Research

The CPCRN’s vision is to create a sustainable pan-Canadian learning health system, supported by patient-oriented, practice-based research that improves primary care. CPCRN aims to facilitate the spread and scale of primary care innovations within four pillars of research: Access to Care, Integration of Care, Indigenous Health, and Primary Care Information System.

CPCRN-supported projects and initiatives were chosen because they address the pillars of research, highlight varying informational sources within the primary health care information system, and demonstrate potential to facilitate change and maximize impact in primary care by applying a learning health system cycle: practice-to-data, data-to-knowledge, knowledge-to-practice. 

Access to Care

The CPCRN is supporting project(s) that explore models of care to facilitate improved health care access. The following project focuses on a specific strategy to enhance access to care.

Impact of a Pan-Canadian CQI Cohort Program on Advanced Access (AA) to Support Primary Healthcare Clinics

Nominated PI: Mylaine Breton

Background: Improving access to primary health care is amongst the top priorities for many countries. Advanced Access (AA) is one of the most recommended models to improve timely access to care. Over the past 15 years, the AA model has been implemented in Canada, but the implementation of AA varies substantially among providers and clinics. Continuous quality improvement (CQI) approaches can be used to promote organizational change like AA implementation. While CQI fosters the adoption of evidence-based practices, knowledge gaps remain, about the mechanisms by which QI happens and the sustainability of the results.

Objectives: The general aim of the study is to analyse the implementation and effects of CQI cohorts on AA for primary care clinics. Specific objectives are: 1) Analyse the process of implementing CQI cohorts to support PHC clinics in their improvement of AA. 2) Document and compare structural organisational changes and processes of care with respect to AA within study groups (intervention and control). 3) Assess the effectiveness of CQI cohorts on AA outcomes. 4) Appreciate the sustainability of the intervention for AA processes, organisational changes and outcomes.

Significance: This research will contribute to filling the gap in the generalizability of CQI interventions and accelerate the spread of effective AA improvement strategies while strengthening local QI culture within clinics. This research will have a direct impact on patients’ experiences of care.

Website: https://accesadapte.ca/

Protocol: https://link.springer.com/article/10.1186/s12875-023-02048-y

Provinces Involved: ON, QC, NB

Integration of Care

Integrated care models within primary care aim to have person-centered care that includes collaboration and communication among all formal and informal care providers to develop a comprehensive care plan that considers the medical and social complexity of the patient. The CPCRN supports a number of projects in this pillar that capture patient reported experience measures (PREM) and/or patient reported outcome measures (PROM) to learn more about patient needs with regard to integrated care. These projects leverage the primary care information system and work with practice-based research and learning networks (PBRLNs) across Canada to scale and expand the projects.

PriCARE 2 – Case Management in Primary Healthcare for People with Complex Care Needs to Improve Integrated Care: The Role of Facilitation

PI: Catherine Hudon, Maud-Christine Chouinard, Kris Aubrey-Bassler, Shelley Doucet

Background: Implementation of complex intervention in real world contexts remains a huge challenge. Change agents, such as external facilitators, may nurture this capability by stimulating, facilitating, and coordinating the change effort required for implementation. We still need to better understand deeper mechanisms of facilitation as well as how they evolve within the context.

Objective: To better understand the role of external facilitation in implementation of complex interventions, such as case management, in the healthcare system.

Significance: Increased understanding of facilitation would help stakeholders to become aware of the multiple roles and dynamics involved and the key competencies to recruit facilitators for the implementation of complex intervention.

Websitehttps://v1sages.recherche.usherbrooke.ca/en/better-care-for-patients-with-complex-needs/

Provinces involved: QC, NB, NS and NL

Screening for Poverty and Related Social Determinants and Intervening to Improve Knowledge of and Links to Resources (SPARK) Study

Nominated PI: Andrew Pinto

Background: The SPARK study is a national study developed due to the lack of data on social determinants of health in primary care settings in Canada. Currently, healthcare organizations rarely integrate social determinants data with clinical data, and health providers are not currently trained to routinely respond to social needs.

