Noah Michael Ivers

Background: Pharmacists’ scope of practice in Ontario expanded in January 2023, allowing them to assess and prescribe for 19 ambulatory conditions (“minor ailments*”). We described the uptake of Ontario's Minor Ailment Services program, including characteristics of patients receiving these services and the community pharmacies that delivered them. Methods: We conducted a repeated cross-sectional study using health administrative data from January 2023 and December 2024. We included data from all Ontario community pharmacies. We plotted trends in uptake and compared pharmacy characteristics after stratifying by their weekly volume of claims for ambulatory conditions. Results: There were 1,471,459 claims during the study period, with an immediate uptake that stabilized within 10 months. Claims for urinary tract infections and conjunctivitis were highest, accounting for 59% of claims. Most services were delivered in-person (88%), in urban settings (83%), and by corporate-owned pharmacies (59%). The mean weekly number of claims per pharmacy was 2.7 (standard deviation 4.4). Compared to pharmacies with no claims, those with high claim volumes (average >7 claims/week) were more often corporate-owned, located in urban areas and areas with a higher neighbourhood income quintile, employed more pharmacists, and had pharmacists with fewer practice years, more female pharmacists, and more pharmacists educated in Canada. Interpretation and conclusion: Our study demonstrated rapid, immediate uptake of ambulatory condition services in Ontario, driven mainly by urinary tract infections and conjunctivitis. We identified variation in uptake, suggesting a potential mismatch between those with a greater need for access to care and the pharmacies that most often delivered ambulatory condition services.

Audit and feedback (A&F) is a widely used strategy to improve professional practice. This is supported by prior Cochrane reviews and behavioural theories describing how healthcare professionals are prompted to modify their practice when given data showing that their clinical practice is inconsistent with a desirable target. Yet there remains uncertainty regarding the effects of A&F on improving healthcare practice and the characteristics of A&F that lead to a greater impact. To assess the effects of A&F on the practice of healthcare professionals and to examine factors that may explain variation in the effectiveness of A&F. With the Cochrane Effective Practice and Organisation of Care (EPOC) group information scientist, we updated our search strategy to include studies published from 2010 to June 2020. Search updates were performed on 28 February 2019 and 11 June 2020. We searched MEDLINE (Ovid), Embase (Ovid), CINAHL (EBSCO), the Cochrane Library, clinicaltrials.gov (all dates to June 2020), WHO ICTRP (all dates to February Week 3 2019, no information available in 2020 due to COVID-19 pandemic). An updated search and duplicate screen was completed on February 14, 2022; studies that met inclusion criteria are included in the 'Studies awaiting classification' section. Randomised trials, including cluster-trials and cross-over and factorial designs, featuring A&F (defined as measurement of clinical performance over a specified period of time (audit) and provision of the resulting data to clinicians or clinical teams (feedback)) in any trial arm that reported objectively measured health professional practice outcomes. For this updated review, we re-extracted data for each study arm, including theory-informed variables regarding how the A&F was conducted and behaviour change techniques for each intervention, as well as study-level characteristics including risk of bias. For each study, we extracted outcome data for every healthcare professional practice targeted by A&F. All data were extracted by a minimum of two independent review authors. For studies with dichotomous outcomes that included arms with and without A&F, we calculated risk differences (RDs) (absolute difference between arms in proportion of desired practice completed) and also odds ratios (ORs). We synthesised the median RDs and interquartile ranges (IQRs) across all trials. We then conducted meta-analyses, accounting for multiple outcomes from a given study and weighted by effective sample size, using reported (or imputed, when necessary) intra-cluster correlation coefficients. Next, we explored the role of baseline performance, co-interventions, targeted behaviour, and study design factors on the estimated effects of A&F. Finally, we conducted exploratory meta-regressions to test preselected variables that might be associated with A&F effect size: characteristics of the audit (number of indicators, aggregation of data); delivery of the feedback (multi-modal format, local champion, nature of comparator, repeated delivery); and components supporting action (facilitation, provision of specific plans for improvement, co-development of action plans). We included 292 studies with 678 arms; 133 (46%) had a low risk of bias, 41 (14%) unclear, and 113 (39%) had a high risk of bias. There were 26 (9%) studies conducted in low- or middle-income countries. In most studies (237, 81%), the recipients of A&F were physicians. Professional practices most commonly targeted in the studies were prescribing (138 studies, 47%) and test-ordering (103 studies, 35%). Most studies featured multifaceted interventions: the most common co-interventions were clinician education (377 study arms, 56%) and reminders (100 study arms, 15%). Forty-eight unique behaviour change techniques were identified within the study arms (mean 5.2, standard deviation 2.8, range 1 to 29). Synthesis of 558 dichotomous outcomes measuring professional practices from 177 studies testing A&F versus control revealed a median absolute improvement in desired practice of 2.7%, with an IQR of 0.0 to 8.6. Meta-analyses of these studies, accounting for multiple outcomes from the same study and weighting by effective sample size accounting for clustering, found a mean absolute increase in desired practice of 6.2% (95% confidence interval (CI) 4.1 to 8.2; moderate-certainty evidence) and an OR of 1.47 (95% CI 1.31 to 1.64; moderate-certainty evidence). Effects were similar for pre-planned subgroup analyses focused on prescribing and test-ordering outcomes. Lower baseline performance and increased number of co-interventions were both associated with larger intervention effects. Meta-regressions comparing the presence versus absence of specific A&F components to explore heterogeneity, accounting for baseline performance and number of co-interventions, suggested that A&F effects were greater with individual-recipient-level data rather than team-level data, comparing performance to top-peers or a benchmark, involving a local champion with whom the recipient had a relationship, using interactive modalities rather than just didactic or just written format, and with facilitation to support engagement, and action plans to improve performance. The meta-regressions did not find significant effects with the number of indicators in the audit, comparison to average performance of all peers, or co-development of action plans. Contrary to expectations, repeated delivery was associated with lower effect size. Direct comparisons from head-to-head trials support the use of peer-comparisons versus no comparison at all and the use of design elements in feedback that facilitate the identification and action of high-priority clinical items. A&F can be effective in improving professional practice, but effects vary in size. A&F is most often delivered along with co-interventions which can contribute additive effects. A&F may be most effective when designed to help recipients prioritise and take action on...

