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.

Importance:It is unclear why areas of medicine overrepresented by female physicians receive lower pay. One theory is devaluation-that work done by women is systematically devalued over time. Objective:To assess whether an increase in the proportion of female physicians in a specialty is associated with a decrease in the median annual payments for that specialty. Design, Setting, and Participants:In 2022, a population-based, repeated cross-sectional analysis was conducted using routinely collected data of all active physicians in Ontario, Canada, from 1992-1993 (1993) to 2019-2020 (2020). For each year, the percentage of female physicians and total annual median payments for each specialty were calculated. Main Outcome and Measure:Random-effects linear regression models were constructed to evaluate the association between the percentage of female physicians and median payments overall. Additionally, we conducted a sensitivity analysis of the subgroup of physicians with 1.0 or more full-time equivalency (FTE). Results:The physician workforce increased from 18 572 in 1993 to 31 374 in 2020 with the number of female physicians increasing from 4151 (22.3%) to 13 205 (42.1%). The mean (SD) age for all physicians in 2020 was 49.6 (12.8) years, and for female physicians in 2020 was 46.2 (11.5) years. Median annual payments increased from $183 033 to $316 570. Regression results found that an absolute 1 percentage point increase in the percentage of female physicians in a specialty over 1 year was associated with a $2183 lower increase in median payments than expected overall (95% CI, -$3932 to -$434; P = .02) and a $3235 lower increase for female physicians (95% CI, -$4888 to -$1583; P < .001), but not for male physicians (-$554; 95% CI, -$2373 to $1264). Conclusion and Relevance:This repeated cross-sectional study did not find evidence to directly support the theory of devaluation, yet the results underscore that occupational segregation, both across and within specialties, is associated with the gender pay gap. These findings should prompt medical leaders and policymakers to reconsider what activities are monetarily valued in medicine and whether these align with what patients and the public consider most valuable from a care perspective.

PURPOSE:An adequate supply of family physicians who deliver comprehensive care is critical for addressing evolving population health needs, fostering health equity, and ensuring a cost-effective health system. Little is known about current trends of family physicians choosing focused practice and concurrent changes in comprehensive family physician numbers relative to population growth. METHODS:We conducted a repeated cross-sectional population-based study using administrative data to understand sex-stratified trends in focused practice from 1993/1994 through 2021/2022 in Ontario, Canada, accounting for population growth. For each fiscal year, we identified all active family physicians and classified them by practice type, leveraging a previously published algorithm on comprehensiveness. RESULTS:The proportion of family physicians in focused practice increased from 7.7% (856/11,103) in 1993/1994 to 19.2% (3,351/17,413) in 2021/2022. The 3 most prevalent focused practice types at the end of the study period were emergency (37.0%), hospitalist (26.5%), and addiction (8.3%) medicine. A greater proportion of focused practice physicians were male (60.1%) vs female (39.9%) in 2021/2022. Over the study period, the number of family physicians increased from 104 to 118 per 100,000; however, the number of comprehensive family physicians decreased from 71 to 64 per 100,000. Of the additional 6,310 family physicians who entered the workforce, 39.5% (2,495/6,310) were in focused practice. CONCLUSIONS:Over the study period, there was a decrease in the percentage of comprehensive family physicians and a substantial increase in family physicians pursuing focused practice, particularly in emergency and hospitalist medicine. Research and policy work is needed to understand and address the complex factors driving these trends.

