Canadian System Works

Background Lipid guidelines for cardiovascular (CV) risk reduction have evolved in recent years, particularly since the introduction of PCSK9 inhibitors. In many jurisdictions, CV risk management is provided by primary care physicians (PCPs). We surveyed Canadian PCPs regarding their awareness and implementation of the 2021 Canadian Cardiovascular Society (CCS) lipid guideline recommendations for patients following an acute coronary syndrome (ACS) or for those with diabetes but without CV disease. Methods and results From a national database of PCPs with interest and/or experience in CV medicine, we invited PCPs to complete a survey regarding lipid management in high-risk patients. A committee of PCPs and specialists with lipid expertise including several co-authors of the 2021 CCS lipid guidelines had designed the survey to probe awareness and practice patterns. A total of 203 PCPs from across Canada completed the survey between January and March 2022. 23.6% of respondents had previously prescribed a PCSK9 inhibitor. Almost all (96.5%) PCPs concurred that a post-ACS patient should be seen by their PCP within 4 weeks of hospital discharge (79.3% within 2 weeks). Almost half (45.3%) responded that discharge summaries provided inadequate information relevant for PCPs, and 43% felt that lipid management post-ACS was the primary responsibility of specialists. More than half (56%) articulated challenges when seeing a post-ACS patient, related to inadequate discharge information, complexities of polypharmacy and duration of therapies, and managing perceived or real statin intolerance. 62% correctly identified the LDL-C intensification threshold of 1.8 mmol/L in post-ACS patients, while 79% considered that PCSK9 inhibitors were indicated only for those patients who were already receiving statins plus ezetimibe or had substantially elevated LDL-C levels. 55.2% were able to correctly identify clinical features associated with greatest absolute benefit of PCSK9 inhibitors in post-ACS patients. For patients with diabetes but without ASCVD, 80% of PCPs incorrectly believed that PCSK9 inhibitors were indicated for LDL-C levels above threshold despite statin therapy, and only 42% correctly identified the LDL-C threshold for treatment intensification of 2.0 mmol/L. Conclusion While PCPs are aware of the urgency regarding lipid management in post-ACS patients, many encounter challenges after hospital discharge, frequently deferring lipid management to specialists. Thus, almost one year following publication of the 2021 CCS lipid guidelines, substantial knowledge gaps remain regarding intensification thresholds and treatment options for patients post-ACS or for those with diabetes. Innovative and effective knowledge translation programs are urgently required. Funding Acknowledgement Type of funding sources: Private company. Main funding source(s): Amgen Canada

The contributions of primary care to improvements in many aspects of population and individual health are well documented (Starfield, Shi, and Macinko 2005). In addition to the health benefits, there are reductions in health system costs and reductions in disparities in health across population subgroups. The findings are robust over time and across areas and health systems. International comparisons show that countries with health systems based on strong primary care have better health at lower costs. Studies within countries, including both industrialized as well as middle income and developing countries, are consistent in showing greater improvements in health consequent to legislative and administrative policy initiatives directed at strengthening primary care, including increases in the supply and use of primary care practitioners and clinical improvements in primary care practice. The special and critical features of primary care are well known and include first contact access and use of primary care facilities and practitioners; person-focused (not disease-focused) care over time; comprehensiveness of services available and provided within primary care; and coordination of services when they are needed elsewhere (Starfield, Shi, and Macinko 2005).

