Physicians Of Ontario Research Articles

Assessing Quality of Referrals to a Community-Based Chronic Pain Clinic

ABSTRACT Introduction Because patients with chronic pain are complex, with significant medical and psychiatric comorbidities, referrals to specialty pain clinics are often necessary. The present study explores the quality of information submitted and the profile of referring physicians associated with rejected patient referrals by a community pain clinic. Methods A retrospective cross-sectional study was conducted on a series of consecutive new patient referrals rejected by a noninterventional community pain clinic (November 2021–June 2022). Data were collected on the reasons for rejected referrals and physicians responsible for these referrals using the public database of the College of Physicians and Surgeons of Ontario. Results During the study period, 120 new referrals made by 99 physicians (88% primary care providers, or PCPs; male : female ratio 1:1.2; 53% Canadian university graduates) were rejected because of inadequate information (62%) or because they were inappropriate (38%). Only 46% of the rejected referrals were resubmitted within a median of 7 days (range 0–96 days) and accepted. Half of the non-resubmitted referrals could have been accepted if the referring provider had sent in the missing information. Conclusion A significant number of referrals to our pain clinic (primarily from PCPs) are rejected for mainly avoidable reasons. The process of rejected referrals and resubmissions requires 92 to 126 h of additional staff time/year. Without additional health care resources, our study highlights simple but effective improvements in the referral process that could facilitate patient care, avoid unnecessary delays, and decrease possible sources of patient complaints.

Primary care payment models and avoidable hospitalizations in Ontario, Canada: A multivalued treatment effects analysis.

Improving access to primary care physicians' services may help reduce hospitalizations due to Ambulatory Care Sensitive Conditions (ACSCs). Ontario, Canada's most populous province, introduced blended payment models for primary care physicians in the early- to mid-2000s to increase access to primary care, preventive care, and better chronic disease management. We study the impact of payment models on avoidable hospitalizations due to two incentivized ACSCs (diabetes and congestive heart failure) and two non-incentivized ACSCs (angina and asthma). The data for our study came from health administrative data on practicing primary care physicians in Ontario between 2006 and 2015. We employ a two-stage estimation strategy on a balanced panel of 3710 primary care physicians (1158 blended-fee-for-service (FFS), 1388 blended-capitation models, and 1164 interprofessional team-based practices). First, we account for the differences in physician practices using a generalized propensity score based on a multinomial logit regression model, corresponding to three primary care payment models. Second, we use fractional regression models to estimate the average treatment effects on the treated outcome (i.e., avoidable hospitalizations). The capitation-based model sometimes increases avoidable hospitalizations due to angina (by 7 per 100,000 patients) and congestive heart failure (40 per 100,000) relative to the blended-FFS-based model. Switching capitation physicians into interprofessional teams mitigates this effect, reducing avoidable hospitalizations from congestive heart failure by 30 per 100,000 patients and suggesting better access to primary care and chronic disease management in team-based practices.

Patient and Provider Satisfaction With a Geomapping Tool for Finding Community Family Physicians in Ontario, Canada: Cross-Sectional Online Survey Study.

Language-concordant health care, or health care in a patient's language of choice, is an important element of health accessibility that improves patient safety and comfort and facilitates an increased quality of care. However, prior research has found that linguistic minorities often face higher travel burdens to access language-concordant care compared to the general population. This study intended to assess patient experiences and satisfaction with an online interactive physician map that allows patients to find family physicians who speak their preferred language in and around Ottawa, Ontario, Canada, as a means of identifying areas of improvement. This study used an online survey with questions related to user satisfaction. Responses to Likert-scale questions were compiled as summary statistics and short-answer responses underwent thematic analysis. The study setting was Ottawa and Renfrew County, Ontario, and the surrounding region, including the province of Quebec. A total of 93 respondents completed the survey and self-identified as living in Ontario or Quebec. Overall, 57 (61%) respondents were "very satisfied" or "somewhat satisfied" with the map, 16 (17%) were "neither satisfied nor dissatisfied," and 20 (22%) were "very dissatisfied" or "somewhat dissatisfied." We found no significant differences in satisfaction by preferred language, age group, physician attachment, or intended beneficiary. A total of 56 respondents provided short-answer responses to an open-ended question about map improvements. The most common specific suggestion was to show which physicians are accepting new patients (n=20). Other suggestions included data refreshes (n=6), user interface adjustments (n=23), and additional languages (n=2). Some participants also provided positive feedback (n=5) or expressed concern with their inability to find a family physician (n=5). Several comments included multiple suggestions. While most patients were satisfied with the online map, a significant minority expressed dissatisfaction that the map did not show which family physicians were accepting new patients. This suggests that there may be public interest in an accessible database of which family physicians in Ontario are currently accepting new patients.

