Purposes: We explored the experience of older adults living with multimorbidity during the COVID-19 pandemic. Methods: Using a phenomenological approach, we conducted semi-structured interviews with 17 participants aged 50 years and older living with multimorbidity. Data collection and analysis were iterative using a thematic approach. We explored participants’ overall pandemic experience as well as querying specifically about pandemic experiences of social isolation, coping and resilience. Results: We describe our findings according to four main themes: (1) Lives disrupted; (2) Diverse social isolation experiences; (3) Coping through seeking solitary and group activities; and (4) Individual ways of enacting resilience and the role of health care to build resilience. Conclusion: We found the experiences of older adults living with multimorbidity during the COVID-19 pandemic were characterized by disruption. When queried social isolation was shared as a prominent concern. We identified the creativity with which participants coped with social isolation and the resilience they marshaled. This study will be used to inform interventions to mitigate social isolation and its effects in a post-pandemic world.

BACKGROUND: The Revised Patient Perception of Patient-Centeredness (PPPC-R) scale was originally formulated in English to examine patient-centeredness. OBJECTIVE: To translate and validate the PPPC-R questionnaire into Arabic. METHODOLOGY: Translating the PPPC-R into Arabic involved forward and back translations by bilingual experts. Content validity was checked through the Item and Scale Content Validity Indices. The instrument underwent pilot testing and was then completed by 179 patients in the emergency department to examine construct validity using both confirmatory and exploratory factor analyses. Reliability was tested using Cronbach’s alpha to ensure internal consistency. RESULTS: The Item Content Validity Index ranged between 0.66 and 1, and the Scale Content Validity Index was 0.96. Initial confirmatory factor analysis of the Arabic-PPPC-R revealed an inadequate fit, prompting an exploratory factor analysis with Promax rotation, which identified three factors that explained 66.3% of the variance. The refined model, tested again using confirmatory factor analysis, demonstrated an acceptable fit with improved statistical measures, including CFI and TLI values above 0.90 and RMSEA of 0.07. Reliability testing revealed high internal consistency with a Cronbach’s alpha of 0.949 for the full scale and between 0.889 and 0.906 for the individual subscales. CONCLUSION: The study findings showed that the Arabic version of the PPPC-R has good structural characteristics and is a reliable and valid instrument for measuring patient-centeredness.

Objective To describe family physicians' experiences of administrative burden in practice. Design Qualitative study using constructivist grounded theory. Setting Ontario. Participants Family physicians. Method In-depth virtual interviews with family physicians practising in Ontario who completed postgraduate training between 2017 and 2022. Main findings A total of 36 family physicians were interviewed. Without external prompting, all participants raised the issue of administrative burden, offering specific contextual factors contributing to their administrative burden. These included volume of paperwork, inbox management, and lack of compensation for the hours of administrative tasks performed. In addition to these contextual factors, 2 main themes were identified: the first revealed the impact of administrative burden on both the time available for patient care and physicians' well-being. This latter issue was exacerbated by deteriorating relationships with specialist colleagues, contributing to family physicians' administrative burden and burnout. A lack of exposure to the volume of administrative duties during training added to this issue. The second theme described participants' personal strategies (eg, creating flex time, setting boundaries) and system solutions (eg, need for compensation for administrative time, funding to increase clinic staff, and interventions by regulatory bodies) to address administrative burden. Conclusion Administrative burden negatively impacts physician well-being and reduces time for direct patient care. These findings highlight2 new sources contributing to administrative burden: deteriorating relationships between family physicians and specialist colleagues and a lack of exposure to managing administrative responsibilities during medical training. Study findings provide personal strategies and system solutions to guide practitioners, policy-makers, and educators.

