UBC Faculty Research and Publications

A comparative analysis of centralized waiting lists for patients without a primary care provider implemented… Breton, Mylaine; Green, Michael; Kreindler, Sara; Sutherland, Jason; Jbilou, Jalila; Wong, Sabrina T; Shaw, Jay; Crooks, Valorie A; Contandriopoulos, Damien; Smithman, Mélanie A; Brousselle, Astrid Jan 21, 2017

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata


52383-12913_2017_Article_2007.pdf [ 694.1kB ]
JSON: 52383-1.0362030.json
JSON-LD: 52383-1.0362030-ld.json
RDF/XML (Pretty): 52383-1.0362030-rdf.xml
RDF/JSON: 52383-1.0362030-rdf.json
Turtle: 52383-1.0362030-turtle.txt
N-Triples: 52383-1.0362030-rdf-ntriples.txt
Original Record: 52383-1.0362030-source.json
Full Text

Full Text

STUDY PROTOCOL Open AccessA comparative analysis of centralizedwaiting lists for patients without a primarycare provider implemented in six Canadianprovinces: study protocolMylaine Breton1*, Michael Green2, Sara Kreindler3, Jason Sutherland4, Jalila Jbilou5, Sabrina T. Wong6, Jay Shaw7,Valorie A. Crooks8, Damien Contandriopoulos9, Mélanie Ann Smithman1 and Astrid Brousselle1AbstractBackground: Having a regular primary care provider (i.e., family physician or nurse practitioner) is widelyconsidered to be a prerequisite for obtaining healthcare that is timely, accessible, continuous, comprehensive, andwell-coordinated with other parts of the healthcare system. Yet, 4.6 million Canadians, approximately 15% of Canada’spopulation, are unattached; that is, they do not have a regular primary care provider. To address the critical need forattachment, especially for more vulnerable patients, six Canadian provinces have implemented centralized waiting listsfor unattached patients. These waiting lists centralize unattached patients’ requests for a primary care provider in agiven territory and match patients with providers. From the little information we have on each province’s centralizedwaiting list, we know the way they work varies significantly from province to province. The main objective of this studyis to compare the different models of centralized waiting lists for unattached patients implemented in six provinces ofCanada to each other and to available scientific knowledge to make recommendations on ways to improvetheir design in an effort to increase attachment of patients to a primary care provider.Methods: A logic analysis approach developed in three steps will be used. Step 1: build logic models that describeeach province’s centralized waiting list through interviews with key stakeholders in each province; step 2: develop aconceptual framework, separate from the provincially informed logic models, that identifies key characteristics ofcentralized waiting lists for unattached patients and factors influencing their implementation through aliterature review and interviews with experts; step 3: compare the logic models to the conceptual framework to makerecommendations to improve centralized waiting lists in different provinces during a pan Canadian face-to-face exchange with decision-makers, clinicians and researchers.Discussion: This study is based on an inter-provincial learning exchange approach where we propose tocompare centralized waiting lists and analyze variations in strategies used to increase attachment to aregular primary care provider. Fostering inter-provincial healthcare systems connectivity to improve centralized waitinglists’ practices across Canada can lever attachment to a regular provider for timely access to continuous,comprehensive and coordinated healthcare for all Canadians and particular for those who are vulnerable.Keywords: Primary health care, Health services accessibility, Comparative study, Waiting lists, Physicians,General practitioners, Physician patient relationship, Unattached patients* Correspondence: mylaine.breton@usherbrooke.ca1Charles-LeMoyne Hospital Research Centre, Sherbrooke University,Longueuil Campus, 150 Place Charles-LeMoyne, Office 200, Longueuil, QCJ4K 0A8, CanadaFull list of author information is available at the end of the article© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Breton et al. BMC Health Services Research  (2017) 17:60 DOI 10.1186/s12913-017-2007-8BackgroundAttachment, a formal or informal affiliation to a regu-lar provider such as a nurse practitioner or familyphysician [1], is widely considered to be a prerequisitefor primary healthcare that is accessible, continuous,comprehensive, and well-coordinated with other levels(e.g., secondary, tertiary) or types (e.g., social, community-based) of care [2–14]. There is strong evidence in thescientific literature that suggests that patients whoare attached to a primary care provider benefit frombetter care coordination [15–17], chronic diseasemanagement [18, 19] and receive more preventativecare [20, 21], use emergency services less frequently[22–24] and have better health outcomes [25, 26].Compared to other OECD countries, Canada rankslow in terms of access to a primary care provider [27].Thus, attachment to a primary care provider is an espe-cially important issue in Canada because this is mostoften the first point of contact to the rest of the health-care system. For example, patients need a referral from afamily physician or need to go through the emergencydepartment to access specialized care. Canadian primarycare providers’ role goes beyond providing primaryhealthcare and preventive care [28] as the structure ofhealthcare systems positions them as the “gatekeepers”to secondary and tertiary care [29–31]. Access to health-care for unattached patient is therefore limited inCanada [32].Several Canadian commissions on healthcare haverecommended that primary healthcare be reinforcedto guarantee access to a primary care provider toevery Canadian [33–38]. Yet, 4.6 million Canadians,approximately 15% of Canada’s population, do nothave a regular primary care provider [39]. Moreover,in Canada, vulnerable patients, those with multipleintersecting determinants of health including complexphysical and mental health and healthcare needs, beingyoung or a recent immigrant, having a low income level,living