OBJECTIVES:To 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 adjusted feedback reports and messages emphasising antibiotic associated harms.DESIGN:Pragmatic, factorial randomised controlled trial.SETTING:Primary care physicians in Ontario, Canada PARTICIPANTS: All primary care physicians were randomly assigned a group if they were eligible and actively prescribing antibiotics to patients 65 years or older. Physicians were excluded if had already volunteered to receive antibiotic prescribing feedback from another agency, or had opted out of the trial.INTERVENTION:A letter was mailed in January 2022 to physicians with peer comparison antibiotic prescribing feedback compared with the control group who did not receive a letter (4:1 allocation). The intervention group was further randomised in a 2x2 factorial trial to evaluate case-mix adjusted versus unadjusted comparators, and emphasis, or not, on harms of antibiotics.MAIN OUTCOME MEASURES:Antibiotic prescribing rate per 1000 patient visits for patients 65 years or older six months after intervention. Analysis was in the modified intention-to-treat population using Poisson regression.RESULTS:5046 physicians were included and analysed: 1005 in control group and 4041 in intervention group (1016 case-mix adjusted data and harms messaging, 1006 with case-mix adjusted data and no harms messaging, 1006 unadjusted data and harms messaging, and 1013 unadjusted data and no harms messaging). At six months, mean antibiotic prescribing rate was 59.4 (standard deviation 42.0) in the control group and 56.0 (39.2) in the intervention group (relative rate 0.95 (95% confidence interval 0.94 to 0.96). Unnecessary antibiotic prescribing (0.89 (0.86 to 0.92)), prolonged duration prescriptions defined as more than seven days (0.85 (0.83 to 0.87)), and broad spectrum prescribing (0.94 (0.92 to 0.95)) were also significantly lower in the intervention group compared with the control group. Results were consistent at 12 months post intervention. No significant effect was seen for including emphasis on harms messaging. A small increase in antibiotic prescribing with case-mix adjusted reports was noted (1.01 (1.00 to 1.03)).CONCLUSIONS:Peer comparison audit and feedback letters significantly reduced overall antibiotic prescribing with no benefit of case-mix adjustment or harms messaging. Antibiotic prescribing audit and feedback is a scalable and effective intervention and should be a routine quality improvement initiative in primary care.TRIAL REGISTRATION:ClinicalTrials.gov NCT04594200.

ABSTRACT Background Population aging 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 inform workforce planning are urgently needed. Objectives To explore temporal trends in early career, mid-career, and near-retirement comprehensive primary care physician characteristics, the medical and social needs of their patients, and the workforce’s capacity to absorb patients of near-retirement physicians. Gender-based workforce trends and trends around alternative practice models were also explored. Design A serial cross-sectional population-based study using health administrative data. Setting Ontario, Canada, where most comprehensive primary care is delivered by family physicians (FPs) under universal insurance. Participants All insured Ontario residents at three time points: 2008 (12,936,360), 2013 (13,447,365), and 2019 (14,388,566) and all Ontario physicians who billed primary care services (2008: 11,566; 2013: 12,693; 2019: 15,054). Exposure(s) Changes in the comprehensive FP workforce over three time periods. Main Outcome(s) and Measure(s) The number and proportion of patients attached to near-retirement comprehensive FPs; the number and proportion of near-retirement comprehensive FPs; the characteristics of patients and their comprehensive FPs. Results Patient attachment to comprehensive FPs increased over time. The overall FP workforce grew, but the proportion practicing comprehensiveness declined from 77.2% (2008) to 70.7% (2019), with shifts into other/focused scopes of practice across all physician career stages. Over time, an increasing proportion of the comprehensive FP workforce was near retirement age. Correspondingly, an increasing proportion of patients were attached to near-retirement comprehensive FPs. By 2019, 13.9% of comprehensive FPs were 65 years or older, corresponding to 1,695,126 (14.8%) patients. Mean patient age increased, and near-retirement comprehensive FPs served markedly increasing numbers of medically and socially complex patients. Conclusions and Relevance Primary care is foundational to high-performing health systems, but the sector faces capacity challenges as both patients and physicians age and fewer physicians choose to practice comprehensiveness. Nearly 15% (1.7 million) of Ontarians with a comprehensive FP may lose their physician to retirement by 2025. To serve a growing and increasingly complex patient population, innovative solutions that extend beyond simply growing the FP workforce are needed.

Background: Five million Canadians lack a family doctor or primary care team. Our goal was to examine trends over time in family physician workforce and service provision in Ontario and Alberta, with a view to informing policy discussions on primary care supply and delivery of services. Methods: We used cross-sectional analyses in Ontario and Alberta for 2005/06, 2012/13 and 2017/18 to examine family physician provision of service days by provider demographic characteristics and geographic location. A service day was defined as 10 or more clinic visits worth $20 or more on the same calendar day. We included all active family physicians who had evidence of billing in each fiscal year analyzed. Results: From 2005/06 to 2017/18, the number of family physicians increased by 35.3% in Ontario and 48.7% in Alberta; however, annual average service days per physician declined by 10.6% in Ontario and 5.9% in Alberta. The average daily patient volume remained stable in Ontario and declined in Alberta, and services per population kept pace modestly with population growth in both provinces. Rural areas had the smallest increases in physician counts and largest declines in average annual service days per physician. Physicians in both provinces who had graduated from medical school at least 30 years earlier accounted for more than one-third of the workforce in 2017/18. Interpretation: Ontario and Alberta experienced rapid growth in the number of family physicians, with the largest increases among those in late career and the lowest increases in rural areas. The decline in service provision among physicians overall and in subgroups in both provinces highlights the importance of measuring activity to inform workforce planning.