BACKGROUND Asynchronous messaging (AM), including patient messages, lab results, specialist correspondence, and internal team communications, is now routine in primary care, offering patients timely access while reducing the need for in-person visits. However, AM has generated substantial workload and is thought to contribute to clinician burnout. Despite its increasing role in primary care, limited empirical work has examined how AM can be intentionally designed to sustainably support compassionate relational care. OBJECTIVE This study aimed to co-design compassionate and sustainable approaches to asynchronous electronic messaging in primary care by engaging patients, clinicians, clinic staff, and health system leaders in identifying challenges and developing feasible solutions for communication workflows, standards, and platform design. METHODS We conducted sequential co-creation workshops between June 2025 and January 2026 as part of a multi-phase, design-led qualitative study. Separate workshops were held with (i) patients; (ii) medical office assistants, nurses, and staff; and (iii) family physicians; followed by (iv) a final multi-stakeholder workshop including patients, clinicians, health system leaders, and digital health stakeholders. Workshops built on prior ethnographic observations and semi-structured interviews across multiple primary care clinics. Structured ideation methods and digital collaboration tools were used to generate, cluster, and refine ideas, which were iteratively synthesized. RESULTS Participants (N=69) from each group described a shared need for convenient, timely communication outside clinical encounters, but focused on different opportunities and challenges. Patients (n) emphasized access, usability, and frustration with opaque messaging processes. Clinic staff (n) highlighted message volume, triage complexity, and workflow burden, while family physicians (n) emphasized emotional labour, tension between patient-centred care and burnout, and the invisibility of messaging work. Through the co-creation process, participants identified three interrelated solution areas: (1) an information-flow management role or software to triage, categorize, and prioritize messages; (2) electronic communication standards that clarify appropriate use, response expectations, and responsibilities; and (3) user-centred messaging platforms . In the final multi-stakeholder workshop, participants underscored that sustainable funding, provincial policy direction, and coordinated governance are prerequisites for implementation. CONCLUSIONS AM can support compassionate primary care when messaging is guided by shared standards, supported by active inbox management, and embedded in team-based, well-designed platforms. Clear roles, expectations, and enabling infrastructure may reduce clinician hesitation, expand capacity, and strengthen equitable, patient-centered care. CLINICALTRIAL Not applicable

Interprofessional team-based primary care models are pursued often as a means to improve access to primary care services and increase capacity within the h