in a rural or remote area, and those with low socialsupport are less likely to be attached to a primary careprovider [40, 41] despite being the ones who would bene-fit most from access to comprehensive and continu-ous primary care [42, 43].Centralized waiting lists for unattached patientsTo address the critical need for attachment, six provinceshave implemented centralized waiting lists to coordinatethe supply of primary care providers and demand ofpatients for attachment (see Table 1). These waiting listsgenerally aim to centralize unattached patients’ requestsfor a primary care provider in a given jurisdiction and tomatch unattached patients with providers, based on avail-ability of primary care workforce and, in some cases,medical need [32, 44].In Canada, the provinces and territories administerand deliver most health care services [45]. The roles ofthe provinces/territories include administration oftheir health insurance plans; planning and funding ofservices in hospitals and other health facilities as wellas of services provided by doctors and other healthprofessionals and planning and implementing healthpromotion and public health initiatives. Therefore, ini-tiatives such as centralized waiting lists for unattachedpatients may be quite different in each province or ter-ritory. Moreover, there is limited knowledge exchangebetween provinces regarding such initiatives.Wide variations in centralized waiting lists for unattachedpatients across CanadaFrom the little information available, we know thereare wide variations between provinces in the waycentralized waiting lists for unattached patients work [46].Each province’s waiting list has distinct characteristics.This study will lead to a better understanding of thecomponents of each of the six centralized waiting lists.A few examples of variations are described below.Guidelines for the centralized waiting listsPatient eligibility for registering in a centralized waitinglist differs from one province to another. In Ontario,patients who already have a primary care provider arenot eligible to register in the centralized waiting list,while in New Brunswick, patients who have a provider,but wish to change providers are allowed to registeron the list [47, 48]. The level of governance of cen-tralized waiting lists is also variable. In Ontario, theprogram is managed at a provincial level with a dele-gation of management to the Community Care AccessCenters at a regional level; while in Quebec, the pro-gram is managed at a local level by the IntegratedCenters for Health and Social Services with some pro-vincial oversight.Table 1 Centralized waiting lists for unattached patientsimplemented across CanadaProvince Program Name ImplementationYearPrince EdwardIslandPatient Registry Program 1998Quebec Guichets d’accès à unmédecin de famille2008Ontario Health Care Connect 2009Manitoba Family Doctor Finder 2013New-Brunswick Patient Connect NB 2013British Columbia A GP for Me 2015Breton et al. BMC Health Services Research  (2017) 17:60 Page 2 of 9Incentives to providers to attach new patientsIncentives to providers to attach new patient differ fromone province to another. In Quebec, primary care pro-viders receive a one-time financial incentive to attach anew patient. These incentives are more substantial if thepatient is attached via a centralized waiting list. For thesepatients, the presence of specific types of vulnerabilitiesdetermines the amount physicians will receive: CAD $23to attach a “non-vulnerable patient” (i.e., healthy patient),CAD$150 to attach a “vulnerable patient” (i.e., with atleast one chronic disease or over 70 years old), andCAD$300 to attach a “super vulnerable patient” (i.e.,suffering from mental illness or substance abuse) [49]. InOntario, family physicians receive a one-time payment ofCAD$350 for attaching a new “complex-vulnerablepatient” from the centralized waiting list [50].Structure to receive & follow-up requests for a providerfrom patientsThe structure for receiving requests for primary careproviders varies quite a bit between provinces. In NewBrunswick, for example, unattached patients contactTele-care 8-1-1, a pre-existing health advice and infor-mation line, to register on the centralized waiting list[51]. In Quebec, requests for a family physician can bemade through a website hosted by the provincial healthinsurance. Additionally, each local health network has anurse and administrative assistant who are available toassist patients fill out a request [44, 52]. In Ontario andManitoba, this part of the process is outsourced to athird party.Identifying & prioritising vulnerable patientsMoreover, there seems to be significant differences inhow vulnerable patients are defined and how they areprioritized when being attached to a primary care pro-vider. In Quebec, patients are prioritized into five prioritycategories (A to E) at a local level based on the urgency oftheir need for a primary care provider [52, 53]. Theurgency of need is assessed based on the self-reportedpresence of specific types of vulnerabilities (e.g., diabetes,mental illness, cancer, HIV/AIDs) or being over 70 yearsold. Patients may also request a health assessment by anurse, which is done over the phone. There are provin-cially recommended wait times for each priority category:≤7 days for A, ≤14 days for B, ≤21 days for C, ≤1 monthfor D and ≤3 months for E. In Ontario, “complex-vulner-able patients” are defined as having one or more co-morbidities, or being frail based on self-assessed healthstatus, chronic conditions or health problems, activitylimiting disability, mental health status and body massindex [54]. Priority is then given to those with thegreatest need for a primary care provider. In NewBrunswick, patients are asked to answer a healthscreening questionnaire regarding long term healthconditions and need for follow-up (multiple medica-tions, history of mental illness, children under 5, etc.),but patients are assigned to a primary care provider ona first-come, first serve basis [48].Matching patients to providersThe way patients are matched with providers is differentin each province. In