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 inform workforce planning are urgently needed. We examined the medical and social characteristics of patients attached to near-retirement comprehensive primary care physicians over time and explored the early-career and mid-career workforce’s capacity to absorb these patients.DesignA serial cross-sectional population-based analysis using health administrative data.SettingOntario, Canada, where most comprehensive primary care is delivered by family physicians (FPs) under universal insurance.ParticipantsAll insured Ontario residents at three time points: 2008 (12 936 360), 2013 (13 447 365) and 2019 (14 388 566) and all Ontario physicians who billed primary care services (2008: 11 566; 2013: 12 693; 2019: 15 054).Outcome measuresThe number, proportion and health and social characteristics of patients attached to near-retirement age comprehensive FPs over time; the number, proportion and characteristics of near-retirement age comprehensive FPs over time. Secondary outcome measures: The characteristics of patients and their early-career and mid-career comprehensive FPs.ResultsPatient attachment to comprehensive FPs increased over time. The overall FP workforce grew, but the proportion practicing comprehensiveness declined (2008: 77.2%, 2019: 70.7%). Over time, an increasing proportion of the comprehensive FP workforce was near retirement age. Correspondingly, an increasing proportion of patients were attached to near-retirement physicians. By 2019, 13.9% of comprehensive FPs were 65 years or older, corresponding to 1 695 126 (14.8%) patients. Mean patient age increased, and all physicians served markedly increasing numbers of medically and socially complex patients.ConclusionsThe primary care sector faces capacity challenges as both patients and physicians age and fewer physicians practice comprehensiveness. Nearly 15% (1.7 million) of Ontarians may lose their comprehensive FP to retirement between 2019 and 2025. To serve a growing, increasingly complex population, innovative solutions are needed.

Background: Walk-in clinics are common in North America and are designed to provide acute episodic care without an appointment. We sought to describe a sample of walk-in clinic patients in Ontario, Canada, which is a setting with high levels of primary care attachment. Methods: We performed a cross-sectional study using health administrative data from 2019. We compared the sociodemographic characteristics and health care utilization patterns of patients attending 1 of 72 walk-in clinics with those of the general Ontario population. We examined the subset of patients who were enrolled with a family physician and compared walk-in clinic visits to family physician visits. Results: Our study found that 562 781 patients made 1 148 151 visits to the included walk-in clinics. Most (70%) patients who attended a walk-in clinic had an enrolling family physician. Walk-in clinic patients were younger (mean age 36 yr v. 41 yr, standardized mean difference [SMD] 0.24), yet had greater health care utilization (moderate and high use group 74% v. 65%, SMD 0.20) than the general Ontario population. Among enrolled Ontarians, walk-in patients had more comorbidities (moderate and high count 50% v. 45%, SMD 0.10), lived farther from their enrolling physician (median 8 km v. 6 km, SMD 0.21) and saw their enrolling physician less in the previous year (any visit 67% v. 80%, SMD 0.30). Walk-in encounters happened more often after hours (16% v. 9%, SMD 0.20) and on weekends (18% v. 5%, SMD 0.45). Walk-in clinics were more often within 3 km of patients’ homes than enrolling physicians’ offices (0 to < 3 km: 32% v. 22%, SMD 0.21). Interpretation: Our findings suggest that proximity of walk-in clinics and after-hours access may be contributing to walk-in clinic use among patients enrolled with a family physician. These findings have implications for policy development to improve the integration of walk-in clinics and longitudinal primary care.

