Primary care lessons for Canada from OECD countries
To improve primary care, Canada can learn from Organisation for Economic Co-operation and Development (OECD) countries with high rates of patients attached to primary care clinicians, write authors in an analysis in CMAJ (Canadian Medical Association Journal) https://www.cmaj.ca/lookup/doi/10.1503/cmaj.221824.
It is well known in Canada that there is a crisis in primary care, with about 17% of people reporting that they were without a regular primary care clinician before the COVID-19 pandemic. The pandemic made the situation worse, with some family physicians retiring early, a situation common in other countries also.
The authors looked at 9 countries where more than 95% of people have a family doctor, primary care clinician or place of care, including France, Germany, New Zealand, United Kingdom, Denmark, Netherlands, Finland, Italy and Norway, and consider lessons for Canada.
Canada's health spending was in the middle of the pack, although the percentage of health spending that was public was the lowest at 70%, a figure unchanged since the 1990s. Canada had similar numbers of family physicians per capita but the lowest number of total physicians per capita and spent less of the total health budget on primary care.
"Other countries have designed their system so that everyone has access to primary care. We need to do the same," says Dr. Tara Kiran, a family physician at St. Michael's Hospital, Unity Health Toronto and the Fidani Chair of Improvement and Innovation at the University of Toronto. "At the core, we need to guarantee access to primary care and increase how much we spend on it."
Historical factors, such as physicians negotiating to remain autonomous at introduction of Medicare, have also affected Canada's health system.
Key lessons for Canada:
- Accountability — In countries with high rates of primary care attachment, family doctors have stronger contractual agreements and accountability to government, insurers or both, whereas in Canada, they are private contractors with little system accountability. These countries also have more family doctors, or general practitioners, working in office-based, generalist practices compared with Canada, where many family doctors work in other parts of the system (e.g., providing emergency or hospital care) or in focused practice (e.g., sports medicine).
- Funding — A higher proportion of the total health budget should be spent on primary care. Medicare coverage in Canada could be extended to prescription medications, dental care and expanded mental health care to reduce the burden on physicians to provide care in these areas. Canada also needs more physicians per capita.
- System organization — Canada should move to a model where residents are guaranteed access to a primary care practice near their home and ensure that these practices are funded appropriately.
- Information systems — Practice efficiency can be improved and patient communications can be streamlined with online booking, secure messaging and a single patient health record accessible across Canada by patients and clinicians.
- Practice organization and physician payment — Governments and medical associations should shift primary care physicians to capitation or salary payments and away from fee for service, which is how most family physicians currently are paid in Canada. More organized after-hours care, fewer walk-in clinics and expanded roles for other health professionals can enable our primary care resources to be used more efficiently.
"These international examples can inform bold policy reform in Canada to advance a vision of primary care for all," the authors conclude.
JOURNAL
Canadian Medical Association Journal
SUBJECT OF RESEARCH
People
ARTICLE TITLE
Primary care for all: lessons for Canada from peer countries with high primary care attachment"
ARTICLE PUBLICATION DATE
4-Dec-2023
New rule for emergency departments to safely reduce use of CTs after falls in older patients
How do emergency department staff determine whether older adults who have fallen need imaging? A new decision rule will help emergency department physicians determine which older adults need imaging for head injuries, describes new research in CMAJ (Canadian Medical Association Journal) https://www.cmaj.ca/lookup/doi/10.1503/cmaj.230634.
With aging populations, emergency departments are managing an increasing number of older adults who fall; falling on level ground, like in one's house, is a common cause of a brain bleed. Computed tomography (CT) of the head is commonly used to assess patients who have fallen, but sending every patient who has fallen for a head scan is inefficient and costly.
"Overuse of CT in this population prolongs the emergency department visit, which has been shown to increase the rate of delirium while also diverting resources from other emergency patients," writes Dr. Kerstin de Wit, Queen's University, Kingston, Ontario, with coauthors from the Network of Canadian Emergency Researchers. "Furthermore, not all emergency departments have 24-hour on-site CT scanning facilities, meaning that some of these patients may be transferred to another centre."
A team of emergency department physicians from across Canada and in the United States developed the Falls Decision Rule, which can be used to identify patients for whom it is safe to forgo a head CT to rule out intracranial bleeding after a fall. The researchers included 4308 patients aged 65 years or older from 11 emergency departments in Canada and the US who visited the emergency department within 48 hours of falling. The median age was 83 years, 64% were female, 26% took anticoagulant medication and 36% took antiplatelet medication, both of which increase the risk of bleeding.
The rule, which if used would avoid head CT in 20% of the study population, can be applied to all older adults who have fallen, whether or not they sustained a head injury or can recall the fall.
This new rule complements the widely used Canadian CT Head rule, which applies to patients with disorientation, amnesia or loss of consciousness.
JOURNAL
Canadian Medical Association Journal
METHOD OF RESEARCH
Observational study
SUBJECT OF RESEARCH
People
ARTICLE TITLE
Derivation of the Falls Decision Rule to exclude intracranial bleeding without head CT in older adults who have fallen
ARTICLE PUBLICATION DATE
4-Dec-2023
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