitudinale : données des services médicaux de la Régie de l’assurance maladie du Québec (RAMQ), pour les patients inscrits via les GACOs entre 2012 et 2014, sur deux années avant et après l’inscription (n=411 065 patients). 3) Étude quasi-expérimentale pré/post avec les données de la RAMQ, comparant les patients inscrits en 2012-2013 à des patients similaires (n=298 306 patients). Résultats. Les patients socialement défavorisés, avec des problèmes de santé mentale, de toxicomanie ou une déficience intellectuelle ont moins de chances d’être inscrits à un médecin de famille via les GACOs. Les patients matériellement défavorisés ou avec des problèmes psychosociaux attendent plus longtemps avant d’être inscrits à un médecin de famille. 2) Comparé à avant leur inscription, les patients ont 103% plus de visites médicales en première ligne dans la première année après l’inscription à un médecin de famille et 29% plus dans la seconde année (p<0,001) et leurs visites ont plus de chances d’être concentrées auprès d’un même médecin de famille et d’une même clinique. 3) Suite à l’inscription, le nombre de visites à l’urgence par année diminue de 36% (p<0,001), en comparaison à des patients similaires. Conclusion. La politique d’inscription à un médecin de famille via les GACOs permet d’obtenir l’effet escompté d’améliorer l’accès et la continuité des services auprès d’un médecin de famille, mais certaines iniquités persistent au sein des GACOs.Abstract: Access to a family physician, based on continuity of the patient-physician relationship, has been shown to reduce emergency department (ED) utilization. In Quebec, 21% of the population is without a family physician, the highest proportion of "unattached" patients among other industrialized countries. To improve access, Quebec has implemented formal attachment to a family physician: a policy that is widespread internationally and remains understudied. Centralized waiting lists for unattached patients (CWLs) provide a unique opportunity to evaluate the effects of attachment on unattached patients’ access to a family physician. Objectives. To evaluate the effects of CWLs on access to a family physician. Specifically, 1) to examine patient characteristics associated with the likelihood and wait time for attachment to a family physician through CWLs, 2) to assess the effects of attachment to a family physician through CWLs on the annual number and continuity (concentration) of primary care visits, and 3) on the number of emergency department visits per year. Methods. 1) Cross-sectional study: administrative data from five CWLs in Montreal and Montérégie between 2013 and 2015 (n=74 859). 2) Longitudinal study: medical services data from the Régie de l'assurance maladie du Québec (RAMQ), for patients attached through CWLs between 2012 and 2014, comparing two years before and after attachment (n=411,065 patients). 3) Pre/post quasi-experimental design with RAMQ data, comparing patients attached in 2012-2013 to similar patients (n=298,306 patients). Results. Patients who are socially disadvantaged, who have a mental health problem, a substance abuse disorder, or an intellectual disability are less likely to be attached to a family physician through the CWLs. 2) Compared to before attachment, patients had 103% more primary care visits in the first year after attachment to a family physician and 29% more in the second year (p<0.001), and their visits were more likely to be concentrated with one family physician and one clinic. 3) Following attachment, the number of ED visits per year decreased by 36% (p<0.001), compared to similar patients. Conclusion. The policy of attachment to a family physician through CWLs achieves the intended effect of improving access and continuity of primary care with a family physician, but some inequities persist within CWLs in terms of which patients are attached

Telephone outreach by volunteer navigators: a theory-based evaluation of an intervention to improve access to appropriate primary care

Abstract Background A pilot intervention in a participatory research programme in Québec, Canada, used telephone outreach by volunteer patient navigators to help unattached persons from deprived neighbourhoods attach successfully to a family doctor newly-assigned to them from a centralized waiting list. According to our theory-based program logic model we evaluated the extent to which the volunteer navigator outreach helped patients reach and engage with their newly-assigned primary care team, have a positive healthcare experience, develop an enduring doctor-patient relationship, and reduce forgone care and emergency room use. Method For the mixed-method evaluation, indicators were developed for all domains in the logic model and measured in a telephone-administered patient survey at baseline and three months later to determine if there was a significant difference. Interviews with a subsample of 13 survey respondents explored the mechanisms and nuances of intended effects. Results Five active volunteers provided the service to 108 persons, of whom 60 agreed to participate in the evaluation. All surveyed participants attended the first visit, where 90% attached successfully to the new doctor. Indicators of abilities to access healthcare increased statistically significantly as did ability to explain health needs to professionals. The telephone outreach predisposed patients to have a positive first visit and have trust in their new care team, establishing a basis for an enduring relationship. Patient-reported access difficulties, forgone care and use of hospital emergency rooms decreased dramatically after patients attached to their new doctors. Conclusions As per the logic model, telephone outreach by volunteer navigators significantly increased patients’ abilities to seek, reach and engage with care and helped them attach successfully to newly-assigned family doctors. This light-touch intervention may have promise to achieve of the intended policy goals for the centralized waiting list to increase population access to appropriate primary care and reduce forgone care