Objective: To develop, implement, and evaluate a standardized tool for the routine collection of data about social determinants of health in primary care, as well as provide guidelines and resources to facilitate its use in diverse primary care settings across Canada.

Significance: The SPARK Tool is a 20-question questionnaire designed to facilitate the routine and systematic collection of demographic (e.g., income, gender) and social needs (e.g., food insecurity, housing) data in diverse primary care settings, which can help teams better address their patient’s social needs. The study team are in the process of making resources (e.g., infographics, change package) and guidelines to facilitate use of the tool available to the public. This project was awarded the 2019 NAPCRG People’s Choice Award for commitment to patient-entered outcomes research.

Website: https://upstreamlab.org/project/spark/

Provinces Involved: AB, SK, MB, ON, NS, NL, PE

Funders & Partners: CIHR

Structured Process Informed by Data, Evidence and Research (SPIDER) Study

Nominated PI: Michelle Griever

Background: One out of four Canadian seniors (26.5%) are on 10 or more different medications. Some of these medications could be harmful to seniors: greater risk of confusion, falls, or hospitalizations. Stopping drugs, or de-prescribing, could help. Structured Process Informed by Data, Evidence and Research (SPIDER) is a large community based and community-informed project designed to test and implement effective approaches to de-prescribing. We target potentially inappropriate prescriptions (PIPs). The SPIDER approach includes the provision of EMR data to support the audit and feedback process for the practice, coaching to facilitate practice change, and learning collaboratives to promote the exchange of learning amongst participating practice teams. Family practices learn and work together to improve care for elderly patients taking many medications.

Objective: To reduce the number of potentially inappropriate prescriptions for seniors living with polypharmacy. Outcomes include fewer potentially inappropriate medications, and are measured in terms of better care, better patient experience, cost effectiveness, and better work lives for primary care team members.

Significance: SPIDER involves Primary Care Practice Based Research and Learning Networks (PBRLNs) in seven provinces across Canada. Following successful feasibility testing in three centres, we have initiated a Randomized Controlled Trial to test this approach in seven centres. The trial compares the SPIDER approach to usual care for seniors on ten or more medications. If SPIDER proves to be successful for this complex community-based population, the model could be used to improve other aspects of care.

Website: https://www.spiderdeprescribing.com/

Provinces Involved: BC, AB, MB, ON, QC, NS, NL

Chronic Kidney Disease (CKD) Epidemiology, Management, and Prevention in Canadian Primary Care

Nominated PI: Paul Ronksley

Background: CKD is a major public health problem worldwide, affecting approximately 10-15% of the general adult population and its rapidly increasing prevalence raises concerns about our capacity to provide effective care and manage its economic impact. Similarly, polypharmacy – commonly defined as the concurrent use of five or more medications – is increasing at an alarming rate. Polypharmacy is recognized as a major clinical challenge and has been described extensively in the literature. Patients with CKD are particularly prone to polypharmacy given their medical complexity, and often require multiple medications to mitigate progression of CKD and treat its common complications and comorbidities. Unfortunately, numerous studies have revealed that potentially inappropriate medication (PIM) use based on level of kidney function is common and often overlooked by prescribers. Given these concerns, proper management of polypharmacy is an important clinical issue in patients with CKD.

Objectives: (1) Describe the burden of polypharmacy and prescribing of appropriate and potentially inappropriate medications among patients with CKD in primary care practices; and (2) implement and evaluate the effectiveness of a Team Approach to Polypharmacy Evaluation and Reduction (TAPER) on process of care, clinical outcomes, and patient experience.