The burden of pregnancy loss remains high in low- and middle-income countries like Pakistan. The Every Newborn Action Plan (ENAP) aims to decrease the stillbirth rate to 12 per 1000 total births by 2030, in every country. Current estimates indicate that Pakistan is unlikely to achieve this ENAP target, as the stillbirth rate stands at 30.6 per 1000 total births. This study used the 2019 Pakistan Maternal Mortality Survey to identify the community-level, sociodemographic, maternal, environmental, and health services factors that are associated with pregnancy loss. Due to characteristic differences in urban and rural communities, separate analyses were carried out for ever-married women of 15 to 49 years. Mixed effects negative binomial regression was used to analyze the urban (n = 5,887) and rural (n = 7,136) samples of women who reported at least one pregnancy. The separate analyses found the factors associated with pregnancy loss to vary between urban and rural areas. In urban areas, pregnancy loss was associated with maternal education, maternal age, current marital status, and sanitation facility type. In rural areas, pregnancy loss was associated with region of residence, wealth index, maternal age, current marital status, drinking water source, cooking fuel type, and sanitation facility type. This study carries significant implications for alleviating the burden of pregnancy loss in Pakistan, in line with ENAP objectives. The separate analyses provide a novel perspective regarding the factors influencing pregnancy loss in urban and rural areas, allowing for targeted interventions.

OBJECTIVE:To describe family physicians' experiences of administrative burden in practice. DESIGN:Qualitative study using constructivist grounded theory. SETTING:Ontario. PARTICIPANTS:Family physicians. METHOD:In-depth virtual interviews with family physicians practising in Ontario who completed postgraduate training between 2017 and 2022. MAIN FINDINGS:A total of 36 family physicians were interviewed. Without external prompting, all participants raised the issue of administrative burden, offering specific contextual factors contributing to their administrative burden. These included volume of paperwork, inbox management, and lack of compensation for the hours of administrative tasks performed. In addition to these contextual factors, 2 main themes were identified: the first revealed the impact of administrative burden on both the time available for patient care and physicians' well-being. This latter issue was exacerbated by deteriorating relationships with specialist colleagues, contributing to family physicians' administrative burden and burnout. A lack of exposure to the volume of administrative duties during training added to this issue. The second theme described participants' personal strategies (eg, creating flex time, setting boundaries) and system solutions (eg, need for compensation for administrative time, funding to increase clinic staff, and interventions by regulatory bodies) to address administrative burden. CONCLUSION:Administrative burden negatively impacts physician well-being and reduces time for direct patient care. These findings highlight 2 new sources contributing to administrative burden: deteriorating relationships between family physicians and specialist colleagues and a lack of exposure to managing administrative responsibilities during medical training. Study findings provide personal strategies and system solutions to guide practitioners, policy-makers, and educators.

BACKGROUND:Virtual care accelerated to the forefront of family physician (FP) care following the COVID-19 pandemic and continues to play a significant role in patient care. The choice between virtual and in-person primary care must be sensitive to patients' contexts particularly for those with multi-morbidity. OBJECTIVES:This study explored how to make the choice between virtual and in-person FP care for persons living with multi-morbidity that is acceptable to patients and FPs. METHODS:We conducted a constructivist grounded theory study to understand the processes patients and FPs employ when deciding on the mode of primary care delivery. We used individual interviews to understand the perspectives and expectations of patients with multi-morbidity (2+ chronic conditions) and FPs. RESULTS:There were two main themes revealed in data analysis: Considerations in choosing mode of delivery (including reason for visit, impact on access, technological logistics, and reimbursement for virtual care) and Process for choosing mode of delivery (including endorsing the patient choice when possible and scheduling visits). CONCLUSION:This paper integrated the experience of both patients and FPs to understand how to make the choice between virtual and in-person care. This understanding can support the future of FP care where diverse modes of delivery are employed, but currently technological barriers remain. Clinical scheduling systems that depend on telephone interactions between clinic staff and patients do not always support the process patients and FPs indicated they prefer; that is, one that respects patient preference and FP clinical expertise.