Mailed feedback to primary care physicians on antibiotic prescribing for patients aged 65 years and older: pragmatic, factorial randomised controlled trial

ObjectivesTo evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also identify effects on antibiotic prescribing from case-mix...

COVID-19 vaccine uptake among Ontario physicians: a descriptive population-based retrospective cohort study

ObjectivesTo determine COVID-19 vaccine uptake among physicians in Ontario, Canada from 14 December 2020 to 13 February 2022.DesignPopulation-based retrospective cohort study.SettingAll registered physicians in Ontario, Canada using data from linked...

Impact of patient–family physician language concordance on healthcare utilisation and mortality: a retrospective cohort study of home care recipients in Ontario, Canada

IntroductionAs the world’s linguistic diversity continues to increase at an unprecedented rate, a growing proportion of patients will be at risk of experiencing language barriers in primary care settings. We...

Attending physicians' annual service volume and use of virtual end-of-life care: A population-based cohort study in Ontario, Canada.

Physicians and their practice behaviors influence access to healthcare and may represent potentially modifiable targets for practice-changing interventions. Use of virtual care at the end-of-life significantly increased during the COVID-19 pandemic, but its association with physician practice behaviors, (e.g., annual service volume) is unknown. Measure the association of physicians' annual service volume with their use of virtual end-of-life care (EOLC) and the magnitude of physician-attributable variation in its use, before and during the pandemic. Population-based cohort study using administrative data of all physicians in Ontario, Canada who cared for adults in the last 90 days of life between 01/25/2018-12/31/2021. Multivariable modified Poisson regression models measured the association between attending physicians' use of virtual EOLC and their annual service volume. We calculated the variance partition coefficients for each regression and stratified by time period before and during the pandemic. Annual service volume of a person's attending physician in the preceding year. Delivery of ≥1 virtual EOLC visit by a person's attending physician and the proportion of variation in its use attributable to physicians. Among the 35,825 unique attending physicians caring for 315,494 adults, use of virtual EOLC was associated with receiving care from a high compared to low service volume attending physician; the magnitude of this association diminished during the pandemic (adjusted RR 1.25 [95% CI 1.14, 1.37] pre-pandemic;1.10 (95% CI 1.08, 1.12) during the pandemic). Physicians accounted for 36% of the variation in virtual EOLC use pre-pandemic and 12% of this variation during the pandemic. Physicians' annual service volume was associated with use of virtual EOLC and physicians accounted for a substantial proportion of the variation in its use. Physicians may be appropriate and potentially modifiable targets for interventions to modulate use of EOLC delivery.

Practices of and Perspectives on Palliative Sedation Among Palliative Care Physicians in Ontario, Canada: A Mixed-Methods Study.

Palliative sedation (PS) is a therapeutic intervention employed to manage severe and refractory symptoms in terminally ill patients at end of life. Inconsistencies in PS practice guidelines coupled with clinician ambiguity have resulted in confusion about how PS is best integrated into practice. Understanding the perspectives, experiences, and practices relating to this modality will provide insight into its clinical application and challenges within the palliative care landscape. The aim is to explore the perspectives of palliative care physicians administering PS, including how practitioners define PS, factors influencing decision making about the use of PS, and possible reasons for changes in practice patterns over time. A survey (n = 37) and semistructured interviews (n = 23) were conducted with palliative care physicians throughout Ontario. Codes were determined collaboratively and applied line-by-line by two independent investigators. Survey responses were analyzed alongside interview transcripts and noted to be concordant. Themes were generated through reflexive thematic analysis. Five key themes were identified: (1) lack of standardization, (2) differing definitions, (3) logistical challenges, (4) perceived "back-up" to Medical Assistance in Dying, and (5) tool of the most responsible physician. There was significant variability in how participants defined PS and in frequency of use of PS. Physicians described greater ease implementing PS when practicing in palliative care units, with significant barriers faced by individuals providing home-based palliative care or working as consultants on inpatient units. Educational efforts are required about the intent and practice of PS, particularly among inpatient interprofessional teams.