Family Physicians Attaching New Patients From Centralized Waiting Lists: A Cross-Sectional Study

Purpose: In response to more than 15% of Canadians not having a family physician, 7 provinces have implemented centralized waiting lists for unattached patients. The aim of this study is to analyze the association between family physicians’ characteristics and their participation in centralized waiting lists. Methods: Cross-sectional observational study using administrative data in 5 local health networks in Quebec, between 2013 and 2015. All physicians who had attached at least 1 patient were included (n = 580). Multivariate linear regressions for the number of patients and proportion of vulnerable patients attached per physician were performed. Results: Physicians with more than 20 years of experience represented more than half of those who had participated in the centralized waiting lists and physicians in traditional primary care models represented more than 40%. Physicians’ number of years of practice, primary care model, local health network, and the number of physicians participating in the centralized waiting lists per clinic influenced physicians’ participation. Physicians with 0 to 4 years of experience and those practicing in network clinics were found to attach more patients. Practicing in a Centre Locaux de Services Communautaires (local community service center) was associated with attaching 19% more vulnerable patients compared with practicing in a Family Medicine Unit (teaching unit). Conclusion: Centralized waiting lists seem to be used by early career physicians to build up their patient panels. However, because of the large number of them participating in the centralized waiting lists, physicians with more experience and those practicing in traditional models of primary care might be of interest for future measures to decrease the number of patients waiting for attachment in centralized waiting lists

Area deprivation and attachment to a general practitioner through centralized waiting lists: a cross-sectional study in Quebec, Canada

Abstract Background Access to primary healthcare is an important social determinant of health and having a regular general practitioner (GP) has been shown to improve access. In Canada, socio-economically disadvantaged patients are more likely to be unattached (i.e. not have a regular GP). In the province of Quebec, where over 30% of the population is unattached, centralized waiting lists were implemented to help patients find a GP. Our objectives were to examine the association between social and material deprivation and 1) likelihood of attachment, and 2) wait time for attachment to a GP through centralized waiting lists. Methods A cross-sectional study was conducted in five local health networks in Quebec, Canada, using clinical administrative data of patients attached to a GP between June 2013 and May 2015 (n = 24, 958 patients) and patients remaining on the waiting list as of May 2015 (n = 49, 901), using clinical administrative data. Social and material area deprivation indexes were used as proxies for patients’ socio-economic status. Multiple regressions were carried out to assess the association between deprivation indexes and 1) likelihood of attachment to a GP and 2) wait time for attachment. Analyses controlled for sex, age, local health network and variables related to health needs. Results Patients from materially medium, disadvantaged and very disadvantaged areas were underrepresented on the centralized waiting lists, while patients from socially disadvantaged and very disadvantaged areas were overrepresented. Patients from very materially advantaged and advantaged areas were less likely to be attached to a GP than patients from very disadvantaged areas. With the exception of patients from socially disadvantaged areas, all other categories of social deprivation were more likely to be attached to a GP compared to patients from very disadvantaged areas. We found a pro-rich gradient in wait time for attachment to a GP, with patients from more materially advantaged areas waiting less than those from disadvantaged areas. Conclusion Our findings suggest that there are socio-economic inequities in attachment to a GP through centralized waiting lists. Policy makers should take these findings into consideration to adjust centralized waiting list processes to avoid further exacerbation of health inequities

Problems in Coordinating and Accessing Primary Care for Attached and Unattached Patients Exacerbated During the COVID-19 Pandemic Year (the PUPPY Study): Protocol for a Longitudinal Mixed Methods Study