Manitoba, patients are asked abouttheir provider preferences (type of provider, languagespoken by provider, provider gender, and distance theyare willing to travel) [55]. Conversely, in Quebec, no ques-tions are asked about patients’ preferences, the only con-sideration is geographic distance to the clinic [52, 56]. Inaddition, provinces such as Ontario and Manitoba offerattachment to a nurse practitioner or family physician,while Quebec, for instance, only offers attachment tofamily physicians. Provinces also have varying pro-cesses in place to match providers and patients. InOntario, nurses called Care Connectors are locallymandated to help patients find a primary care providerand are the patients’ main contact during their timeon the waiting list [57]. In Quebec, physicians calledLocal Medical Coordinators are mandated to help thecentralized waiting list attach patients, but are notassigned to patients like in Ontario.Impacts of centralized waiting listsCurrently, we have access to very little information thatallows us to compare the impacts of centralized waitinglists across provinces. However, we know that thevolume of patients attached to primary care providersvaries significantly. For instance, in Manitoba, around30 000 patients have been attached through FamilyDoctor Finder since its implementation in 2013 [58]. Incomparison, the guichets d’accès aux médecins defamille in Quebec has attached over 800 000 patientssince its implementation in 2008 [53]. We also knowthat, over the last year, the effectiveness of the centralizedwaiting list in attaching complex patients has beenheterogeneous. Ontario has successfully attached 85% ofwhat they identified as being “complex-vulnerable patients”[59]; while Quebec has attached only 20% of the patientsidentified as being “vulnerable”.British Columbia: a special caseMost centralized waiting lists in the other five provinceswere mandated at a provincial level and implementedmore or less uniformly across the province with slightvariations in local practices. However, for the “A GP forMe” initiative in British Columbia, each division ana-lyzed their needs and implemented various strategies toimprove attachment according to those needs. There-fore, only a handful of divisions implemented some typeBreton et al. BMC Health Services Research  (2017) 17:60 Page 3 of 9of centralized waiting list for unattached patients. Thecase of British Columbia, although different from theother provinces, is especially interesting because of thevariety of innovative strategies combined with central-ized waiting lists to improve attachment. Therefore, wewill identify common characteristics at a provincial level,but will also conduct an in-depth analysis of somedivisions.Study objectiveThe main objective of this study is to compare the dif-ferent models of centralized waiting lists for unattachedpatients implemented in six provinces of Canada to eachother and to available scientific knowledge to makerecommendations on ways to improve their design in aneffort to increase attachment of patients to a primarycare provider.MethodsOverall study designWe will conduct a logic analysis to compare, analyzeand identify improvement strategies for the centralizedwaiting lists for unattached patients across Canada. Allsix provinces that have implemented a centralized waitinglist for unattached and complex patients will be includedin this study.Logic analysis is a theory-based evaluation that teststhe adequacy between the intended outcomes of anintervention and the actions undertaken to achievethose outcomes [60, 61]. It assesses the validity of theintervention’s theory by identifying the main character-istics of the program and the key contextual factors thatmay affect the intervention’s effectiveness to produceintended outcomes [61, 62].There are several benefits of using a logic analysis toevaluate an intervention. First, because it examines the fitbetween actual activities and strategies of the intervention,and those that should be implemented to achieve theintended outcomes, the use of a logic analysis may revealgaps in logic [63]. Second, testing the program’s theorycan provide important insights into the intervention’sstrengths and weaknesses while mobilizing various stake-holders in a valuable reflection process [60]. It can there-fore provide stakeholders with a rapid feedback on thevalidity of their intervention and on the ways they canimprove the effectiveness of their intervention. Finally, itallows for the identification of adequate performance indi-cators based on data that is relevant to the intervention’scomponents.A logic analysis is conducted in three steps: 1) buildinglogic models of the interventions, 2) developing a concep-tual framework based on scientific knowledge (literatureand expert views), and 3) comparing the logic models tothe conceptual framework [60].Step 1: Build logic models that describes each province’scentralized waiting listThe logic models will be elaborated based on Mitchell &Lewis’s Manual to Guide the Development of LocalEvaluation Plans [63]. This particular model offers asimple diagram of the main components of a uniqueintervention and is widely used in research on primaryhealthcare interventions in Canada. For instance, Mitchell& Lewis’ model is currently being used by the 12 researchprograms in the Canadian Institutes of Health Research'ssignature initiative on community based primary health-care [64]. It is therefore relevant to use this model toevaluate complex, multilevel and multifaceted interven-tions such as centralized waiting lists for unattachedpatients.This model assumes that inputs/strategies of the inter-vention will influence the processes and structures, whichwill then influence the impacts, which will in turn leadto the intended outcomes of the intervention. It aims toidentify every component involved in the desired change,indicators to measure these components, as well as gapsin the intervention’s logic. Six categories of componentsmust be included in the model. Action areas: the focus area of the intervention; Outcomes: intended changes in health andwellbeing of targeted population; Inputs/strategies: resources, strategies and activitiesneeded to launch the intervention; Processes and structures: mechanisms andcharacteristics of services, systems or activities thathave to be maintained over time to achieve impacts; Impacts: changes that are crucial to achievingintended outcomes; Contextual factors: political, cultural, socioeconomicand geographic factors that might affect theintervention’s effectiveness in producing intendedoutcomes.We have provided below an example of how the logicmodel will be used to map out the different componentsof centralized waiting lists for unattached patients (seeFig. 