BACKGROUND Mental health disorders are associated with high morbidity and reduced life expectancy, and are largely managed in primary care. We sought to assess the equity of distribution of new alternative payment models and teams introduced under primary care reform in Ontario for patients with mental health disorders. METHODS We conducted a retrospective observational study using population-level administrative data for insured Ontario adults (age ≥ 18 yr) to identify all primary care payments to physicians that were allocated to individual patients in 2002/03 and 2011/12. We identified patients with mental health disorders using validated algorithms, and modelled the relations between per capita primary care costs and mental health disorders over time, stratified by type of mental health or substance use disorder and type of primary care payment. In an adjusted model, we adjusted for age, sex, rurality, neighbourhood income quintile, immigrant status, comorbidity and primary care model. For comparative purposes, we also examined the distribution of primary care payments for people with diabetes mellitus. RESULTS Total per capita primary care payments increased more slowly over the study period for patients with mental health disorders (62.0%) than for the general population (88.3%). Total payments for patients with substance use disorders increased by 142.7%, largely owing to urine drug testing in opioid substitution clinics. Adjusted total payments for those with versus without mental health disorders decreased by 10% between 2002/03 and 2011/12, driven by lower alternative payments. Similar decreases, also driven by lower alternative payments, were found for all mental health disorder subgroups except substance use and for diabetes. INTERPRETATION Payment and team reforms were associated with inequitable resource allocation to people with mental health disorders. The findings suggest the need for monitoring reforms for their impact on high-needs populations and making appropriate adjustments.

INTRODUCTION:Little is known about how mortality in multiple sclerosis (MS) may differ based on sociodemographic factors, such as immigrant status. We compared mortality in immigrants versus long-term residents with MS in Ontario, Canada. METHODS:In this retrospective cohort study, we applied a validated algorithm to linked, population-based immigration and health administrative data to identify incident MS cases in Ontario between 1994 and 2014. We identified date of death, if it occurred. We used a Cox model adjusting for age, sex, income, and comorbidity, to compare survival in immigrants versus long-term residents. RESULTS:There were 23,603 incident MS cases of whom 1,410 (6.0%) were immigrants. After adjusting for covariates, risk of death was higher in immigrants in the first year after diagnosis (hazard ratio [HR] 1.66; 95% CI 1.05-2.63, p = 0.031). However, in years 1-5 (HR 0.63; 95% CI 0.40-0.98, p = 0.041) and 5-10 (HR 0.42; 95% CI 0.24-0.75, p = 0.003) after diagnosis, risk of death was lower in immigrants. Older age at onset and comorbidity were associated with higher mortality; female sex and higher socioeconomic status were associated with lower mortality. CONCLUSIONS:In this large population with universal access to health care, immigrants with MS had higher mortality compared to long-term residents in the first year after onset and lower mortality thereafter. Lower mortality in immigrants to Canada is well described and thought to be due to the healthy immigrant effect. Higher mortality in the first year after MS onset warrants further investigation as some early deaths may be preventable.

BACKGROUND:Access to neurology specialty care can influence outcomes in individuals with multiple sclerosis (MS), but may vary based on patient sociodemographic characteristics, including immigration status.OBJECTIVE:To compare health services utilization in the year of MS diagnosis, one year before diagnosis and two years after diagnosis in immigrants versus long-term residents in Ontario, Canada.METHODS:We identified incident cases of MS among adults aged 20-65 years by applying a validated algorithm to health administrative data in Ontario, Canada, a region with universal health insurance and comprehensive coverage. We separately assessed hospitalizations, emergency department (ED) visits, outpatient neurology visits, other outpatient specialty visits, and primary care visits. We compared rates of health service use in immigrants versus long-term residents using negative binomial regression models with generalized estimating equations adjusted for age, sex, socioeconomic status, urban/rural residence, MS diagnosis calendar year, and comorbidity burden.RESULTS:From 2003 to 2014, there were 13,028 incident MS cases in Ontario, of whom 1,070 (8.2%) were immigrants. As compared to long-term residents, rates of hospitalization were similar (Adjusted rate ratio (ARR) 0.86; 95% CI: 0.73-1.01) in immigrants the year before MS diagnosis, but outpatient neurology visits (ARR 0.93; 95% CI: 0.87-0.99) were slightly less frequent. However, immigrants had higher rates of hospitalization during the diagnosis year (ARR 1.20, 95% CI: 1.04-1.39), and had greater use of outpatient neurology (ARR 1.17, 95% CI: 1.12-1.23) but fewer ED visits (ARR 0.86; 95% CI: 0.78-0.96). In the first post-diagnosis year, immigrants continued to have greater numbers of outpatient neurology visits (ARR 1.16; 95% CI: 1.10-1.23), but had fewer hospitalizations (ARR 0.79; 95% CI: 0.67-0.94).CONCLUSIONS:Overall, our findings were reassuring concerning health services access for immigrants with MS in Ontario, a publicly funded health care system. However, immigrants were more likely to be hospitalized despite greater use of outpatient neurology care in the year of MS diagnosis. Reasons for this may include more severe disease presentation or lack of social support among immigrants and warrant further investigation.

