Essays

Essays April 2017
Open Letters

Unified Primary Care Engagement: Is It Time?

Tupper Bean

This letter is part of series of Open Letters from Canadian leaders in Healthcare. To see the complete series please click here. 

In the past 15 years, primary care in Ontario and across Canada has experienced both growth and increased prominence in our health system. Today, well-functioning primary care is widely regarded as a cornerstone to an effective and efficient health system. However, the gap between what primary care providers could do based on the best evidence available and what they actually do is wide, variable and growing (Grol, R & Grimshaw, J., 2003).  Many factors contribute to this knowledge-practice gap. Providers are inundated with new and sometimes conflicting clinical information, which is not always based on the best clinical evidence. Further contributing to the gap between best evidence and practice over the past several years are increased workloads and the complexity of patient caseloads (Lau et al., 2016).

As a result, primary care “engagement” now occupies a central role in numerous strategic plans across many agencies, programs and initiatives in Ontario (and elsewhere). Under different names like quality improvement (QI) and knowledge translation (KT), we are asking more and more of these providers.

Whether it be better screening and prevention, diagnostic ordering, prescribing, chronic disease management, end-of-life care, or dozens of other topics, primary care providers are asked to implement meaningful change in the way they practice medicine. Increasingly, they are asked to redesign their workflow to address issues such as advanced access for patients, better transitions in care, closer integration with community services and the list goes on.

While these are all laudable goals, they represent a growing set of demands on a key group of health professionals. They ultimately lead us to the question: how well do we support these critical care providers to implement change across the province?

The answer, I’m afraid, is not very well. There are many examples of how we fall short. Ontario is one of the highest prescribers of opioids in the world (Centre for Addiction and Mental Health, 2016), and our province had the highest annual prescribing rate of high dose oxycodone and fentanyl in 2014 in Canada (Gomes et al., 2014). Additionally, a recent report found that up to 30 per cent of medical tests, treatments and procedures performed in Canada may be unnecessary (Canadian Institute for Health Information, 2017), including up to one third of all MRI and CT scans ordered for uncomplicated low back pain that are not indicated by evidence (Health Quality Ontario, 2017).

It isn’t for lack of trying or spending for that matter. In 2015, the Centre for Effective Practice worked with the Ontario College of Family Physicians to map QI and Practice Improvement initiatives for Health Quality Ontario. Until then, we knew this was a busy space but had not mapped it in detail. The results were sobering. We found dozens of organizations leading 117 initiatives all focused on primary care. Several organizations had more than 10 initiatives running simultaneously. More troubling was that when these organizations were interviewed, the findings suggested:

  • Inconsistent terminology regarding things like tools, toolkit, program, communication, dissemination, engagement, etc.
  • An unclear “ask” of primary care and why it was important for providers to participate in the initiative(s).
  • Ambiguity regarding partnership versus collaboration — with numerous organizations struggling to define the role of different partners or collaborators.
  • Wide variation in the selection and description of roles such as clinical leads and clinical working group members.
  • Lack of measurement or evaluation for reach and impact on target end-users.

In addition to those initiatives, the Centre for Effective Practice recently mapped over 30 publicly (provincially or nationally) funded organizations and programs providing knowledge translation interventions in primary care within Ontario. Keep in mind, our work was not exhaustive — the list is surely growing as sub-regions and LHINs take on new responsibilities, for example. Plus, we have yet to fully understand the extent to which pharmaceutical companies and other organizations in the private sector are reaching out to primary care providers.

If you think this looks busy from the system level, imagine yourself as a busy family physician on the ground. Over 30 organizations and over 100 initiatives asking you to do something different, better, faster, etc. Clinical leads, tools, websites, workshops, reports and emails, all trying to “engage” you. How much time can busy providers spend on a single website, let alone 30 separate sites? How can they trust, navigate and meaningfully apply information from dozens of tools designed by dozens of different organizations? How many “change projects” would you be able to handle simultaneously? How many things can we reasonably expect to change at once?

We compete for hearts and minds in primary care. Yet, in spite of all of this, I continue to attend meetings at organizations where people ask why primary care isn’t doing more or responding to a specific initiative. Is it surprising that many family physicians and other providers are increasingly more cynical and fatigued? There are other contributing factors to provider burnout but surely we are not helping them by overwhelming them in this uncoordinated manner.

There are better ways to use scarce resources to reach primary care providers. We can learn from the other jurisdictions’ experience. Australia’s NPS Medicine Wise program, for example, integrates several proven change interventions under one umbrella. They do it at scale, supporting over 14,000 family physicians annually, with compelling results. We have many key pieces in place in Ontario. But until we do better and build a cohesive approach for primary care engagement, we can’t reasonably expect providers to be better. We must come together to build a unified strategy that considers the needs and realities of providers to ensure we put patients first.

About the Author

Tupper Bean is the Executive Director of the Centre for Effective Practice. The Centre for Effective Practice (CEP) aims to close the gap between evidence and practice for healthcare providers. It gives providers what they need to deliver the best care to their patients by engaging them throughout its processes to create evidence-based solutions that can be adapted into local contexts. The CEP is an independent federally incorporated, not-for-profit organization.

References

Centre for Addiction and Mental Health (2016). Prescription Opioid Policy Framework. Toronto, ON: CAMH.

Gomes, T., Mamdani, M.M., Paterson, J.M., Dhalla, I.A., Juurlink, D.N. (2014). Trends in high-dose opioid prescribing in Canada. Canadian Family Physician, 60(9), 826-832.

Grol, R & Grimshaw, J. (2003). From best evidence to best practice: effective implementation of change in patients’ care. Lancet, 362(9391), 1225–30.

Lau, R., Stevenson, F., Ong, B.N., Dziedzic, K., Treweek, S., Eldridge, S., Everitt, H., Kennedy, A., Qureshi, N., Rogers, A., Peacock, R., Murray, E. (2016). Achieving change in primary care—causes of the evidence to practice gap: systematic reviews of reviews. Implementation Science, 11(40).

Health Quality Ontario (2017). Spotlight on Leaders of Change: Implementing Choosing Wisely Canada Recommendations in Ontario to Improve Quality of Care. Toronto, ON: HQO.

Canadian Institute for Health Information (2017). Unnecessary Care in Canada. Ottawa, ON: CIHI.

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