1).In each of the six cases, a variety of data sources will beused. First, we will review the grey literature to identifythe main characteristics of each centralized waiting list.The grey literature will be reviewed using search enginessuch as Google and Google Scholar as well as specificsources such as websites from health institutions, nationaland provincial government, provincial and local newspa-pers [65]. We will also use the grey literature to identifykey stakeholders in each province (professional associa-tions, decision-makers, clinicians, etc.). In addition, ourknowledge users will help us identify key stakeholders ofBreton et al. BMC Health Services Research  (2017) 17:60 Page 4 of 9the centralized waiting list in their province. We will thenconduct semi-structured interviews with the key stake-holders identified and use a snowballing method to iden-tify additional participants. The aim of these interviews isto gain an in depth understanding of the characteristicseach centralized waiting list (for more details, please con-sult interview guide in Additional file 1). Interviews willbe conducted in person, by phone or by videoconferencedepending on the location of the interviewee. We plan toconduct interviews in each province until we reach satur-ation (around eight interviews per case). All interviewswill be taped and transcribed when formally authorized byrespondents.All documents and interview transcriptions will becoded using NVivo (QSR) software. A list of initial codesbased on the logic model template (Fig. 1) has beenestablished. This list details the five elements of logicalanalysis on centralized waiting list which are 1) theneeded inputs for implementation of centralized waitinglist, 2) process for requesting a family physician, 3)prioritization of patients and attachment to a primarycare provider, 4) perceived outputs of the centralizedwaiting list and 5) elements from the contexts thatmight have an influence on the implementation of thecentralized waiting list. This list will be modified andenhanced over the course of the analyses.Two independent team members will code the data toensure reproducibility and reliability. A double-codingtechnique will be used in order to control the codingstep and to guaranty the repeatability and reliability ofFig. 1 Logic model templateBreton et al. BMC Health Services Research  (2017) 17:60 Page 5 of 9the method. Coding results will be compared. The codeswill be refined where differences appear and then codingwill be repeated. This process will be repeated until thetwo analysts obtain inter-coder agreement of more than90% [66]. Codes will be grouped in the correspondingthemes and also in new themes that have appeared duringanalysis. We will analyze transcripts for each provinceseparately in order to better understand the how eachcentralized waiting list works. Coded materials will be an-alyzed using a thematic analysis and results will be synthe-tized using tables and matrices [66, 67]. Data obtained foreach province will be summarized.The characteristics of each province’s centralizedwaiting list will be presented in a logic model. We willthen use these logic models to perform a cross-case(inter-provincial) analysis of the six centralized waitinglists. We will compare the centralized waiting lists,highlight similarities and differences between themand identify factors that can lead to an increase in at-tachment of patients to a primary care provider. Thelogic models will be presented in a graphic form. Wewill collaborate closely with a graphic designer to ensurethe models are easy to understand. The information ineach logic model will be validated by key stakeholdersfrom the centralized waiting list in each province. A face-to-face meeting will be organized on each site between thekey informants and members from our team.Step 2: Develop a conceptual framework based on keycharacteristics of centralized waiting lists for unattachedpatients and factors influencing their implementationDeveloping a conceptual framework is a core componentof the logic analysis and critical to assessing an interven-tion’s rationale. This step consists of identifying “the bestways of doing things” [60]. This is done by analysing thecentralized waiting lists’ components and identifying theoptimal way to achieve the intended outcomes or byidentifying alternative ways, if any, of achieving theseoutcomes.In order to develop a conceptual framework, a realistreview approach will be used. Based on evidence fromthe scientific literature and experts’ views related to theintervention [61, 68, 69], the realist review is a theory-driven approach developed in order to explore causalprocesses that generate outcomes within programs or in-terventions. This approach aims to evaluate the context,mechanism and outcomes of interventions with a het-erogeneous body of evidence. Given that this study isbeing conducted over a 12 month period and thatthere is very limited literature on centralized waitinglists for unattached patients, this approach waschosen in order to assemble a body of evidence onthe mechanisms of different aspects of centralizedwaiting lists for unattached patients.We will use the realist review approach for three keycomponents of centralized waiting lists for unattachedpatients:1) What are unattached patients’ characteristics andprimary care needs?2) What are the best ways to manage centralizedwaiting lists?3) What are the most effective incentives (financialor other) to increase the number of