BackgroundIn the current context of increasingly fragmented healthcare systems where patients are seen by multiple doctors in different settings, patients’ relational continuity with one doctor is regaining relevance; however little is known about relational continuity with specialists. The aim of this study is to explore perceptions of relational continuity with primary care and secondary care doctors, its influencing factors and consequences from the viewpoint of users of the Catalan national health system (Spain).MethodsWe conducted a descriptive-interpretative qualitative study using a two-stage theoretical sample; (i) contexts: three healthcare areas in the Catalan national health system with differing characteristics; (ii) informants: users 18 years or older attended to at both care levels. Sample size (n = 49) was reached by saturation. Data were collected by individual semi-structured interviews, which were audio recorded and transcribed. A thematic content analysis was carried out segmenting data by study area, and leaving room for new categories to emerge from the data.ResultsPatients across the areas studied generally experienced consistency of primary care doctors (PCD), alongside some inconsistency of specialists. Consistency of specialists did not seem to be relevant to some patients when their clinical information was shared and used. Patients who experienced consistency and frequent visits with the same PCD or specialist described and valued having established an ongoing relationship characterised by personal trust and mutual accumulated knowledge. Identified consequences were diverse and included, for example, facilitated diagnosis or improved patient-doctor communication. The ascription to a PCD, a health system-related factor, facilitated relational continuity with the PCD, whereas organizational factors (for instance, the size of the primary care centre) favoured consistency of PCD and specialists. Doctor-related factors (for example, high technical competence or commitment to patient care) particulary fostered the development of an ongoing relationship.ConclusionsConsistency of doctors differs depending on the care level as does the relevance attributed to it. Most influencing factors can be applied to both care levels and might be addressed by healthcare managers to foster relational continuity. More research is needed to fully understand the relevance patients assign to relational continuity with specialists.

Plastic and reconstructive surgeons’ views of a single payer health care system: Implications for patients and practice

105 Background: Previous research using nationally representative data showed significant differences between primary care physician (PCP) and oncologists’ attitudes and practices with respect to care of cancer survivors and called for more effective communication and coordination to improve care. This study compared PCP and oncologists’ attitudes and practices for follow-up cancer care within an integrated health system sharing a common electronic health record and clinical infrastructure to examine whether the integrated setting facilitated communication and coordination between PCPs and oncologists. Methods: 41 PCPs and 24 oncologists (response rate = 52%) affiliated with an integrated safety-net health system completed a validated survey. The survey assessed PCP and oncologists’ preferred models for delivering care, attitudes towards follow-up care, and cancer surveillance practices in this setting. Results: 41% of PCPs preferred an oncologist-led care delivery model as compared to 21% of oncologists. More PCPs than oncologists (73% vs 58%) agreed that PCPs have the skills necessary to initiate cancer surveillance. Yet, PCPs more often disagreed (56% vs 42% of oncologists) that they should have primary responsibility for providing cancer follow-up care. PCPs and oncologists differed significantly over cancer surveillance practices. Oncologists more consistently reported that PCPs ordered tests for cancer surveillance, evaluated patients for cancer recurrence and for adverse physical and psychological effects of cancer or its treatment, as well as managed pain and adverse outcomes of cancer treatment. PCPs, however, did not report equivalent ordering for these services. Conclusions: Even within an integrated health system, we found significant uncertainty as to who is responsible for care of cancer survivors. Oncologists more commonly assigned responsibility for cancer survivorship care to PCPs than PCPs recognized. This imbalance indicates many cancer survivors may not be receiving recommended care. Consensus guidelines are needed to delineate shared responsibilities for cancer survivors between primary care and oncology specialty care physicians.

Little or no longitudinal data have been available to date on the utilization of primary care physicians' services, particularly by chronically ill and multimorbid patients and by those who see their primary care physician often ("frequent attenders"). We collected anonymous data on 305 896 patients from 155 primary care practices over the period 1996-2006 and analyzed them with descriptive statistics, correlations, and multiple logistic regression. Over the period of the study, patients visited their primary care physicians about 7 times per year on average. Frequent attendance, defined as 24 or more contacts per year, was not strongly associated with chronic illness or multimorbidity (r=0.19 and r=0.24, respectively) but was found to be linked to time-consuming medical services, such as detailed counseling (adjusted odds ratio [OR], 5.8) and house calls (OR, 3.5). Chronically ill patients utilized their primary care physicians' services less than we had expected. Chronic illness and multimorbidity were more common with increasing age; also correlated with age were the utilization of medical services, the number of visits to the primary care physician, and the number of visits to the primary care physician among frequent attenders. Although in Germany visits to physicians of all types (both primary care physicians and specialists) in private practice became more frequent in total over the period of this study, visits to primary care physicians alone did not. Frequent attenders do not necessarily have chronic illness or multimorbidity but seem to constitute a particularly problematic group. Chronic illness is not a predictor for greater utilization of primary care physicians' services.