From 0-50 in Pandemic, and Then Back? A Case Study of Virtual Care in Ontario Pre–COVID-19, During, and Post–COVID-19

We review the evolution of virtual care (VC) in Ontario. Pre–COVID-19, the primary focus was on patients in remote and underserved areas who went to host sites for care. Ontario’s vision pre-pandemic was for a gradual increase in VC by physicians registered with the Ontario Telemedicine Network (OTN), using OTN-approved video technologies; some accommodated patients and doctors wherever they were. Less than 1% of care was virtual pre-pandemic. We discuss how policies that altered access to in-person care (pandemic lockdowns and guidelines to seek and provide care virtually), compensation policy changes (allowing any Ontario physician to be compensated for VC), and policies allowing common technologies not previously allowed (including, importantly, the telephone), drove and enabled a rapid shift to >50% of care being virtual at the start of the pandemic, leveling off to ∼30% over time. We review policy changes in late 2022 and predict these will result in a drop in VC compared with the policies during the pandemic, particularly for walk-in clinic patients, in a province where 2.2-4.6 million people do not have a primary care doctor and presumably use walk-in clinics. This is because, going forward, physicians will be compensated less for telephone care than for in-person or video care for rostered patients, and because compensation will be less still for telephone or video care provided to walk-in patients. Through this case study we develop a visual model of how these key policy and technology factors influence the provision of VC.

Ethical Implications of End-Of-Life Decisions

This paper examines the recent policy update by the College of Physicians and Surgeons of Ontario (CPSO), which allows physicians to override patient wishes for cardiopulmonary resuscitation (CPR) without consent. It critically analyzes the ethical implications of this shift, emphasizing the juxtaposition between the legal protections for patient’s Last Wills and the relatively diminished safeguarding of their end-of-life care preferences. The paper highlights the potential for bias in physician decision-making, the risk of reverting to a more paternalistic healthcare model, and the challenge of balancing patient autonomy with medical authority. The study underscores the need for a nuanced approach to healthcare policy that respects patient autonomy while addressing the complexities of end-of-life decisions.

New Developments and Old Dilemmas in Ontario’s Resuscitation Policy at the End of Life

This paper deals with changes in code status policy in Ontario and endorses a new College of Physicians and Surgeons of Ontario (CPSO) policy. We argue that the recent policy changes in this area necessitate an active educational strategy around end-of-life care to prevent harm to dying patients.

"Building More Connected Primary Care: Improving Connections between Primary Care and Community Care, Specialists and Hospitals for Timely and Appropriate Care"

Although strong, well connected primary care results in better health outcomes and health equity at a lower cost, most family physicians in Ontario, Canada are not supported by teams and have variable connections to other system sectors resulting in variable access and quality of care. A continuous relationship with a family physician and primary care team facilitates access to timely care, appropriate preventive care, reduced acute care utilization and costs, reduced mortality and more satisfied patients. This was further confirmed during the COVID 19 pandemic when patients who were attached to primary care teams had superior care for both COVID and non-COVID health issues.
 Together with patients, families, family physicians and all health care sectors, we co-created and evaluated efficient models of connecting family physicians to: specialists for just in time advice, virtual and in-person consults; to interprofessional teams tailored to the needs of their practices and to navigation services tailored to primary care. These models were co-designed with family physicians and continue to evolve based on their evolving needs:
 SCOPE (Seamless Care Optimizing the Patient Experience) connects primary care providers (PCPs) in the community to real-time supports through a single point of access, Co-designed with local PCPS, SCOPE improves access to an interprofessional team who can help with urgent medical consultations, diagnostic imaging, curated home and community care, mental health, and navigation of other services available in the hospital or in the community.
 TIP (Telemedicine IMPACT PLUS) TIP (Telemedicine IMPACT Plus) provides rapid access to case consultation by a virtual team of health care professionals to enable proactive health and social care for patients living with multi-morbidity. The case conference involves the patient/caregivers, family physician and TIP RN along with the consulting team that consists of: Psychiatrist, Internist, Pharmacist, Social Worker, Home Care Coordinator, Dietitian and others as required. The purpose of this consultation is to coordinate care and derive new solutions for addressing chronic conditions. A dedicated
 TIP nurse facilitator prepares the case, facilitates the consultation with one of 12 available teams, summarizes a coordinated care plan and coordinates the patient’s circle of care.
 Building interprofessional primary care teams based on family physician patient roster needs relies on nourishing foundational relationships with local PCPs to help identify gaps in care, engaging PCPS in continuous program improvement and developing partnerships with key stakeholders: leadership from the anchor hospital and their specialist groups, home and community care and community organizations. Joint implementation is based on the value proposition that all sectors win when care is appropriately triaged and managed in the community.
 When combined, connected and integrated into primary care practices, these initiatives build the Patient Medical Home, with the PCP at the centre of care, support to more effectively co-manage patients using existing resources more efficiently mapped to patient needs. These initiatives support relationship-based navigation, the underpinning of team-based primary care essential to improving system navigation for timely access to needs-based care.
 The target audience: patients, families, interprofessional primary care providers, specialists, home care and community providers, and hospitals.
 
