Impact of the COVID-19 Pandemic on Primary Care Access for Patients with Hematologic Malignancies

Introduction: Primary care physicians are essential to cancer care. They frequently identify signs and symptoms leading to a diagnosis of cancer, and provide ongoing support and management of non-cancer health conditions during cancer treatment. Both primary care and cancer care have been greatly affected by the COVID-19 pandemic. In the United States, cancer-related patient encounters and cancer screening decreased over 40% and 80% respectively in January to April 2020 compared to 2019 (London et al. JCO Clin Cancer Inform 2020). However, the impact of the COVID-19 pandemic on primary care access for cancer patients remain unclear. Methods: We undertook a population-based, retrospective cohort study using healthcare databases held at ICES in Ontario, Canada. Patients with a new lymphoid or myeloid malignancy diagnosed within the year prior to the COVID-19 pandemic, between July 1, 2019 and September 30, 2019 (COVID-19 cohort) were compared to patients diagnosed in years unaffected by the COVID-19 pandemic, between July 1, 2018 - September 30, 2018 and July 1, 2017 - September 30, 2017 (pre-pandemic cohort). Both groups were followed for 12 months after initial cancer diagnosis. In the COVID-19 cohort, this allowed for at least 4 months of follow-up data occurring during the COVID-19 pandemic. The primary outcome was number of in-person and virtual visits with a primary care physician. Secondary outcomes of interest included number of in-person and virtual visits with a hematologist, number of visits to the emergency department (ED), and number of unplanned hospitalizations. Outcomes, reported as crude rates per 1000 person-months, were compared between the COVID-19 and pre-pandemic cohorts using Poisson regression modelling. Results: We identified 2882 individuals diagnosed with a new lymphoid or myeloid malignancy during the defined COVID-19 timeframe and compared them to 5997 individuals diagnosed during the defined pre-pandemic timeframe. The crude rate of in-person primary care visits per 1000 person-months significantly decreased from 574.4 [95% CI 568.5 - 580.4] in the pre-pandemic cohort to 402.5 [395.3 - 409.7] in the COVID-19 cohort (p < 0.0001). Telemedicine visits to primary care significantly increased from 5.3 [4.8 - 5.9] to 173.0 [168.4 - 177.8] (p < 0.0001). The rate of combined in-person and telemedicine visits to primary care did not change from 579.8 [573.8 - 585.8] in the pre-pandemic cohort to 575.5 [566.9 - 584.2] in the COVID-19 cohort (p = 0.43). In-person visits to hematologists decreased from 504.1 [498.5 - 509.7] to 432.8 [425.3 - 440.3] (p < 0.0001), and telemedicine visits to hematologists increased from 6.6 [6.0 - 7.3] to 75.9 [72.8 - 79.1] (p < 0.0001). The rate of combined visits to hematologists did not change from 510.7 [505.1 - 516.4] to 508.7 [500.6 - 516.8] (p = 0.68). The rate of ED visits significantly decreased from 95.1 [92.7 - 97.6] in the pre-pandemic cohort to 84.7 [81.4 - 88.0] in the COVID-19 cohort (p < 0.0001). The rate of unplanned hospitalizations did not change from 64.8 [62.8 - 66.8] to 65.7 [62.9 - 68.7] (p = 0.60). Conclusions: Primary care visits for patients with hematologic malignancies did not significantly change during the pandemic, but there was a sizeable shift from in-person to telemedicine visits. Similar findings were seen for visits to hematologists. While the rate of visits to the ED decreased, potentially due to concern of being exposed to the COVID-19 virus, the shift in ambulatory practices did not seem to impact the rate of unplanned hospitalizations. Disclosures No relevant conflicts of interest to declare.

Meaningful and deep community engagement efforts for pragmatic research and beyond: engaging with an immigrant/racialised community on equitable access to care

Primary healthcare access is one of the crucial factors that ensures the health and well-being of a population. Immigrant/racialised communities encounter a myriad of barriers to accessing primary healthcare. As global migration continues to grow, the development and practice of effective strategies for research and policy regarding primary care access are warranted. Many studies have attempted to identify the barriers to primary care access and recommend solutions. However, top-down approaches where the researchers and policy-makers ‘prescribe’ solutions are more common than community-engaged approaches where community members and researchers work hand-in-hand in community-engaged research to identify the problems, codevelop solutions and recommend policy changes. In this article, we reflect on a comprehensive community-engaged research approach that we undertook to identify the barriers to equitable primary care access among a South Asian (Bangladeshi) immigrant community in Canada. This article summarised the experience of our programme of research and describes our understanding of community-engaged research among an immigrant/racialised community that meaningfully interacts with the community. In employing the principles of community-based participatory research, integrated knowledge translation and human centred design, we reflect on the comprehensive community-engaged research approach we undertook. We believe that our reflections can be useful to academics while conducting community-engaged research on relevant issues across other immigrant/racialised communities.