An important determinant of health system performance is contracting. Providers often respond to financial incentives, despite the ethical underpinnings of medicine, and payers can craft contracts to influence performance. Yet contracting is highly imperfect in both single-payer and multi-payer health systems. Arguably, in a competitive, multi-payer environment, contractual innovation may occur more rapidly than in a single-payer system. This innovation in contract design could enhance performance. However, contractual innovation often fails to improve performance as payer incentives are misaligned with public policy objectives. Numerous countries seek to improve healthcare contracts, but thus far no health system has demonstrably crafted the necessary blend of incentives to stimulate optimal contracting.

Background Despite the increasing usage and popularity of chiropractic care, there has been limited research conducted to examine the professional relationships between conventional trained primary care physicians (PCPs) and chiropractors (DCs). The objectives of our study were to contrast the intra-professional referral patterns among PCPs with referral patterns to DCs, and to identify predictors of PCP referral to DCs.Methods We mailed a survey instrument to all practicing PCPs in the state of Iowa. Descriptive statistics were used to summarize their responses. Multivariable logistic regression analyses were conducted to identify demographic factors associated with inter-professional referral behaviors.Results A total of 517 PCPs (33%) participated in the study. PCPs enjoyed strong intra-professional referral relationships with other PCPs. Although patients exhibited a great deal of interest in chiropractic care, PCPs were unlikely themselves to make formal referral relationships with DCs. PCPs in a private practice arrangement were more likely to exhibit positive referral attitudes towards DCs (p = 0.01).Conclusion PCPs enjoy very good professional relationships with other PCPs. However, the lack of direct formalized referral relationships between PCPs and chiropractors has implications for efficiency, continuity, quality, and patient safety in the health care delivery system. Future research must focus on identifying facilitators and barriers for developing positive relationships between PCPs and chiropractors.

The world we live in: Health policy from a primary care perspective

One Stop Health Care Shopping? The Rise of “McClinics” and Their Impact on Emergency Care