 
 

Effects of extending residencies on the supply and quality of family medicine practitioners; difference-in-differences evidence from the implementation of mandatory family medicine residencies in Canada.

I examine the impacts of extending residency training programs on the supply and quality of physicians practicing primary care. I leverage mandated extended residency lengths for primary care practitioners that were rolled out over 20years in Canada on a province-by-province basis. I compare these primary care specialties to other specialties that did not change residency length (first difference) before and after the policy implementation (second difference) to assess how physician supply evolved in response. To examine quality outcomes, I use a set of scraped data and repeat this difference-in-differences identification strategy for complaints resulting in censure against physicians in Ontario. I find declines in the number of primary care providers by 5% for up to 9years after the policy change. These changes are particularly pronounced in new graduates and younger physicians, suggesting that the policy change dissuaded these physicians from entering primary care residencies. I find no impacts on quality of physicians as measured by public censure of physicians. This suggests that extending primary care training caused declines in physician supply without improvement in the quality of these physicians. This has implications for current plans to extend residency training programs.

Characteristics of patients attached to near-retirement family physicians: a population-based serial cross-sectional study in Ontario, Canada

ObjectivesPopulation ageing is a global phenomenon. Resultant healthcare workforce shortages are anticipated. To ensure access to comprehensive primary care, which correlates with improved health outcomes, equity and costs, data to...

Interventional pain blocks in Ontario: a population-based cross-sectional study on 2019 procedural volumes, clustering, and physician billings.

Multidisciplinary chronic pain management includes pharmacologic, psychological, and interventional strategies. In Canada, the use of interventional pain blocks (PBs) has increased in recent years. We sought to determine the distribution and clustering of PBs among physicians in Ontario, and to examine differences in the patient and physician characteristics by volume of PBs administered. We conducted a population-based cross-sectional study of PBs administered for chronic pain to Ontario residents between 1 January and 31 December 2019. Our primary outcome was the total number of PBs administered in an outpatient setting for chronic pain by eligible physicians. We used Lorenz curves, overall and stratified by PB type and physician specialty, to examine clustering of PBs among physicians, and compared patient and physician characteristics using standardized differences. Among physicians who provided PBs, provision was highly clustered, with the top 1% of physicians providing 39% of blocks. In these high-volume PB providers, the majority of whom were general practitioners (88.4%), PBs made up the vast majority (median [interquartile range (IQR)], 87% [84-89]) of their billings, with the majority of the patients in their practices (63.0%) receiving at least one PB in 2019. Patients who received a PB from a high-volume provider had a higher annual frequency of visit for PBs (median [IQR], 10 [3-23]) and number of PBs administered per visit (median [IQR], 5 [4-6]). Pain block administration is highly clustered in Ontario, with many patients receiving PBs in ways that are not supported by best evidence. Further research is required to determine whether the Ontario fee-for-service model of billing has created a suboptimal use of these health care resources.

Cohort profile: recruitment and retention in a prospective cohort of Canadian healthcare workers during the COVID-19 pandemic

PurposeHealthcare workers were recruited early in 2020 to chart effects on their health as the COVID-19 pandemic evolved. The aim was to identify modifiable workplace risk factors for infection and...

Resource allocation decisions under pandemic conditions: A cross-sectional survey of Ontario physicians.