new patientsattached to primary care providers?The realist review will comprise three distinct reviewprocesses, covering the three aforementioned aspects.The primary literature searches will be performed by amember of the research team with the EBSCOhost inter-face through four databases: Medline, CINAHL, PsychInfoand SocIndex. The research will be limited to peer-reviewed texts in French and English published between2000 and 2016. A Boolean search will be performed usingsearch terms specific to each subject developed by theresearch team with the help of an information specialist.A classic two-step review selection process will beconducted by two reviewers to identify the relevant arti-cles to be included in the review. The first step of theselection process will be a review based on articles' titleand abstract. Articles from the primary literature re-search will be reviewed by the two reviewers on the basisof potential relevance regarding the process of each re-search questions. Following the title and abstract screening,articles will be screened for full text review by the tworeviewers based on agreement of reviewing and discussionon disagreement. Criteria for the full text review will beelaborated by main researcher and the reviewers in order toproceed to the selection of the relevant texts to be includedon the studies.To ensure the maximal selection of relevant articles,each of the selected will get their references screenedand a research through Google Scholar will be done tofind articles citing the article as well as similar articles.An expert in each of components studied in this reviewwill also be contacted in order to validate the content ofthe selected data and ensure that important articles werenot forgotten in the process.Data will be extracted following an extraction griddeveloped by a member of the research team for each ofthe three research aspects. A second member of the re-search team will review the extraction to ensure all rele-vant information has been extracted. The research teamwill construct the extraction grids in order to extract allrelevant information that can be linked to the researchquestions. The analysis of the data collected with theextraction grids will be done following a thematic ana-lysis method.Breton et al. BMC Health Services Research  (2017) 17:60 Page 6 of 9To ensure balance between relevance and scientificrigour, papers will be assessed based on both relevanceand quality. The quality appraisal will be based on theprompts outlined by Dixon & Woods [70] and willbe used to determine the contribution of the data to thereviews.Step 3: Compare the logic models to the conceptualframework to make recommendations to improvecentralized waiting lists in different provincesWe will compare the logic models built in step 1 to theconceptual framework developed by consulting expertsand reviewing the literature in step 2. This should producenew readings of the centralized waiting lists for un-attached patients that highlight strengths and weaknesses,as well as the strength of the causal chain toward the im-pacts and intended outcomes [60]. Our aim is to identifythe strengths and weaknesses of each centralized waitinglist under study, the characteristics that seem promisingto promote attachment, particularly for vulnerable pa-tients and the contextual factors that may affect the inter-vention’s effectiveness in order to propose strategies toimprove attachment to a primary care provider that arerelevant to each province’s context.This step will be done using a participatory approachduring a one-day face-to-face meeting with the researchteam and key stakeholders involved in centralized waitinglists for unattached patients across the six provinces. A par-ticipative approach will create consensus on what is re-quired to improve current practices and adapt promisingstrategies to different contexts, enhance the appropriationof results, and initiate the necessary changes [71].Results’ disseminationPromising strategies will be described in short videotapedinterviews with the decision-makers of each province. Thefootage from these interviews will be used to put togethershort video clips. The video editing will be done in themultimedia laboratory at the Centre de recherche HôpitalCharles-Le Moyne. Also, the promising strategies will besummarized in a brief report. A dissemination strategy ofthe video clips, logic model illustrations and brief reportproduced will be developed in complementarity to theproduction of peer-reviewed scientific articles and presen-tations in international conferences.DiscussionNo study has compared these complex organizationalmodels across Canada and analyzed variations in strat-egies used to increase attachment to a regular primarycare provider, for the general population and for vulner-able populations. To our knowledge, only one study hasexamined the implementation and outcomes of central-ized waiting lists for unattached patients and this studyfocuses on the province of Quebec [7] and further com-parative studies are needed. The natural experimentationof centralized waiting lists for unattached patients imple-mented in six provinces represents a unique opportunityto better understand these different models, to learnfrom the different experiences and to identify promisingstrategies to improve the effectiveness of these central-ized waiting lists. The results from this study will be use-ful for decision-makers of healthcare systems in Canadaand countries with similar healthcare systems by provid-ing strategies and key elements for implementing effect-ive centralized waiting lists.Implications for implementationThis study is based on an inter-provincial learning ex-change approach where we propose to compare central-ized waiting lists and analyze variations in strategiesused to increase attachment to a regular primary careprovider. To date, there has been very little collaborationbetween the decision-makers of each province’s central-ized waiting lists to discuss best practices or promisingstrategies. Our research team has developed collabora-tions with key stakeholders in each province of the