Background and Study Aims: Multicomponent audit and feedback (A&F) initiatives pair performance reports with education to improve quality. A&F is most effective for those with greatest room for improvement, but effects depend on engagement with A&F. The study objectives were to (1) determine the proportion of potentially lower-performing endoscopists who participated in a voluntary multicomponent A&F initiative, (2) identify barriers and facilitators to endoscopist participation, and (3) describe the actions taken by endoscopists after exposure to this initiative. Participants and Methods: We conducted an explanatory sequential mixed methods study. All potentially lower-performing endoscopists practicing in Ontario in 2015 were invited to participate in a voluntary multicomponent A&F initiative; participation rates were tracked. Subsequently, endoscopists were invited to an interview to share their experience with the A&F initiative. Interviews were transcribed. Data were analyzed using directed and conventional content analyses. Results: We identified 121 potentially lower-performing endoscopists among the 885 practicing in Ontario in 2015. Only 25 endoscopists (20.7%) participated in the A&F initiative. Eleven of 121 endoscopists completed the interview. Interviewees discussed 18 facilitators and 11 barriers to participation in the A&F initiative. Some interviewees took steps to improve their colonoscopy quality, changed documentation practices to improve the accuracy of future A&F reports, or adopted potentially inappropriate documentation or patient care practices to look better on future A&F reports. Conclusions: The low participation rate, the range of drivers of endoscopist participation, and the intended and unintended effects identified suggest that A&F initiatives are complex interventions requiring careful design and evaluation.

BACKGROUND Vaccines protect not only individuals but entire communities through a phenomenon called community immunity (herd immunity). However, understanding this concept can be challenging. OBJECTIVE To evaluate the effects of a web-based, personalized avatar intervention conveying the concept of community immunity on risk perception (perceptions of the risk of infection spreading to self, family, community, vulnerable individuals) and cognitive and emotional responses across 4 vaccine-preventable disease contexts: measles, pertussis, influenza, and an unnamed “vaccine-preventable disease.” METHODS Through user-centered design process, we developed a web application, “herdimm,” showing how community immunity works. In herdimm, people personalize a virtual community by creating avatars (themselves, 2 vulnerable people in their community, and 6 others e.g., family members or co-workers.) Herdimm integrates these avatars in a 2-minute narrated animation showing how infections spread with and without the protection of community immunity. The present study was a 2x4 factorial randomized controlled trial to assess herdimm’s effects. We recruited 3883 adults via Qualtrics in Canada who could complete an online study in English or French. We pre-registered our study on Open Science Framework (https://osf.io/hkysb/). The trial ran from March 1 to July 1, 2021. We compared herdimm to no intervention (control) on primary outcome risk perception, divided into objective (accuracy) and subjective (sense of risk), and on secondary outcomes–emotions (worry, anticipated guilt), knowledge, and vaccination intentions–using analysis of variance for continuous outcomes and logistic regression for dichotomous outcomes. We conducted planned moderation analyses using participants’ scores on a validated scale of individualism and collectivism. RESULTS Overall, herdimm had desirable effects on all outcomes. People randomized to herdimm were more likely to score high on objective risk perception (58.0%, 95% confidence interval 56.0%-59.9%) compared to those assigned to the control condition (38.2%, 95% confidence interval 35.5%-40.9%). Subjective risk perception increased from a mean of 5.30 in the control group to 5.54 in the herdimm group (scale 1–7) The application also increased emotions (F(1,3875)=13.13, p<0.001), knowledge (F(1,3875)=36.37, p<0.001) and vaccination intentions (Chi-squared(1)=9.4136, p=0.002). Objective risk perception did not differ significantly by disease context, but subjective risk perception, emotions, knowledge, and vaccination intentions did. Moderation models showed that many findings were moderated by participants’ individualism and collectivism scores. Overall, whereas outcomes tended not to vary by individualism and collectivism among participants in the control condition, the positive effects of herdimm were larger among participants with more collectivist orientations and effects were sometimes negative among participants with more individualist orientations. CONCLUSIONS Prosocial messaging emphasizing collective vaccination benefits may enhance effectiveness among collectivist audiences but could backfire among individualistic individuals. CLINICALTRIAL ClinicalTrials.gov (NCT04787913) Open Science Framework (https://osf.io/hkysb/)