BackgroundThe COVID-19 pandemic has significantly disrupted primary care in Canada, with many walk-in clinics and family practices initially closing or being perceived as inaccessible; pharmacies remaining open with restrictions on patient interactions; rapid uptake of virtual care; and reduced referrals for lab tests, diagnostics, and specialist care. ObjectiveThe PUPPY Study (Problems in Coordinating and Accessing Primary Care for Attached and Unattached Patients Exacerbated During the COVID-19 Pandemic Year) seeks to understand the impact of the COVID-19 pandemic across the quadruple aims of primary care, with particular focus on the effects on patients without attachment to a regular provider and those with chronic health conditions. MethodsThe PUPPY study builds on an existing research program exploring patients’ access and attachment to a primary care practice, pivoted to adapt to the emerging COVID-19 context. We intend to undertake a longitudinal mixed methods study to understand critical gaps in primary care access and coordination, as well as compare prepandemic and postpandemic data across 3 Canadian provinces (Quebec, Ontario, and Nova Scotia). Multiple data sources will be used such as a policy review; qualitative interviews with primary care policymakers, providers (ie, family physicians, nurse practitioners, and pharmacists), and patients (N=120); and medication prescriptions and health care billing data. ResultsThis study has received funding by the Canadian Institutes of Health Research COVID-19 Rapid Funding Opportunity Grant. Ethical approval to conduct this study was granted in Ontario (Queens Health Sciences & Affiliated Teaching Hospitals Research Ethics Board, file 6028052; Western University Health Sciences Research Ethics Board, project 116591; University of Toronto Health Sciences Research Ethics Board, protocol 40335) in November 2020, Québec (Centre intégré universitaire de santé et de services sociaux de l'Estrie, project 2020-3446) in December 2020, and Nova Scotia (Nova Scotia Health Research Ethics Board, file 1024979) in August 2020. ConclusionsTo our knowledge, this is the first study of its kind to explore the effects of the COVID-19 pandemic on primary care systems, with particular focus on the issues of patient’s attachment and access to primary care. Through a multistakeholder, cross-jurisdictional approach, the findings of the PUPPY study will inform the strengthening of primary care during and beyond the COVID-19 pandemic, as well as have implications for future policy and practice. International Registered Report Identifier (IRRID)DERR1-10.2196/2998

Attaching Patients in Primary Care Through Centralized Waiting Lists: Seven Canadian Provinces Compared

Canada has the lowest rate of attachment to primary care providers among OECD countries, which makes access and continuity of care problematic. To address this important issue, seven Canadian provinces have implemented centralized waiting lists (CWLs) for unattached patients in primary care. Introduced at different times, no two provinces' CWLs are exactly alike. The main goal of these CWLs is to reduce the number of unattached patients. In some provinces, CWLs also serve to monitor primary care activity or prioritize vulnerable patients. Societal pressure and broader primary care reform influenced the implementation of the CWLs in each province. Monitoring, in terms of data collected and purpose, differs between provinces. The interprovincial comparison enables identification of strengths, weaknesses, opportunities and threats during implementation and at each step of the CWLs: registration, patient assessment and attachment. Common issues with CWLs across provinces include the importance of monitoring to facilitate implementation, the need for specific measures to ensure access for vulnerable and complex patients, and the shortage of primary care providers. Le taux d'inscription à un professionnel de la santé en première ligne au Canada est le plus bas parmi les pays de l'OCDE, ce qui soulève un important problème d'accessibilité et de continuité aux soins de première ligne. Pour répondre à cette préoccupation, sept provinces canadiennes ont mis en place des listes d'attente centralisées (LAC) pour les patients non-affiliés à un professionnel de la santé en première ligne. Les LAC ont été implantées à différents moments, et diffèrent beaucoup d'une province à l'autre. Le principal objectif des LAC est de diminuer le nombre de patients non-affiliés, mais dans certaines provinces elles peuvent également servir à surveiller les activités de la première ligne ou à prioriser les patients vulnérables. La pression sociale et d'importantes réformes des soins de première ligne ont influencé l'implantation des LAC. Le monitorage, en termes de données collectées et d'utilisation, diffère d'une province à l'autre. La comparaison interprovinciale permet l'identification des forces, faiblesses, opportunités et menaces à l'implantation et à chaque étape de la LAC&nbsp;: l'enregistrement, l'évaluation du patient et l'affiliation. L'importance de la surveillance afin de faciliter l'implantation, le besoin d'interventions spécifiques pour garantir l'accès pour les patients vulnérables et complexes et le manque de prestataire de soins de première ligne sont quelques exemples des problématiques des LAC communes à toutes les provinces