Objective To determine risk factors for multiple sclerosis (MS) in immigrants and to compare MS risk in immigrants and long-term residents in Ontario, Canada. Methods We applied a validated algorithm to linked, population-based immigration and health claims data to identify incident cases of MS in immigrants and long-term residents between 1994 and 2016. We conducted 2 multivariable Cox proportional hazards regression analyses: 1 analysis limited to the immigrant cohort assessing potential risk factors for developing MS, and 1 analysis comparing MS risk between immigrants and matched long-term residents (1:3 match). Results We identified 2,304,302 immigrants for the immigrant-only analysis, of whom 1,526 (0.066%) developed MS. Risk was greatest in those <15 years old at landing (referent <15 years; 16–30 years: hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.63–0.85; 31–45 years: HR 0.55, 95% CI 0.47–0.64). Immigrants from the Middle East (HR 1.22, 95% CI 1.06–1.40) were at greater MS risk than immigrants from Western nations; all other regions had lower risk (p < 0.0001). The matched analysis included 2,207,751 immigrants and 6,362,169 long-term residents. Immigrants were less likely to develop MS than long-term residents (p < 0.0001), although this lower risk was attenuated with longer residence in Canada. Conclusions MS incidence in immigrants to Ontario, Canada, varied widely by region of origin, with greatest risk seen in those from the Middle East. Longer residence in Canada was associated with increased risk, even with migration in adulthood, suggesting that environmental exposures into adulthood contribute to MS risk.

Objectives Medical Regulatory Authorities (MRAs) provide licences to physicians and monitor those physicians once in practice to support their continued competence. In response to physician shortages, many Canadian MRAs developed alternative licensure routes to allow physicians who do not meet traditional licensure criteria to obtain licences to practice. Many physicians have gained licensure through alternative routes, but the performance of these physicians in practice has not been previously examined. This study compared the performance of traditionally and alternatively licenced physicians in Ontario using quality indicators of primary care. The purpose of this study was to examine the practice performance of alternatively licenced physicians and provide evaluative evidence for alternative licensure policies. Design A cross-sectional retrospective examination of Ontario health administrative data was conducted using Poisson regression analyses to compare the performance of traditionally and alternatively licenced physicians. Setting Primary care in Ontario, Canada. Participants All family physicians who were licenced in Ontario between 2000 and 2012 and who had complete medical billing data in 2014 were included (n=11 419). Outcome measures Primary care quality indicators were calculated for chronic disease management, preventive paediatric care, cancer screening and hospital readmission rates using Ontario health administrative data. Results Alternatively licenced physicians performed similarly to traditionally licenced physicians in many primary care performance measures. Minimal differences were seen across groups in indicators of diabetic care, congestive heart failure care, asthma care and cancer screening rates. Larger differences were found in preventive care for children less than 2 years of age, particularly for alternatively licenced physicians who entered Ontario from another Canadian province. Conclusions Our findings demonstrate that alternatively licenced physicians perform similarly to traditionally licenced physicians across many indicators of primary care. Our study also demonstrates the utility of administrative data for examining physician performance and evaluating medical regulatory policies and programmes.

