Designing centralized waiting lists for attachment to a primary care provider: Considerations from a logic analysis

Bréton, Mylaine; Smithman, Mélanie Ann; Kreindler, Sara A.; Jbilou, Jalila; Wong, Sabrina T.; Marshall, Emily Gard; Sasseville, Martin; Sutherland, Jason M.; Crooks, Valorie A.; Shaw, Jay; Contandriopoulos, Damien; Brousselle, Astrid; Green, Michael E.

doi:10.1016/j.evalprogplan.2021.101962

Cited by 7 publications

(3 citation statements)

References 51 publications

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“…Physicians should accept patients into their practice on a first-come, first-served basis [ 17 ] and must not discriminate against patients according to the Nova Scotia Human Rights Act. Family physicians have been offered financial incentives for attaching patients to their practice and providing ongoing care [ 18 ]. In Nova Scotia, 14.4% of the population was reported as unattached as of 2019, and there has been growth in the unattached population in the province over the course of the pandemic.…”

Section: Methodsmentioning

confidence: 99%

COVID-19 – an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada)

Bréton

Marshall

Deslauriers

et al. 2022

BMC Health Serv Res

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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.

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Section: Methodsmentioning

confidence: 99%

COVID-19 – an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada)

Bréton

Marshall

Deslauriers

et al. 2022

BMC Health Serv Res

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“…If health system decision makers wish to promote greater patient attachment, they must take a systems approach and consider the various factors that contribute to poor access and attachment. Practice and funding models are known to influence providers' willingness to attach patients ( Breton et al 2021 ). Providers who are employed directly by the health system or who are working in interdisciplinary teams may have an increased willingness to attach new patients.…”

Section: Discussionmentioning

confidence: 99%

“A Band-Aid Solution”: Policy Maker and Primary Care Provider Perspectives on the Value of Attachment Incentives

Marshall¹,

Cook²,

Moritz³

et al. 2023

hcpol

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Approximately 15% of Canadians are without a primary care provider (“unattached”). To address “unattachment,” several provinces introduced a financial incentive for family physicians who attach new patients. A descriptive qualitative approach was used to explore perspectives of patient access and attachment to primary care. Semi-structured qualitative interviews were conducted with family physicians, nurse practitioners and policy makers in Nova Scotia. Thematic analysis was performed to identify participant perspectives on the value and efficacy of financial incentives to promote patient attachment. Three themes were identified: (1) positive impacts of the incentive, (2) shortcomings of the incentive and (3) alternative strategies to strengthen primary healthcare. Participants felt that attachment incentives may offer short-term solutions to patient unattachment; however, financial incentives cannot overcome systemic challenges. Participants recommended alternative policy levers to strengthen primary healthcare, including addressing the shortage of primary care providers and developing remuneration and practice models that support sustainable patient attachment.

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“…Self-referrals tended to be for younger and healthier patients (68), explaining the observed differences between our exposed and control cohorts. However, these policies should be carefully designed by engaging patients, physicians, nurses, centralized waiting list staff, regional decision-makers, and researchers to improve equitable attachment without sti ing physician participation (71).…”

Section: Policy Implication #1mentioning

confidence: 99%

Does attachment to a family physician reduce emergency department visits? A difference-in-differences analysis of Quebec’s centralized waiting lists for unattached patients

Smithman,

Breton,

Haggerty

2023

Preprint

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Background Patients without a regular primary care provider – unattached patients – are more likely to visit hospital emergency departments (ED), leading to poor patient and health system outcomes. In many Canadian provinces, policy responses to improve primary care access and reduce ED utilization of unattached patients have included centralized waiting lists to help find a primary care provider and formal attachment (rostering, empanelment, enrollment, registration) to a family physician. While previous work suggests attachment improves access and continuity of primary care (1), it is unknown whether this translates into fewer ED visits. The aim of this study was to determine whether the rate of emergency department visits significantly decreases in patients attached to a family physician through Quebec’s centralized waiting lists for unattached patients. Methods We used a quasi-experimental difference-in-differences approach, studying patients attached through Quebec’s centralized waiting lists in 2012–2014. We used administrative medical services physicians’ billing data from the Régie de l’Assurance Maladie du Québec (RAMQ). Attachment was determined based on fee codes used to formalize attachment. We compared the change in the rate of emergency department visits over two 12-month periods, for ‘exposed’ patients who became attached (n = 207,669) and ‘control’ patients who remained unattached during the study period (n = 90,637). To balance baseline patient characteristics in the exposed and control cohorts, we calculated a propensity score including age, sex, Charlson-co-morbidity index, medical vulnerability, and region remoteness and performed inverse probability of treatment weighting. We used descriptive statistics and estimated negative binomial regression models, fitted with generalized estimating equations. Results After weighting, cohorts had similar characteristics (standardized differences < 10%). Attached (exposed) patients’ mean annual ED visits decreased from 0.60 to 0.49 (18.3%) following attachment, while unattached (control) patients’ increased from 0.54 to 0.69 (27.8%). The difference-in-differences estimate (Time period*exposure) showed a significant 36% relative reduction (IRR = 0.64, p < 0.001) in the rate of ED visits for patients who were attached, compared to patients who remained unattached on the centralized waiting lists during the study period. Conclusion Our findings suggest that attachment to a family physician through centralized waiting lists for unattached patients significantly reduces the rate of ED utilization.

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Designing centralized waiting lists for attachment to a primary care provider: Considerations from a logic analysis

Cited by 7 publications

References 51 publications

COVID-19 – an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada)

COVID-19 – an opportunity to improve access to primary care through organizational innovations? A qualitative multiple case study in Quebec and Nova Scotia (Canada)

“A Band-Aid Solution”: Policy Maker and Primary Care Provider Perspectives on the Value of Attachment Incentives

Does attachment to a family physician reduce emergency department visits? A difference-in-differences analysis of Quebec’s centralized waiting lists for unattached patients

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