Development and validation of an algorithm using health administrative data to define patient attachment to primary care providers

PurposeThe authors developed and validated an algorithm using health administrative data to identify patients who are attached or uncertainly attached to a primary care provider (PCP) using patient responses to a survey conducted in Ontario, Canada.Design/methodology/approachThe authors conducted a validation study using as a reference standard respondents to a community-based survey who indicated they did or did not have a PCP. The authors developed and tested health administrative algorithms against this reference standard. The authors calculated the sensitivity, specificity positive predictive value (PPV) and negative predictive value (NPV) on the final patient attachment algorithm. The authors then applied the attachment algorithm to the 2017 Ontario population.FindingsThe patient attachment algorithm had an excellent sensitivity (90.5%) and PPV (96.8%), though modest specificity (46.1%) and a low NPV (21.3%). This means that the algorithm assigned survey respondents as being attached to a PCP and when in fact they said they had a PCP, yet a significant proportion of those found to be uncertainly attached had indicated they did have a PCP. In 2017, most people in Ontario, Canada (85.4%) were attached to a PCP but 14.6% were uncertainly attached.Research limitations/implicationsAdministrative data for nurse practitioner's encounters and other interprofessional care providers are not currently available. The authors also cannot separately identify primary care visits conducted in walk in clinics using our health administrative data. Finally, the definition of hospital-based healthcare use did not include outpatient specialty care.Practical implicationsUncertain attachment to a primary health care provider is a recurrent problem that results in inequitable access in health services delivery. Providing annual reports on uncertainly attached patients can help evaluate primary care system changes developed to improve access. This algorithm can be used by health care planners and policy makers to examine the geographic variability and time trends of the uncertainly attached population to inform the development of programs to improve primary care access.Social implicationsAs primary care is an essential component of a person's medical home, identifying regions or high need populations that have higher levels of uncertainly attached patients will help target programs to support their primary care access and needs. Furthermore, this approach will be useful in future research to determine the health impacts of uncertain attachment to primary care, especially in view of a growing body of the literature highlighting the importance of primary care continuity.Originality/valueThis patient attachment algorithm is the first to use existing health administrative data validated with responses from a patient survey. Using patient surveys alone to assess attachment levels is expensive and time consuming to complete. They can also be subject to poor response rates and recall bias. Utilizing existing health administrative data provides more accurate, timely estimates of patient attachment for everyone in the population.

Low-acuity emergency department use among patients in different primary care models in Hamilton and Ontario

Jurisdictions such as Hamilton, Ontario, where most primary care practices participate in patient enrolment models with enhanced after-hours access, may demonstrate overall improved health equity outcomes. Non-urgent Emergency Department (ED) use has been suggested as an indicator of primary care access; however, the impact of primary care access on ED use is uncertain and likely varies by patient and contextual factors. This population-based, retrospective study investigated whether or not different primary care models were associated with different rates of non-urgent ED visits in Hamilton, a city with relatively high neighbourhood marginalization, compared to the rest of Ontario from 2014/2015 to 2017/2018. In Ontario, enrolment capitation-based practices had more non-urgent ED visits than non-enrolment fee-for-service practices. In Hamilton, where most of the city’s family physicians are in enrolment capitation-based practices, differences between models were minimal. The influence of primary care reforms may differ depending on how they are distributed within regions.

General medical practitioners in Czechia: development trends and regional differences

In Czechia general practical medicine represents the bulk of basic primary healthcare both in terms of the number of doctors and the range of services provided. For the healthcare system to function effectively as a whole requires sufficient capacity and the even distribution of providers across the country. As observed throughout Europe, a key risk is the age structure of the general practitioner population, with most of the capacity being provided by older practitioners, which could affect overall primary care access in the future. In Czechia, the general practitioner age structure is skewed, with the proportion of older age groups continually increasing. This article analyses changes in selected indicators of the number, capacity and age structure of general practitioners at the regional level in 2010–2019 and identifies regions where general healthcare access may be at risk. These areas are often rural and, as the specially created municipality typology shows, the pace of change differs along an urban vs rural line.