The COVID-19 pandemic has forced physicians to confront difficult choices regarding the allocation of scarce resources, such as ventilators and critical care beds. Developing policies to guide the allocation of such resources has proven challenging. An understanding of physicians' attitudes and beliefs surrounding resource allocation could help inform policymaking. As a replication and extension of a survey of Ottawa physicians conducted in 2020, we surveyed physicians across Ontario, Canada in April 2021. This survey examined physicians' sense of preparedness to allocate critical care resources during the pandemic, attitudes concerning resource allocation policy, and approaches to resource allocation decision-making. Of the 253 responses included for analysis, the majority (67%) of respondents indicated feeling "somewhat" or "a little prepared" to make resource allocation decisions, while 20% indicated feeling "not at all prepared." Most respondents (86%) agreed that a policy to guide resource allocation in the event of scarcity should exist. Physicians overwhelmingly agreed that important factors to consider when making resource allocation decisions included the patient likelihood of survival, frailty index, comorbidities, and cognitive status. Responses from the province-wide survey conducted in 2021 resemble the results of an analogous survey of Ottawa physicians conducted in 2020. Physicians generally felt underprepared to make resource allocation decisions and agreed that official policies should guide such decisions. Identification of factors relevant to resource allocation was remarkably consistent across this sample and that taken in 2020.

Factors Affecting Healthcare Provider Referral to Heart Function Clinics: A Mixed-Methods Study.

Heart failure (HF) care providers are gatekeepers for patients to appropriately access lifesaving HF clinics. The aim of this study was to investigate referring providers' perceptions regarding referral to HF clinics, including the impact of provider specialty and the coronavirus disease pandemic. An exploratory, sequential design was used in this mixed-methods study. For the qualitative stage, semistructured interviews were performed with a purposive sample of HF providers eligible to refer (ie, nurse practitioners, cardiologists, internists, primary care and emergency medicine physicians) in Ontario. Interviews were conducted via Microsoft Teams. Transcripts were analyzed concurrently by 2 researchers independently using NVivo, using a deductive-thematic approach. Then, a cross-sectional survey of similar providers across Canada was undertaken via REDCap (Research Electronic Data Capture), using an adapted version of the Provider Attitudes toward Cardiac Rehabilitation and Referral scale. Saturation was achieved upon interviewing 7 providers. Four themes arose: knowledge about clinics and their characteristics, providers' clinical expertise, communication and relationship with their patients, and clinic referral process and care continuity. Seventy-three providers completed the survey. The major negative factors affecting referral were skepticism regarding clinic benefit (4.1 ± 0.9/5), a bad patient experience and believing they are better equipped to manage the patient (both 3.9). Cardiologists more strongly endorsed clarity of referral criteria, referral as normative and within-practice referral supports as supporting appropriate referral versus other professionals ( P s < .02), among other differences. One-third (n = 13) reported the pandemic impacted their referral practices (eg, limits to in-person care, patient concerns). Although there are some legitimate barriers to appropriate clinic referral, greater provider education and support could facilitate optimal patient access.

Defining the capabilities and competencies of high-performing family physicians: a mixed methods study

IntroductionHigh-performing primary care is recognised as the foundation of an effective and efficient healthcare system. Many medical graduates report they are not prepared for independent practice. To date, no research...

Distance, access and equity: a cross-sectional geospatial analysis of disparities in access to primary care for French-only speakers in Ottawa, Ontario.

Although language concordance between patients and primary care physicians results in better quality of care and health outcomes, little research has explored inequities in travel burden to access primary care people of linguistic minority groups in Canada. We sought to investigate the travel burden of language-concordant primary care among people who speak French but not English (French-only speakers) and the general public in Ottawa, Ontario, and any inequities in access across language groups and neighbourhood ruralities. Using a novel computational method, we estimated travel burden to language-concordant primary care for the general population and French-only speakers in Ottawa. We used language and population data from Statistics Canada's 2016 Census, neighbourhood demographics from the Ottawa Neighbourhood Study, and collected the main practice location and language of primary care physicians from the College of Physicians and Surgeons of Ontario. We measured travel burden using Valhalla, an open-source road-network analysis platform. We included data from 869 primary care physicians and 916 855 patients. Overall, French-only speakers faced greater travel burdens than the general population to access language-concordant primary care. Median differences in travel burden were statistically significant but small (median difference in drive time 0.61 min, p < 0.001, interquartile range 0.26-1.17 min), but inequities in travel burden between groups were larger among people living in rural neighbourhoods. French-only speakers in Ottawa face modest - but statistically significant - overall inequities in travel burden when accessing primary care, compared with the general population, and higher inequities in specific neighbourhoods. Our results are of interest to policy-makers and health system planners, and our methods can be replicated and used as comparative benchmarks to quantify access disparities for other services and regions across Canada.