OBJECTIVE:To determine risk factors for multiple sclerosis (MS) in immigrants and to compare MS risk in immigrants and long-term residents in Ontario, Canada.METHODS:We applied a validated algorithm to linked, population-based immigration and health claims data to identify incident cases of MS in immigrants and long-term residents between 1994 and 2016. We conducted 2 multivariable Cox proportional hazards regression analyses: 1 analysis limited to the immigrant cohort assessing potential risk factors for developing MS, and 1 analysis comparing MS risk between immigrants and matched long-term residents (1:3 match).RESULTS:We identified 2,304,302 immigrants for the immigrant-only analysis, of whom 1,526 (0.066%) developed MS. Risk was greatest in those <15 years old at landing (referent <15 years; 16-30 years: hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.63-0.85; 31-45 years: HR 0.55, 95% CI 0.47-0.64). Immigrants from the Middle East (HR 1.22, 95% CI 1.06-1.40) were at greater MS risk than immigrants from Western nations; all other regions had lower risk (p < 0.0001). The matched analysis included 2,207,751 immigrants and 6,362,169 long-term residents. Immigrants were less likely to develop MS than long-term residents (p < 0.0001), although this lower risk was attenuated with longer residence in Canada.CONCLUSIONS:MS incidence in immigrants to Ontario, Canada, varied widely by region of origin, with greatest risk seen in those from the Middle East. Longer residence in Canada was associated with increased risk, even with migration in adulthood, suggesting that environmental exposures into adulthood contribute to MS risk.

BACKGROUND:In 2012, the Ontario government withdrew public insurance coverage of imaging tests for uncomplicated low back pain. We studied the impact of this restriction on test ordering by physicians.METHODS:We compared the numbers of lumbar spine radiography, computed tomography (CT) and single-segment magnetic resonance imaging (MRI) studies ordered by physicians in the 3 years before and after the policy change. We linked claims data from the Ontario Health Insurance Program with physician details to calculate rates per test-ordering physician. We compared changes in rates of monthly test ordering by family physicians and specialists before and after the policy change using segmented regression analysis of interrupted time series data.RESULTS:The number of lumbar spine radiography and spine CT studies ordered by family physicians decreased by 98 597 (28.7%) and 17 499 (28.7%), respectively, in the year after the policy change; there was little change in ordering by specialists. The number of lumbar spine radiography studies ordered per family physician by month decreased by 0.81 tests (p < 0.001) after the intervention, followed by a smaller rebound increase that remained below baseline. Monthly ordering of spine CT per family physician declined by 0.1 tests (p < 0.001), and that of limited spine MRI rose before the intervention, decreased by 0.18 tests (p < 0.001) after the intervention, then started to rise again. Monthly ordering of limited spine MRI by specialists, which had been stable before the policy change, decreased by 0.1 tests per specialist (p < 0.001) afterward, then rose to preintervention levels.INTERPRETATION:The restriction in coverage of imaging tests caused a larger decrease in test ordering by family physicians than by specialists and a larger, more sustained reduction in the use of lumbar spine radiography and spine CT than of spine MRI.

BACKGROUND:Given the changing landscape of primary care, there may be fewer primary care physicians available to provide a broad range of services to patients of all age groups and health conditions. We sought to identify physicians with comprehensive primary care practices in Ontario using administrative data, investigating how many and what proportion of primary care physicians provided comprehensive primary care and how this changed over time.METHODS:We identified the pool of active primary care physicians in linked population-based databases for Ontario from 1992/93 to 2014/15. After excluding those who saw patients fewer than 44 days per year, we identified physicians as providing comprehensive care if more than half of their services were for core primary care and if these services fell into at least 7 of 22 activity areas. Physicians with 50% or less of their services for core primary care but with more than 50% in a single location or type of service were identified as being in focused practice.RESULTS:In 2014/15, there were 12 891 physicians in the primary care pool: 1254 (9.7%) worked fewer than 44 days per year, 1619 (12.6%) were in focused practice, and 1009 (7.8%) could not be classified. The proportion in comprehensive practice ranged from 67.5% to 74.9% between 1992/93 and 2014/15, with a peak in 2002/03 and relative stability from 2009/10 to 2014/15. Over this period, there was an increase of 8.8% in population per comprehensive primary care physician.INTERPRETATION:We found that just over two-thirds of primary care physicians provided comprehensive care in 2014/15, which indicates that traditional estimates of the primary care physician workforce may be too high. Although implementation will vary by setting and available data, this approach is likely applicable elsewhere.