sixprovinces that have implemented a centralized waitinglist for unattached patients. Comparing the six prov-inces’ models to the conceptual framework will allow usto understand the differences between the centralizedwaiting lists in the six provinces, to explain these differ-ences according to context, and identify strategies to im-prove certain components and mechanisms for the sixcentralized waiting lists to better achieve intended out-comes. Our inter-provincial learning exchange approachwill allow stakeholders from different provinces to cometogether to discuss the results of our study which in turnwill enhance their appropriation of results, and initiateconversations about changes that could be made in eachprovince. In addition to our integrated approach withkey stakeholders, six Strategy for Patient-Oriented Re-search (SPOR) on Primary and Integrated Health CareInnovation Networks have agreed to provide support inconnecting with additional stakeholders and disseminat-ing results of the study within their province.Fostering inter-provincial healthcare systems' connect-ivity to improve centralized waiting lists’ practices acrossCanada can therefore lever attachment to a regular pro-vider for timely access to continuous, comprehensiveand coordinated healthcare for all Canadians and par-ticular for those who are vulnerable.Additional filesAdditional file 1: Semi-structured interview guide. Interview guide.(PDF 183 kb)Breton et al. BMC Health Services Research  (2017) 17:60 Page 7 of 9AcknowledgementsKey stakeholders from each province under study have accepted tocollaborate actively in this project as knowledge users and collaborators. Wewish to thank them for their collaboration in this study. We wish to thank allorganizations that have provided financial and inkind support.FundingThis study is funded by the Canadian Institutes of Health Research (#145183),Charles-LeMoyne Hospital Research Center, Quebec SPOR Network in Primaryand Integrated and Chair in Applied Health Economics/Health Policy held byDr. Michael Green.Availability of data and materialsNot applicable.Authors’ contributionsMB led the coordination and the conceptualization of the study. MB andMAS wrote the first draft and all authors critically reviewed it and providedcomments to improve the manuscript. MG, SK, JSutherland, JJ, STW, JShaw,VAC, DC and AB read and commented on the final manuscript. All authorsread and approved the final manuscript.Competing interestsSabrina T. Wong is an Associate Editor of BMC Health Services Research.The others authors declare that they have no competing interests.Consent for publicationNot applicable.Ethics approval and consent to participateEthical approval was obtained from the research ethics board of the CentreHospitalier Universitaire de Sherbrooke (ref. number 2017–1433), fromQueen’s University Community Support Service Organizations andCommunity Mental Health and Addiction Agencies (ref. number 6018938),from the Office of Research Services Behavioral Research Ethics Board ofUniversity of British Columbia, (ref. number H16-01697), from the comitéd’éthique de la recherche avec les êtres humains de l’Université de Moncton(ref. number 1516–081), from University of Manitoba (ref. number HS 19960(H2016:271)) and from PEI Ethics Board from Health PEI (date of ethicalapproval July 21st, 2016). Those six ethical approvals cover all the settingswhere the research will be conducted, as we have obtained one of everyprovince involved in the study.Information about participation’s terms and conditions will be explain andread to all participants. Then, they will be asked to complete and sign awritten consent form.Author details1Charles-LeMoyne Hospital Research Centre, Sherbrooke University,Longueuil Campus, 150 Place Charles-LeMoyne, Office 200, Longueuil, QCJ4K 0A8, Canada. 2Family Medicine and Public Health Sciences and CHSPR,Queen’s University, Abramsky Hall, 3rd Floor 21 Arch St., Kingston, ON K7L3N6, Canada. 3Manitoba Research Chair in Health System Innovation andCommunity Health Sciences, University of Manitoba, 200-1155 ConcordiaAve., Winnipeg, MB R2K 2M9, Canada. 4Centre for Health Services and PolicyResearch, University of British Columbia, 201-2206 East Mall, Vancouver, BCV6T 1Z3, Canada. 5School of psychology, Université de Moncton, Centre deformation médicale du Nouveau-Brunswick, Pavillon Léopold-TaillonUniversité de Moncton, 18 Ave Antonine-Maillet, Moncton, NB E1A 3E9,Canada. 6School of Nursing and Centre for Health Services and PolicyResearch in the School of Population and Public Health, University of BritishColumbia, 2211 Wesbrook Mall, Vancouver, BC V6T 2B5, Canada. 7Institute forHealth System Solutions and Virtual Care, Women’s College Hospital, 76Grenville Street, Toronto, ON M5S1B2, Canada. 8Canada Research Chair inHealth Service Geographies, Simon Fraser University, 8888 University Drive,Burnaby, BC V5A 1S6, Canada. 9Faculty of nursing, University of Montréal,2375, chemin de la Côte-Ste-Catherine, Montréal, Québec H3T 1A8, Canada.Received: 30 September 2016 Accepted: 12 January 2017References1. Karazivan P. La médecine familiale vue par les jeunes omnipraticiens: rejetde la vocation et de la continuité des soins. Montréal: Université deMontréal; 2010.2. Jatrana S, Crampton P. Affiliation with a primary care provider in NewZealand: Who is, who isn’t. Health Policy. 2009;91(3):286–96.3. Jatrana S, Crampton P, Richardson K. Continuity of care with generalpractionners in New Zealand: results from So-FIE-Primary care. J N Z MedAssoc. 2011;124(1329):286–96.4. Haggerty J, Lévesque JF, Santor D, Burge F, Beaulieu C, Baouharaoui F.Accessibility from the patient perspective: comparison of primary healthcareevaluation instruments. Healthc Policy. 2011;7:94–107.5. Lévesque J-F, Haggerty JL, Burge F, Beaulieu M-D, Gass D, Pineault R, et al.Canadian experts’ views on the importance of attributes within professionaland community-oriented primary healthcare models. Healthc Policy. 2011;7(Special Issue):21–30.6. Levesque J-F, Harris MF, Russell G. Patient-centred access to health care:conceptualising access at the interface of health systems and populations.Int J Equity Health. 