OBJECTIVE:To assist in workforce planning by updating trends in the characteristics of near-retirement comprehensive family physicians (FPs) and their patients since the COVID-19 pandemic. DESIGN:Population-level serial cross-sectional analysis using linked health administrative datasets. SETTING:Ontario. PARTICIPANTS:The Ontario population as of March 31, 2022 (15,023,570), and the comprehensive FPs to whom they are attached (9375). We compared these populations to pre-pandemic analyses (2008, 2013, and 2019). MAIN OUTCOME MEASURES:Temporal trends in the number, proportion, and characteristics of comprehensive FPs; comprehensive FPs nearing retirement; and patients attached to comprehensive FPs, focusing on FPs nearing retirement. RESULTS:After 2019, growth in the overall comprehensive FP workforce stagnated (2019: 9377; 2022: 9375). For the first time during the study period, in 2022 there was a decline in the number and proportion of early-career physicians (age <35 years) and female physicians comprised the majority (51.5%) of the workforce. An increasing proportion of the workforce is age 65 and older (2008: 10.0%; 2013: 14.4%; 2019: 13.9%; 2022: 15.2%), and correspondingly, an increasing number and proportion of patients are attached to near-retirement FPs. The oldest FP cohort (age ≥70) also increased in number and proportion in 2022. Patients attached to near-retirement FPs were older and had higher levels of chronic conditions compared with patients across the overall FP workforce. Mean roster sizes remained relatively stable and female FPs consistently cared for smaller rosters than male FPs. An increasing proportion of patients had the highest level of complexity, and practices of all FP age groups comprised increasing proportions of those with the highest resource needs. CONCLUSION:Changes to the comprehensive FP workforce since the COVID-19 pandemic, together with increasing patient complexity, raise concerns about the workforce's capacity to absorb patients whose FPs are poised to retire.

Introduction and Objective: Large-scale, real-world data on age- and sex-specific Level 3 hypoglycemia rates in type 1 or 2 diabetes (T1D, T2D) remain critically sparse. We aimed to address this gap using prospective data from the iNPHORM study. Methods: Adults (≥18 years) with T1D or T2D on insulin and/or secretagogues recruited from a US-wide probability-based internet panel completed an online screener, baseline, and up to 12 monthly follow-up questionnaires. For complete cases with ≥1 follow-up, we calculated annualized Level 3 hypoglycemia rates overall and by age, sex (assigned-at-birth), and diabetes type. Results: N=978 participants were analyzed; Table 1 reports overall and group-specific Level 3 hypoglycemia rates. Across diabetes types, adults aged 18-39 years—particularly males—reported the highest event rates, which sharply dropped after age 39, regardless of sex. In T1D, females aged 40-49 years had higher rates than males (p=0.04), a trend that persisted (non-significantly) in cohorts aged ≥60 years. In T2D, males had higher Level 3 hypoglycemia rates than females until after age 59, when increasing female rates surpassed (non-significantly) declining male rates. Conclusion: Our results reveal age- and sex-based disparities in Level 3 hypoglycemia, suggesting that younger males and older females are key at-risk groups. Targeted prevention strategies are crucial to ensure equitable outcomes across diverse populations with diabetes. A. Ratzki-Leewing: Other Relationship; Abbott, Dexcom, Inc. Consultant; Sanofi. Other Relationship; Sanofi. Consultant; Sanofi-Aventis U.S. Advisory Panel; Sanofi-Aventis U.S. J.E. Black: None. A. Kahkoska: None. K. Gandhi: None. B.L. Ryan: None. G. Zou: None. S.B. Harris: Advisory Panel; Abbott. Consultant; Abbott. Research Support; Boehringer-Ingelheim. Advisory Panel; Dexcom, Inc. Consultant; Dexcom, Inc. Research Support; Canadian Institutes of Health Research. Advisory Panel; Eli Lilly and Company. Research Support; Eli Lilly and Company. Consultant; Medscape. Advisory Panel; Novo Nordisk. Research Support; Novo Nordisk, Novartis Pharmaceuticals Corporation. Advisory Panel; Sanofi. Consultant; Sanofi. The iNPHORM study was funded through an investigator-initiated grant from Sanofi Global.

AIMS:This study evaluated the incidence proportion and rate of self-reported Level 3 hypoglycemia and explored associated risk factors in young adults with type 2 diabetes (T2D). METHODS:Subgroup analyses with a one-year U.S.-wide T2D dataset were performed. Retrospective and prospective data on Level 3 hypoglycemia and participant characteristics were analyzed for 207 young adults (18-39 years old) and 436 middle-aged adults (40-64 years old). Age group-stratified multivariable negative binomial regression was used to identify factors associated with Level 3 hypoglycemia. RESULTS:Young adults exhibited a threefold higher incidence of Level 3 hypoglycemia events requiring medical assistance compared to the middle-aged cohort at baseline (p < 0.001). During follow-up, the young adults experienced a twofold higher incidence proportion of Level 3 hypoglycemia (p < 0.001), and n a fivefold higher annualized rate (p < 0.001); they also reported greater hypoglycemia fear (p < 0.001). Distinct sociodemographics, general health and lifestyle factors, diabetes medical history, and diabetes therapy and technology use characteristics were observed in the young-adult group, as were unique risk factors for Level 3 hypoglycemia frequency CONCLUSION: Our results suggest that young adults with T2D are at particularly high risk of Level 3 hypoglycemia, with attributes that differ from those of the traditional middle-aged cohort.