BACKGROUND:Recently, many Canadian emergency departments (EDs) have struggled with physician staffing shortages. In 2006, the Ontario Ministry of Health and Long-Term Care funded a brief "emergency medicine primer" (EMP) course for family physicians to upgrade or refresh skills, with the goal of increasing their ED work intensity. We sought to determine the effect of the EMP on the ED work intensity of family physicians.METHODS:A retrospective longitudinal study was conducted of the ED work of 239 family physicians in the 2 years before and after a minimum of 6 months and up to 2 years from completing an EMP course in 2006 to 2008 compared to non-EMP physicians. ED work intensity was defined as the number of ED shifts per month and the number of ED patients seen per month. We conducted two analyses: a before and after comparison of all EMP physicians and a matched cohort analysis matching each EMP physician to four non-EMP physicians on sex, year of medical school graduation, rurality, and pre-EMP ED work intensity.RESULTS:Postcourse, EMP physicians worked 0.5 more ED shifts per month (13% increase, p  =  0.027). Compared to their matched controls, EMP physicians worked 0.7 more shifts per month (13% increase, p  =  0.0032) and saw 15 more patients per month (17% increase, p  =  0.0008) compared to matched non-EMP physicians. The greatest increases were among EMP physicians who were younger, were urban, had previous ED experience, or worked in a high-volume ED. The effect of the EMP course was negligible for physicians with no previous ED experience or working in rural areas.CONCLUSION:The EMP course is associated with modest increases in ED work intensity among some family physicians, in particular younger physicians in urban areas. No increase was seen among physicians without previous ED experience or working in rural areas.

INTRODUCTION To determine if using a combination of hospital administrative data and ambulatory care physician billings can accurately identify patients with congestive heart failure (CHF), we tested 9 algorithms for identifying individuals with CHF from administrative data. METHODS The validation cohort against which the 9 algorithms were tested combined data from a random sample of adult patients from EMRALD, an electronic medical record database of primary care physicians in Ontario, Canada, and data collected in 2004/05 from a random sample of primary care patients for a study of hypertension. Algorithms were evaluated on sensitivity, specificity, positive predictive value, area under the curve on the ROC graph and the combination of likelihood ratio positive and negative. RESULTS We found that that one hospital record or one physician billing followed by a second record from either source within one year had the best result, with a sensitivity of 84.8% and a specificity of 97.0%. CONCLUSION Population prevalence of CHF can be accurately measured using combined administrative data from hospitalization and ambulatory care.

Background Large multispecialty physician group practices, with a central role for primary care practitioners, have been shown to achieve high-quality, low-cost care for patients with chronic disease. We assessed the extent to which informal multispecialty physician networks in Ontario could be identified by using health administrative data to exploit natural linkages among patients, physicians, and hospitals based on existing patient flow. Methods We linked each Ontario resident to his or her usual provider of primary care over the period from fiscal year 2008/2009 to fiscal year 2010/2011. We linked each specialist to the hospital where he or she performed the most inpatient services. We linked each primary care physician to the hospital where most of his or her ambulatory patients were admitted for non-maternal medical care. Each resident was then linked to the same hospital as his or her usual provider of primary care. We computed “loyalty” as the proportion of care to network residents provided by physicians and hospitals within their network. Smaller clusters were aggregated to create networks based on a minimum population size, distance, and loyalty. Networks were not constrained geographically. Results We identified 78 multispecialty physician networks, comprising 12 410 primary care physicians, 14 687 specialists, and 175 acute care hospitals serving a total of 12 917 178 people. Median network size was 134 723 residents, 125 primary care physicians, and 143 specialists. Virtually all eligible residents were linked to a usual provider of primary care and to a network. Most specialists (93.5%) and primary care physicians (98.2%) were linked to a hospital. Median network physician loyalty was 68.4% for all physician visits and 81.1% for primary care visits. Median non-maternal admission loyalty was 67.4%. Urban networks had lower loyalties and were less self-contained but had more health care resources. Interpretation We demonstrated the feasibility of identifying informal multispecialty physician networks in Ontario on the basis of patterns of health care–seeking behaviour. Networks were reasonably self-contained, in that individual residents received most of their care from providers within their respective networks. Formal constitution of networks could foster accountability for efficient, integrated care through care management tools and quality improvement, the ideas behind “accountable care organizations.”