2013;12(1):18–26.7. Breton M, Brousselle A, Boivin A, Loignon C, Touati N, Dubois C-A, et al.Evaluation of the implementation of centralized waiting lists for patientswithout a family physician and their effects across the province of Quebec.Implement Sci. 2014;9(1):117.8. Frenk JA. The concept and measure of accessibilty. In: White KL, Frenk JA,Ordonez C, Paganini JM, Starfield B, editors. Health services research: ananthology. Washington DC: Pan American Health Organization; 1992. p. 842-55.9. Nutting P, Goodwin M, Flocke S, Zyzanski S, Stange K. Continuity of primarycare: to whom does it matter and when? Ann Fam Med. 2003;1(3):149–55.10. Burge F, Haggerty J, Pineault R, Beaulieu MD, Lévesque JF, Beaulieu C, et al.Relational continuity from the patient perspective: comparison of primaryhealthcare evaluation instruments. Healthc Policy. 2011;7:124–38.11. Chan BTB. The declining comprehensiveness of primary care. Can MedAssoc J. 2002;166(4):429–34.12. Bazemore A, Petterson S, Peterson L, Philips Jr RL. More comprehensive careamong family physicians is associated with lower costs and fewerhospitalizations. Ann Fam Med. 2015;13:206–13.13. Brown AD, Goldacre MJ, Hicks N, Rourke JT, et al. Hospitalization for ambulatorycare-sensitive conditions: a method for comparative access and quality studiesusing routinely collected statistics. Can J Public Health. 2001;92(2):155–9.14. Weingarten S, Henning J, Badamgarav E, Knight K, Hasselblad V, Gano A, etal. Interventions used in disease management programmes for patientswith chronic illness which ones work? Meta-analysis of published reports.BMJ. 2002;325(7370):925.15. Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Coordinating care acrossdiseases, settings, and clinicians: a key role for the generalist in practice.Ann Intern Med. 2005;142(8):700–8.16. Bayliss EA, Edwards AE, Steiner JF, Main DS. Processes of care desired byelderly patients with multimorbidities. Fam Pract. 2008;25(4):287–93.17. Fung CS, Wong CK, Fong DY, Lee A, Lam CL. Having a family doctor wasassociated with lower utilization of hospital-based health services. BMCHealth Serv Res. 2015;15(1):1–9.18. Rothman AA, Wagner EH. Chronic illness management: what is the role ofprimary care? Ann Intern Med. 2003;138(3):256–61.19. Østbye T, Yarnall KSH, Krause KM, Pollak KI, Gradison M, Michener JL. Is theretime for management of patients with chronic diseases in primary care?Ann Fam Med. 2005;3(3):209–14.20. Starfield B, Shi L, Machinki J. Contribution of primary care to health systemsand health. Milbank Q. 2005;83:457–502.21. Grunfeld E, Levine MN, Julian JA, Coyle D, Szechtman B, Mirsky D, et al.Randomized trial of long-term follow-up for early-stage breast cancer: acomparison of family physician versus specialist care. J Clin Oncol. 2006;24(6):848–55.22. Christakis DA, Wright JA, Koepsell TD, Emerson S, Connell FA. Is greatercontinuity of care associated with less emergency department utilization?Pediatrics. 1999;103(4 Pt 1):738–42.23. Christakis DA, Mell L, Koepsell TD, Zimmerman FJ, Connell FA. Association oflower continuity of care with greater risk of emergency department useand hospitalization in children. Pediatrics. 2001;107(3):524–9.24. Burge F, Lawson B, Johnston G. Family physician continuity of care andemergency department use in end-of-life cancer care. Med Care. 2003;41(8):992–1001.Breton et al. BMC Health Services Research  (2017) 17:60 Page 8 of 925. Oates J, Weston WW, Jordan J. The impact of patient-centered care onoutcomes. Fam Pract. 2000;49:796–804.26. Griffin SJ, Kinmonth A-L, Veltman MWM, Gillard S, Grant J, Stewart M. Effecton health-related outcomes of interventions to alter the interactionbetween patients and practitioners: a systematic review of trials. Ann FamMed. 2004;2(6):595–608.27. Commonwealth Fund International Health Policy Survey, Schoen C, et al.Toward higher-performance health systems: adults’ health care experiencesin seven countries, 2007. Health Aff. 2007;26(6):w717–w34.28. College of Family Physicians of Canada. Four principles of family medicine.Available from: http://www.cfpc.ca/principles/. Accessed 17 Jan 2017.29. Watt D. The Family Physician: gatekeeper to the health-care system. CanFam Physician. 1987;33:1101–4.30. Pena-Dolhun E, Grumbach K, Vranizan K, Osmond D, Bindman AB.Unlocking specialists’ attitudes toward primary care gatekeepers. J FamPract. 2001;50 Suppl 12:1032–7.31. Health Council of Canada. Decisions, decisions: family doctors asgatekeepers to prescription drugs and diagnostic imaging in Canada.Toronto: Health Council; 2010.32. Crooks VA, Agarwal G, Harrison A. Chronically ill Canadians’ experiences ofbeing unattached to a family doctor: a qualitative study of marginalizedpatients in British Columbia. BMC Fam Pract. 2012;13:69.33. Romanow RJ. Building on values - the future of Health Care in Canada. Finalreport. Commission on the Future of Health Care in Canada. Ottawa:Government of Canada; 2002.34. Clair M. Les solutions émergentes: Rapport et recommandations.Commission d’étude sur les services de santé et les services sociaux.Québec: Gouvernement du Québec; 2001. Contract No.: Report.35. Government of Alberta, Mazankowski D. A framework for reform: Premier’sAdvisory Council on Health. 2001.36. Government of Ontario. Looking back, looking forward:The Ontario HealthServices Restructuring Commission (1996–2000). Toronto: The OntarioHealth Services Restructuring Commission; 2000. Contract No.: Report.37. Government of Saskatchewan. Caring for Medicare: Sustaining a QualitySystem. Regina: Commission on Medicare; 2001.38. Kirby JL, LeBreton M. The Health of Canadians - The Federal role. Volume 6:Recommendations for Reform. Standing Senate Committee on Social Affairs,Science and Technology. Ottawa: Government of Canada; 2002.39. Statistics Canada. Access to a regular medical doctor—CanadianCommunity Health Survey 2013. Ottawa: Statistics Canada; 2014.40. Talbot Y, Fuller-Thomson E, Tudiver F, Habib Y, McIsaac WJ. Canadians withoutregular medical doctors. Who are they? Can Fam Physician. 