AIMS:Level 3 (severe) hypoglycaemia is a serious, yet preventable, complication of insulin- or secretagogue-treated diabetes. However, real-world insight into its incidence and risk factors remains limited. We analysed data from the iNPHORM study to address this gap. MATERIALS AND METHODS:iNPHORM is a prospective internet panel survey of US adults (aged 18-90) with type 1 diabetes (T1D) or insulin- and/or secretagogue-treated type 2 diabetes (T2D). A screener, baseline and 12-monthly follow-up questionnaires captured data on Level 3 hypoglycaemia and participant characteristics. Crude incidence proportions and annualized event rates were calculated. Repeated LASSO selection and negative binomial regression identified risk factors, with separate models for T1D and T2D. RESULTS:Among 985 participants (T1D: 16.7%), 35.0% experienced ≥1 Level 3 event over follow-up (T1D: 45.0%; T2D: 33.0%). The annualized rate was 4.98 EPPY (T1D: 3.56; T2D: 5.26). In T1D, rates were higher among individuals identifying as non-White (RR [rate ratio]: 2.03), with prior diabetes ketoacidosis (RR: 6.49), and greater fear of hypoglycaemia (RR: 1.41). Prior diabetes education (RR: 0.42) was protective. In T2D, rates were higher with younger age (RR: 0.77 per 10-year increase), greater fear of hypoglycaemia (RR: 1.18), more diabetes complications, higher secretagogue dose, more diabetes visits (RR: 1.72), longer use of continuous/flash glucose monitoring, impaired awareness of hypoglycaemia and a greater number of past healthcare-requiring severe hypoglycaemia (RR: 1.12). CONCLUSIONS:Level 3 hypoglycaemia remains common in T1D and T2D. Findings support risk-targeted prevention and diabetes care strategies that co-prioritize safety and effectiveness.

INTRODUCTION:Following the COVID-19 pandemic, the role of virtual family medicine care is evolving. It can be tempting to consider only the technological aspects of virtual care; we argue we must attend to compassion's essential role in virtual family medicine care. This research aimed to understand the components contributing to compassionate family medicine virtual care and how these were demonstrated. METHODS:We conducted a qualitative Constructivist Grounded Theory study with 2 components; individual interviews with patients and family physicians (FP), and Collaborative Discussions, informed by the interviews, that brought patients and FPs together. Data collection and analysis were iterative using a constant comparative analysis. RESULTS:We recruited nineteen patient and fourteen FP participants for the first component and 6 patient and 4 FP participants for the second. We identified 4 themes: Conveying virtual compassion through actions; External factors affecting virtual compassion; Virtual visits extending compassionate care; and Role of the patient-FP relationship. These themes can be characterized as a stance that FPs assume in their practice of virtual care. DISCUSSION:We highlight 4 themes important to the delivery of compassionate virtual care. We provide specific actions FPs may consider in delivering virtual care. Offering virtual visits was viewed as a compassionate bridge between in-person visits. CONCLUSION:Our findings support that it is possible to convey compassion in virtual visits including telephone interactions. As virtual care evolves, our findings can support patients and family physicians to safeguard compassion so that it remains a hallmark of care for all modes of delivery.

Background: Medical office assistants (MOAs), also known as receptionists and clerks, are frontline workers and the most accessible member of the primary care team. Historically, their contributions to primary care have been unrecognised and undervalued. The COVID- 19 pandemic put pressure on existing roles and systems in primary care: how MOAs adapted is unknown. Aim: To explore the experiences of MOAs working in primary care during the COVID- 19 pandemic from the perspectives of MOAs and family physicians (FPs) who worked with MOAs during this period. Design & setting: A qualitative study, using constructivist grounded theory (CGT), was conducted in Method: Seventeen participants were recruited through professional contacts of the research team. Individual semi- structured interviews were undertaken with MOAs and FPs across the province. Results: MOAs' many responsibilities in primary care intensified during the pandemic. MOAs leveraged their healthcare system knowledge and therapeutic relationships with patients to reduce patient distress. Unfortunately, MOAs experienced more frustration, and in some cases, abuse from patients. MOAs' ability to adapt to new systems and respond to high patient needs seemed to be positively influenced by their relationships with patients and FPs. FPs showed support for MOA welfare and recognised their critical role on primary care teams. Conclusion: MOAs made considerable contributions to primary care during the COVID- 19 pandemic. This study suggests MOAs have greater capacity than previously recognised, which has important implications for planning in an era of under- resourced health care.