Background: One potential approach to eliminating or reducing health inequities for health systems is audit and feedback (A&F). A&F involves providing measurements of quality indicators to health professionals to support continuous quality improvement, and to increase clinicians’ adherence to clinical practice guidelines. In theory, A&F could help direct efforts toward equity deserving sub-groups (e.g., gender-diverse individuals or those living with low-income) by highlighting factors that may place such sub-groups at higher risk of poor health outcomes. In cases where healthcare professionals can make adjustments to their practice or advocate for mitigating supports or services, A&F – when applied broadly – could help to address some health inequities. However, it is unknown whether and how A&F interventions are currently being used to support equity-oriented quality improvement. In this study, we sought to examine the extent to which trials evaluating A&F interventions address health equity. Methods: We conducted a secondary analysis of randomized controlled trials included in the latest Cochrane systematic review on the effects of A&F on professional practice, which included articles published up to 2020. We used the PROGRESS-Plus framework to consider the extent to which variables related to equity were examined in the trials. Based on extracted data, studies were categorized as not equity-oriented, equity-informed, or equity-focused. Results: Of the 271 articles included within this analysis, 44% of trials were classified as not equity-oriented (n = 120), 35% as equity-informed (n = 95), and 21% as equity-focused (n = 56). The proportion of equity-focused and informed trials increased over the timeline assessed. Only two articles described an equity-oriented framework approach. Only three articles explicitly reported how equity was embedded in their A&F process by highlighting factors including age, gender/sex, and substance use as part of the patient data presented in their feedback. The PROGRESS-Plus factors most commonly considered in the methods or analysis of the trials were age, insurance status, place of residence, and gender/sex. Conclusions: A&F trials rarely examine or report the extent to which equity issues inform trial design, A&F processes, analyses, and/or interpretations. Our findings suggest a need for future A&F trials that test explicit approaches to incorporating equity-related interventions to address health equity by helping healthcare professionals, teams, and organizations to be more aware of inappropriate discrepancies in care.

Background: Healthcare initiatives have a larger impact if effective initiatives are spread (brought from one site to the next) or scaled (infrastructure developed to underpin and support widespread implementation), while sustaining initial benefits. Unfortunately, many initiatives, including digital health initiatives, remain confined to the pilot stage. Of those initiatives that do progress, little is known about how to plan for the equitable spread and scale of effective initiatives. There are many structural “models” of spread and scale, defined here as conceptual representations of how initiatives are organised and delivered across multiple settings (i.e., hub-and-spoke model), yet little is known about these models. Objectives: Primary Objective: To identify and describe structural models for spreading and scaling digital health initiatives. Secondary Objectives: 1. To describe the associated factors, strengths, limitations, and necessary preconditions associated with each model. 2. To describe the barriers and facilitators experienced when applying each model. 3. To explore whether and how each model prioritized equitable delivery of care. 4. To determine which pre-established types of scale (horizontal, vertical, diversification, and spontaneous) are associated with each model. Methods: A scoping review will be conducted following Joanna Briggs Institute (JBI) methodology and reported in accordance with PRISMA-ScR guidelines. The search strategy includes peer-reviewed databases for health and business, alongside grey literature sources. Eligibility criteria follow the Population-Concept-Context framework, focusing on digital health initiatives delivered in healthcare settings. Results: The review will produce a comprehensive overview of structural models for spreading and scaling digital health initiatives, including model names, descriptions, strengths, limitations, preconditions, associated barriers and facilitators of applying each model, relationships between models and established types of scale, and equity considerations. Conclusions: This novel review aims to inform practical planning of how to bring digital health initiatives to new settings and populations, to support more equitable access to these initiatives.

Background The Reproductive Mental health of Ontario Virtual Intervention Network (MOVIN) aims to improve perinatal depression care across a large Canadian health jurisdiction. It involves a web-based platform, care coordinator for personalized treatment planning, and psychiatrist to liaise with primary care clinicians, and provide direct consultation as needed. This was a pilot randomized controlled trial (RCT) of MOVIN. Methods Participants aged ≥18 years, pregnant or within 12 months postpartum and with Edinburgh Postnatal Depression Scale (EPDS) score >12 recruited from across Ontario, Canada, were randomized 1:1 to MOVIN for 24 weeks or a control condition. The primary outcome was feasibility, inclusive of recruitment, acceptability, and research protocol follow-up. Depression symptom remission was a main secondary outcome for the pilot trial. EPDS scores and remission (EPDS ≤ 12) were compared between groups. Results Of 101 participants (n = 48 MOVIN; n = 53 control), 80% completed 24-week follow-up. Participant views of MOVIN were very positive (high acceptability) and multiple opportunities for protocol adjustment in a larger future study were identified. At 24 weeks post-randomization, EPDS scores were lower in MOVIN vs. controls, with a mean difference adjusted for baseline score of −2.32 (95% Confidence Interval, CI −4.23 to −0.42). At the same time point, 75.0% of the MOVIN group vs. 51.1% of controls were in remission (chi-square=4.83, p = 0.03). Conclusions With high feasibility, including in recruitment, acceptability, and research protocol adherence, and preliminary suggestion of efficacy, the results of this study support proceeding to a large-scale RCT of MOVIN to definitively evaluate its efficacy at a larger scale.