Back to table of contents Previous article Next article ProfessionalFull AccessResidents Interested in Public Sector Career Would Benefit From Geriatric TrainingHana Ali, M.D., Melanie Scharrer, M.D.Hana AliSearch for more papers by this author, M.D., Melanie ScharrerSearch for more papers by this author, M.D.Published Online:3 Mar 2021https://doi.org/10.1176/appi.pn.2021.2.31AbstractThe U.S. population is rapidly aging, and many have serious mental illness. Psychiatry residents should consider geriatric training to augment training in community psychiatry.“Do you like it?” Ms. M asked, fluffing her newly permed hair. It did seem unbelievable that several months ago, she had been referred for hospice care. At the time, the patient rarely spoke or ate during her frequent discharges and readmissions to the state geriatric psychiatric hospital and the university hospital nearby. Slowly, through collaboration among specialists from geriatric psychiatry, palliative care, and geriatric primary care, her multiple comorbid conditions were addressed, and her complex psychotropic medication regime was simplified. She experienced a remarkable recovery and was now ready to go on living.Community psychiatrists constantly use the skills acquired during a geriatric psychiatry fellowship, which can allow them to provide more comprehensive care for aging patients with serious mental illness (SMI), most of whom have multiple psychiatric and medical comorbidities.As the nation’s population ages, so too are individuals living with SMI. These individuals have unique needs that fall at the intersection of the subspecialties of public psychiatry and geriatric psychiatry. Today, many older patients with SMI receive care at public mental health clinics where they are cared for by community psychiatrists and in Assertive Community Treatment programs. However, the shortage of geriatric psychiatrists in this country is well known, and more public-sector psychiatrists with expertise in geriatric psychiatry are needed.In the last decade, fellowship programs in public and community psychiatry have gained popularity among psychiatry residents. A survey of psychiatry trainees found that most had a significant level of interest in public psychiatry. Since 2006 the number of public and community psychiatry fellowship programs in the United States has expanded from two to 21 programs, according to the American Association for Community Psychiatry. These programs equip trainees with skills needed to navigate increasingly complex public mental health infrastructures to provide care for individuals living with SMI. To provide more comprehensive and high-quality care for the rapidly aging population in the United States, trainees who intend to work in public mental health clinics will benefit from geriatric psychiatry training and should consider completing a postgraduate fellowship in geriatric psychiatry.Geriatric psychiatry and public psychiatry already overlap significantly. Geriatric psychiatrists care for patients with complex disease presentations that require collaboration with other medical specialists. They work on interdisciplinary teams to navigate complicated behavioral health and social service systems and are often at the forefront of developing innovative systems of care to meet the needs of our nation’s aging population. In many ways, geriatric training is a natural fit for residents interested in working in the public sector.The challenges that excite individuals interested in public and community psychiatry are the same challenges that exist in the field of geriatric psychiatry: working collaboratively with health care professionals in other disciplines; navigating complex health systems; effectively utilizing local, state, and federal resources; and developing other structural interventions to meet the mental health needs of underserved populations. The overlap is clear. Exposing trainees who have an interest in community and public psychiatry to experiences in geriatric mental health can help alleviate the geriatric workforce shortage and ultimately result in better treatment for our aging SMI population. ■To learn more about geriatric training and other opportunities in the field, please visit the American Association for Geriatric Psychiatry (AAGP) website here.Psychiatry residents and medical students are also encouraged to apply to the AAGP Scholars Program. Both authors are alumni of the AAGP Honors Scholars Program.Hana Ali, M.D., is a PGY-4 psychiatry resident at Yale University.Melanie Scharrer, M.D., is a community psychiatrist who recently completed her geriatric psychiatry fellowship training at the University of Wisconsin School of Medicine and Public Health. ISSUES NewArchived

for public psychiatric services, (2) making psychiatric professionals and governments accept real responsibility for the seriously mentally ill, (3) changing laws to focus on treatment needs rather than individual autonomy, and (4) expanding two key funding areas-housing and research. These would shift priorities within the mental health field to focus exclusively on illness, on treatment priorities, and on the most severe cases, and to rely absolutely on research to find answers. No attempt would be made to prevent mental problems or to address problems other than the major illnesses, presumably schizophrenia and depression. The book ends with an inspiring vision of what life would be like if these recommendations were carried out. But, where would the line be drawn between “serious” mental illness and other severe and more or less disabling conditions causing individual suffering? How do advocates maintain interest and concern once the most heart-rending cases are no longer visible? Are the most seriously mentally ill the only concern of the field? If we do not study “normal” behavior, how can “abnormal” be understood? If one keeps these concerns in mind, Nowhere to Go is highly recommended as a constructively provocative challenge. One cannot come away without a sense of shame that our society permits such suffering, or without a sense of frustration with the prag matism and incrementalism of public policy. Both are valuable reminders for those who may too easily distance themselves from the plight of people with serious, disabling mental illness.