Multimorbidity is becoming highly prevalent across the globe. Current medical curricula predominantly focus on single-disease management, leaving future physicians underprepared to provide patient-centred care to address the multimorbidity epidemic. Through a systematic review, this short communication identified the current state of multimorbidity education in medical curricula and evaluated existing educational approaches. A narrative systematic review (CRD42024585500) of studies meeting stringent inclusion criteria focusing on multimorbidity education was conducted. The review found limited evidence regarding the integration and effectiveness of current educational approaches. Although multimorbidity education was associated with improved self-reported student confidence, there was a notable absence of structured, formal teaching frameworks, with education primarily occurring through informal clinical exposure. This systematic review discovered the absence of an evidence base on structured, validated teaching methods that are urgently needed to better prepare future physicians to manage patients with multimorbidity effectively.

Literature before 2014 told a relatively good news story, providing evidence that teaching and practicing patient-centered care showed positive impact on clinician behavior and patient outcomes. This chapter updates the literature through two reviews of the effects of patient-centered interventions on 1) physician wellness and 2) patient outcomes. The three intervention studies on clinician wellness assessed interventions aimed at enhancing clinician self-reflection, empathy, kindness, mindfulness, and patient-centeredness. These interventions positively influenced clinician burnout, mindfulness, and satisfaction with the encounter with the patient. The 16 studies of interventions to improve patient-centered encounters with patients, mostly focused on the component of finding common ground, and positively influenced patients' experience with care, and to a lesser extent, patients' reported outcomes and clinical status measures. These 16 studies raised issues of implementation failure of the interventions as well as potential equity issues. A key advantage to the intervention studies was the inclusion of qualitative elements to help understand the nature and mechanisms of the impact on clinician and patient outcomes.

This chapter describes the development, evolution, and application of the Measure of Patient-Centered Communication (MPCC), a measure based on observation of the clinical encounter. It includes Component 1, Exploring Both the Disease and the Illness Experience; Component 2, Understanding the Whole Person; and Component 3, Finding Common Ground. This chapter also provides the reliability and validity of the MPCC. Process categories, along with the most recent coding and scoring of the MPCC, are outlined in detail. We describe how the MPCC can be used in a variety of patient-clinician settings with actual patients, as well as with standardized patients. Since 2001, over 230 requests have been received to use the MPCC working paper.

BACKGROUND:Despite the Canadian healthcare system's commitment to equity, evidence for disparate access to primary care (PC) providers exists across individual social identities/positions. Intersectionality allows us to reflect the realities of how social power shapes healthcare experiences at an individual's interdependent and intersecting social identities/positions. The objectives of this study were to determine: (1) the extent to which intersections can be used classify those who had/did not have a PC provider; (2) the degree to which each social identity/position contributes to the ability to classify individuals as having a PC provider; and (3) predicted probabilities of having a PC provider for each intersection. METHODS AND FINDINGS:Using national cross-sectional data from 241,445 individuals in Canada aged ≥18, we constructed 320 intersections along the dimensions of gender, age, immigration status, race, and income to examine the outcome of whether one had a PC provider. Multilevel analysis of individual heterogeneity and discriminatory accuracy, a multi-level model using individual-level data, was employed to address intersectional objectives. An intra-class correlation coefficient (ICC) of 23% (95%CI: 21-26%) suggests that these intersections could, to a very good extent, explain individual variation in the outcome, with age playing the largest role. Not all between-intersection variance in this outcome could be explained by additive effects of dimensions (remaining ICC: 6%; 95%CI: 2-16%). The highest intersectional predicted probability existed for established immigrant, older South Asian women with high income. The lowest intersectional predicted probability existed for recently immigrated, young, Black men with low income. CONCLUSIONS:Despite a "universal" healthcare system, our analysis demonstrated a substantial amount of inequity in primary care across intersections of gender, age, immigration status, race, and income.