2001;47:58–64.41. Hay C, Pacey M, Bains N, Ardal S. Understanding the unattached populationin Ontario: evidence from the Primary Care Access Survey (PCAS). HealthcPolicy. 2010;6(2):33–47.42. Loignon C, Allison P, Landry A, Richard L, Brodeur J, Bedos C. Providinghumanistic care: dentists' experience in deprived areas. J Dent Res. 2010;89(9):991-5.43. Loignon C, Haggerty J, Fortin M, Bedos C, Allen D, Barbeau D. Physicians’social competence in the provision of care to persons living in poverty:research protocol. BMC Health Serv Res. 2010;10(1):79.44. Breton M, Gagne J, Gankpé F. Implementing centralized waiting list forpatients without family physicians across Québec. Health Reform Observer/Observatoire des Réformes de Santé. 2014;1(2):1–12.45. Health Canada. Canada’s Health Care System: Gouvernment of Canada;2012. Available from: http://www.hc-sc.gc.ca/hcs-sss/pubs/system-regime/2011-hcs-sss/index-eng.php. Accessed 14 Sept 2016.46. Breton M, Ricard J, Walter N. Connecting orphan patients with familyphysicians: differences among Quebec’s access registries. Can FamPhysician. 2012;58(9):921–2.47. Ontario Ministry of Health and Long-Term Care. Find a family doctor ornurse practitioner: How to find or change a family doctor or nursepractitioner through Health Care Connect. 2015 [2015-11-03]. Availablefrom: http://www.ontario.ca/page/find-family-doctor-or-nurse-practitioner#section-1. Accessed 3 Nov 2015.48. Government of New Brunswick. Patient Connect NB—Frequently askedquestions 2013 [2015-11-03]. Available from: https://www.gnb.ca/0217/pdf/2013/patient_connect_faq-e.pdf. Accessed 3 Nov 2015.49. Fédération des médecins omnipraticien du Q, Ministère de la santé et desservices s. Guide de gestion relatf à l’application de la Lettre d’entente no245 (guichets d’accès aux clientèles orphelines). 2013 Contract No.: Report.50. Primary Health Care Branch. INFOBulletin - Changes to Primary Health CarePhysician Payments. 2015. Bulletin 1125. Available from: http://www.health.gov.on.ca/en/pro/programs/ohip/bulletins/11000/bul11125.pdf. Accessed 3Nov 2015.51. Salisbury C, Sampson F, Ridd M, Montgomery AA. How should continuity ofcare in primary health care be assessed? Br J Gen Pract. 2009;59(561):e134–e41.52. Ministère de la Santé et des Services S. Cadre de référence provincial desguichets d’accès pour la clientèle sans médecin de famille. 2016.53. Breton M, Brousselle A, Boivin A, Roberge D, Pineault R, Berbiche D. Whogets a family physician through centralized waiting lists? BMC FamilyPractice. 2015;16(1):10. doi:10.1186/s12875-014-0220-7.54. Ontario Ministry of Health and Long-Term Care. Public Information—HealthCare Connect Program Results 2014 [2015-11-03]. Available from:http://www.health.gov.on.ca/en/ms/healthcareconnect/public/results.aspx.Accessed 3 Nov 2015.55. Manitoba Health HLS. Family Doctor Finder Online Registration -Connecting Me to My Primary Care 2015 [2015-11-03]. Available from:https://www.gov.mb.ca/health/familydoctorfinder/register.html. Accessed 3Nov 2015.56. Gouvernement du Québec. Guichet d’accès à un médecin de famille. 2016.https://www4.prod.ramq.gouv.qc.ca/GRL/LM_GuichAccesMdFamCitoy/fr.Accessed 3 Nov 2015.57. Ionescu-Ittu R, McCusker J, Ciampi A, Vadeboncoeur A-M, Roberge D,Larouche D, et al. Continuity of primary care and emergency departmentutilization among elderly people. Can Med Assoc J. 2007;177(11):1362–8.58. Manitoba Health Healthy Living & Seniors. Family Doctor Finder ProgramResults 2015. Available from: http://www.gov.mb.ca/health/familydoctorfinder/stats.html. Accessed 3 Nov 2015.59. Ontario Ministry of H, Long-Term c. Health Care Connect, Program Results. 2012.60. Brousselle A, Champagne F. Program theory evaluation: logic analysis. EvalProgram Plann. 2011;34(1):69-78. http://dx.doi.org/10.1016/j.evalprogplan.2010.04.001.61. Rey L, Brousselle A, Dedobbeleer N. Logic analysis: testing program theoryto better evaluate complex interventions. In: Houle J, Dubois N, Lloyd S,Mercier C, Hartz Z, Brousselle A, editors. L’évaluation des interventionscomplexes. 26(3): Revue Canadienne d’Évaluation de Programme/CanadianJournal of Program Evaluation; 2012. p. 61–89.62. Newcomer KE, Hatry HP, Wholey JS. Handbook of practical evaluation:Hoboken: Wiley; 2015.63. Mitchelle P, Lewis V. A Manual to Guide the Development of LocalEvaluation Plans. Australian Government Department of Health andAging. 2003.64. Haggerty J, Tamblyn R, Boileau L, Levesque J, Katz A, Russell G. BuildingSystems-Level Evidence From The Mosaic of 12 Research Programs In TheCIHR Signature Initiative On Community Based Primary Health Care.Montreal: Canadian Association of Health Services and Policy ResearchConference; 2014.65. Bonato S. Google scholar and scopu for finding gray literature publications.J Med Libr Assoc. 2016;104(3):252–4.66. Maddison P, Jones J, Breslin A, Barton C, Fleur J, Lewis R, et al. Improvedaccess and targeting of musculoskeletal services in northwest Wales:targeted early access to musculoskeletal services (TEAMS) programme. BMJ.2004;329(7478):1325–7.67. Attride-Stirling J. Thematic networks: an analytic tool for qualitative research.Qual Res. 2001;1(3):385–405.68. Wong G, Greenhalg T, Westhorp G, Buckingham J, Pawson R. RAMESESpublication standards: realist syntheses. BMC Med. 2013;11(1):1.69. Greenhalgh T, Wong G, Westhorp G, Pawson R. Protocol-realist and meta-narrative evidence synthesis: evolving standards (RAMESES). BMC Med ResMethodol. 2011;11(1):115.70. Dixon-Woods M, Cavers D, Agarwal S, Annandale E, Arthur A, Harvey J, et al.Conducting a critical interpretive synthesis of the literature on access tohealthcare by vulnerable groups. BMC Med Res Methodol. 2006;6(1):1–13.71. Donaldson SI. Theory-Driven Program Evaluation in the New Millenium. In:Donaldson SI, Scriven M, editors. Evaluating Social Programs and Problems:Visions for the new millenium. Mahwah, NJ: Lawrence Erlbaum Associates;2003. p. 109–41.Breton et al. BMC Health Services Research  (2017) 17:60 Page 9 of 9


Citation Scheme:


Citations by CSL (citeproc-js)

Usage Statistics



Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            async >
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:


Related Items