Primary care is the entry point for most people into the health system and primary care physicians (PCPs) are ideally placed to serve as the central service provider for patients with depressive disorders. Identifying and managing depressive disorders is challenging in primary care and the long-term outcomes and factors affecting prognosis remain unclear particularly in non-Western settings where few studies have been conducted. This study aimed to examine the prevalence, incidence and 12-month outcomes of depressive disorders in Hong Kong’s primary care.
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\nA practice-based research network was formed consisting of 59 PCPs who assisted in recruitment of subjects and data collection. These doctors worked in public and private sector clinics territory-wide representative of the settings where primary care is delivered in Hong Kong. 
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\nA cross-sectional followed by a 12-month cohort study was conducted on adult patients recruited from the doctors’ waiting rooms. Key study instruments included the Patient Health Questionnaire-9 Item (PHQ-9), the Centre for Epidemiologic Studies Depression Scale (CES-D) and the Short-Form Health Survey Version 2.0 (SF-12v2).
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\n10,179 subjects completed the cross-sectional survey and index doctor visit (response rate 81.0%). 4358 subjects joined the cohort study (response rate 42.8%) and were followed-up by telephone interview at 12, 26 and 52 weeks.
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\nThe cross-sectional prevalence of PHQ-positive depressive disorders was 10.7%; 12-month cumulative incidence was 5.3%; and 12-month cumulative remission was 60.3%. PCPs identified 23.1% of the PHQ-positive subjects as having depression. At highest risk for prevalence were patients with a past history of depression, with multiple co-morbidities or who were unemployed. PCP identification did not affect 12-month remission but was associated with a faster improvement in health-related quality of life (HRQOL). Patients with milder depressive symptoms, better physical health and better HRQOL at baseline were more likely to report symptom remission over 12 months. Patients with moderate to severe depressive symptoms at baseline had a more heterogeneous set of symptom trajectories. Patients at greatest risk of chronicity were those with multiple co-morbidities or with pain. Patients reporting low levels of health service use were at greatest risk of deterioration over 12 months. 
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\nUptake of mental health services was low in patients who were screened PHQ-positive. Over 12-months, 21.7% reported receiving mental health treatments from a psychiatrist, 11.6% from a PCP, and 3.6% from a psychologist. Identification of depression by the PCP was associated with a higher uptake of mental health services, however baseline depressive symptom severity was not.
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\nIdentification of depression is challenging, nonetheless, PCP non-detection does not appear to contribute to persistence of depressive symptoms as most patients in this setting improve naturalistically over time. 
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\nIn clinical practice, doctors need to be more vigilant in patients who are at high-risk for prevalence and incidence to prevent delays in detection and treatment. Greater treatment attention is required for patients with multiple co-morbidities or who suffer from pain, to enable them to cope better with their complex bio-psycho-social health problems and enhance HRQOL. Regular follow-up should be scheduled for those who are at risk for poor prognosis.

The increasing use of electronic communications has enhanced access to physicians for patients and clinical staff. Primary care physicians (PCPs) have anecdotally identified electronic inbox management as a new source of work-related stress. To describe PCPs' experiences managing their electronic inboxes and to characterize the array of management strategies developed by individual physicians and practice groups. This qualitative study was conducted in 8 medical centers of a large group practice with more than 4 million patients in diverse settings and a mature electronic health record. The group encourages patients to use portal secure messaging to enhance access to their physicians and the care experience. Semistructured interviews were conducted with 24 internists and family medicine physicians identified via snowball sampling. Interviews were conducted July through November 2018. Data analysis was conducted between November 2018 and April 2019. Audio recorded interviews were transcribed and analyzed using thematic analysis to identify major themes and subthemes. The 24 participants (12 women [50.0%]; mean [SD] age, 45.5 [6.5] years), including 9 department chiefs and 15 PCPs, had a mean (SD) of 16.8 (7.8) years since medical school graduation. Participants described substantial changes in medical practice due to electronic communication, including perceived patient expectations to receive rapid responses to portal secure messages. They described portal secure messaging as useful for building relationships with patients, but also reported that electronic message management has created new stressors, including erosion of work-life boundaries and anxiety associated with unlimited inbox volume. Individual PCPs used a diverse array of strategies, including multitasking during and outside work and delegating to medical assistants. Chiefs described group-level strategies, including reserving clinic time for inbox management, coverage systems for vacation and sick days, physician-to-physician training, and interdisciplinary teams to share messaging work. Individual physicians and local practice groups have developed a wide array of strategies for electronic inbox management. The volume of electronic messages and PCPs' perceptions that patients expect rapid responses have created new stressors in primary care practice. Medical groups and health systems can support PCPs by facilitating knowledge transfer among physicians about inbox management strategies and further developing team structures for inbox coverage.

Dual job holding practitioners in Bangladesh: an exploration