Significance: This will be the most comprehensive evaluation of polypharmacy in individuals with CKD in a Canadian primary care setting. Further, the evaluation of the TAPER initiative will provide key insights into the effectiveness of a web-based approach to polypharmacy reduction in this high-risk patient population. Our work will be instrumental in the eventual scale and spread of appropriate polypharmacy prescribing guidelines and assistive technologies to other provinces and territories and will equip clinicians and policy makers with a better understanding of polypharmacy and how this can be addressed in patients with multi-morbidity.

Provinces Involved: AB, MB, ON

Indigenous Health

Responding to the Truth and Reconciliation Commission, the CPCRN has developed an Indigenous specific focus on decolonizing primary care, mobilizing research resources and partnering to heal Indigenous communities. The CPCRN continues to expand relationships with Indigenous (First Nation, Métis and Inuit) scholars and patients with a focus on a co-creation process to support a project focused on Indigenous health priorities, that includes continuous Indigenous guidance and ensures outcomes for Indigenous communities. The CPCRN will support projects that recognize the value of lived experience and showcase practices, connections and the healing strength of traditional knowledge. The CPCRN supports a rural and remote pan-Northen Indigenous partnership grounded in cultural safety, humility and Indigenous leadership with projects that go beyond medical solutions, understanding how  social and political contexts impact health outcomes.

Overuse of Emergency Rooms in Remote Regions in Canada: Exploring Impacts of Access to Primary Care and Community Awareness

Nominated PI: Susan Chatwood

Background: Non-urgent (NU) conditions are not life-threatening, do not require rapid care and can be safely delayed without increasing the likelihood of adverse outcomes. In Canada, about 17% of emergency department (ED) visits are due to NU conditions. Barriers in accessing healthcare result in significant health disparities for Indigenous people due to the systemic impacts of colonialism. Northerners experience more difficulties in accessing primary care when compared to other Canadians. This disparity can result in Indigenous people having a greater dependence on EDs and having more visits triaged as NU or less urgent than non-Indigenous people. In Alberta, Indigenous people have stated that their reasons for visiting the ED are due to long wait times to see a primary care physician and times when there is a lack of availability of healthcare providers at the clinics. Indigenous patients’ primary care experiences are under researched in the NWT. In addition, there is a lack of data for the NWT for people who visit the ED for NU conditions. This research will address these gaps.

Objectives: (1) To describe the rates of non-urgent (NU) conditions emergency room use in the NWT; (2) to determine the sociodemographic factors that influence Indigenous patients’ decisions to visit the emergency department (ED) for NU conditions; (3) to assess the Indigenous patients’ knowledge and perceptions of NU conditions; and (4) to investigate Indigenous patients’ primary care experiences.

Significance: This novel research will strengthen theory that will guide policies that will lead to more effective and efficient use of human and physical resources in EDs and improve primary health care in rural and Indigenous communities. Post the COVID-19 pandemic there has been a primary care backlog and increased closure of EDs. Therefore, this research is timely as it will offer important knowledge on how to improve these challenges.

Provinces Involved: NWT

Primary Care Information System

The CPCRN is committed to understanding the current state of the primary care data infrastructure within Canada, developing a plan to support a comprehensive primary care information system that includes Practice-based Research and Learning Networks (PBRLN) and a variety of data sources, and moving towards a primary care learning health system. The following projects demonstrate the potential impact of this infrastructure.

Spreading and Scaling Ways to Decrease Inappropriate Antibiotic Use in Primary Care Patients with Viral Respiratory Tract Infections

Nominated PI: David Barber

Background: Up to 30% of tests, treatments, and procedures in Canada are potentially unnecessary. Unnecessary tests, treatments, and procedures do not add value for patients, potentially expose patients to harm, lead to more testing to investigate false positives, contribute to unwarranted stress for patients and their families, and consume precious time and resources. The purpose of this project is to develop and assess methods for decreasing unnecessary care and preventing harm as identified by the Choosing Wisely Canada (CWC) recommendations. In particular, this study will assess the feasibility and effectiveness of audit and feedback reports about antibiotic prescribing to reduce unnecessary antibiotics in primary care.

Objective: implement and evaluate iterative improvements on standard provider audit and feedback (A&F) reports to reduce unnecessary antibiotics across a national network of primary care prescribers (CPCSSN).

Significance: Judicious use of antibiotics is crucial to our fight against the growing public health threat of antimicrobial resistance. We already know that in general, about 40% of antibiotics prescribed for respiratory tract infection in primary care are unnecessary and could be avoided. But we cannot improve something without first measuring it accurately and that’s where our project provides a more granular look at pan-Canadian prescribing practices across specific respiratory tract infection conditions and by prescriber. Primary care providers do not receive much feedback regarding how their antibiotic prescribing practices compare to their peers. Individualized reports in the hands of the prescribers help them identify practice improvement opportunities and link them to tools developed by Choosing Wisely Canada to support best practice.

Provinces Involved: BC, MB, ON

An Infrastructure for Primary Care to Learn Together with our Patients (CPIN)

Nominated PI: Sharon Johnston

Background: The need for an information system for primary healthcare (PHC) is crucial, requiring effective methods for collecting patient feedback (PREMs) and self-reported outcome measures (PROMs). Primary care clinics (PCCs) are adopting digital tools to improve patient engagement. The lack of a coordinated national strategy hinders the implementation and evaluation of these solutions.

Objective: To collect PREMs and PROMs in various clinics across Canada and develop an approach to linking those responses to EMR and administrative data to support a learning health system.

Significance: The CPIN SPOR project is focused on building a sustainable approach to POR – building the tools that make patient engagement easier, more accessible, wider reaching, and more reliable, so researchers, policymakers and practitioners can count on being able to get patient input in a timely, focused way and patients can count on a low burden system to capture and amplify their perspective. As CPIN learns from patients, the team will make data and findings available aiming to mobilize knowledge that informs and transforms practice, clinical care and decision making for better and more equitable health outcomes, especially for people with complex and/or unmet needs due to multiple, intersecting determinants affecting their health including linguistic minority status.

Website: https://cpin-rcip.com/

Provinces Involved: ON, NL

OECD Patient Reported Indicator Survey (PaRIS) Project

Nominated PI: Sabrina Wong, Marie-Eve Poitras

Background: The Organization for Economic Co-operation and Development (OECD) provides international standards on health system reporting. In 2017, at the OECD Health Ministerial Meeting, countries requested the OECD  develop new ways to measure health system performance. Ministers specifically requested the OECD develop new health statistics to measure and compare patient-reported experiences and outcomes in health care. PaRIS is the OECD Patient-Reported Indicator Surveys initiative where countries work together to develop, standardize, and implement a new generation of indicators that measure the outcomes and experiences of health care that matter most to people. The new generation of patient-reported outcome and experience measures (PROMs and PREMs) were developed to reflect patient and public concerns about responsive health care. PROMs capture health status, symptoms, functioning, and quality of life. PREMs focus on patients’ experiences while receiving care, reflecting organizational care processes.

Objective: Adoption and reporting of validated, standardized, internationally comparable patient reported indicators in primary care.

Significance: The PaRIS study provides Canada with rich data to compare nationally equivalent health outcomes and experiences of patients with chronic conditions treated in primary care. These data are useful to identify areas of excellence and improvement. This study is consistent with the Canadian federal government’s action plan for Working Together to Improve Health Care for Canadians and CIHI’s work on health system performance. At the Canadian level, this study will provide a comparable indicator base across provinces to inform the delivery of primary care services and the health of Canadians. This will enable provincial jurisdictions to report to Canadians based on comparable indicators of how primary care is delivered across Canada, how it performs, and how it compares internationally.

Website: https://www.oecd.org/health/paris/

Provinces Involved: BC, AB, SK, MB, ON, QC, NB, NS, PEI, NL