Shuaib Hafid

Background: Family physicians provide most outpatient care in patients’ last year of life, but it remains unclear how geographic distance between patients and their physicians affects continuity of care. Patients living farther from care providers may experience reduced access and more fragmented care. This study examined whether geographic proximity to a family physician is associated with relational continuity of outpatient care in the last year of life. Methods: We conducted a population‑level retrospective cohort study of adults who died in Ontario, Canada, from 2021 to 2024, using linked health administrative data. Geographic proximity was measured using quartiles of the shortest driving distance (km) between each patient’s residence and their family physician’s practice location. Relational continuity was assessed using established measures capturing the concentration of visits, dispersion of care across physicians, and the temporal regularity of visits. Associations were estimated using proportional‑odds regression models adjusted for demographic, socioeconomic, and clinical factors. Results: Among 400,499 patients, the mean age at death was 76.0 years, 52.2% were male, the mean (SD) distance to their family physician was 25.5 (92.0) km, with the highest quartile residing more than 14.2 km away from their family physician. Greater distance was associated with modestly lower relational continuity: each one-quartile increase in distance was linked to lower odds of higher continuity with the usual family physician (cOR: 0.88, 95%CI: 0.87, 0.88). Sensitivity analyses using travel time and Euclidean distance produced consistent findings. Discussion: Geographic proximity is a significant determinant of outpatient continuity near the end of life. Patients living farther from their family physicians experience more fragmented care, underscoring the need for system-level strategies to reduce geographic barriers, including improved local access to primary care and enhanced virtual-care models.

Context: Arts‐based knowledge mobilisation (ABKM) is a powerful means of interpreting and communicating health services research, centreing experiential, iterative, and reflective knowledge rooted in co‐creation. We developed a research‐to‐public‐to‐research feedback loop methodology extending beyond existing ABKM practices and our previous research‐to‐public methodology, creating a novel bidirectional epistemic process wherein meaning making occurs from research to public and from public to research. This approach produces knowledge that is rich, contextually grounded, and otherwise potentially inaccessible through conventional research. Objectives: We present a case study documenting the first application of the feedback loop, with the aim of advancing and refining the methodological framework by: sharing quantitative findings with the public and eliciting public engagement via a design installation, and levering engagement to inform subsequent qualitative research. Methods: Using the design‐driven research‐to‐public‐to‐research feedback loop, we developed a participatory design installation focused on end‐of‐life care. Within an overarching mixed‐methods sequential study, we leveraged design and health services methods to: develop design principles; select installation aims and concept; prototype, refine, and iterate the design; and conduct descriptive analysis of installation outputs. Results: Borrowing characteristics of a classic diner, the installation entitled The Terminal Diner , invited individuals to complete orders for their desired end‐of‐life healthcare experience or leave reviews drawn from lived experience with a deceased loved one's end‐of‐life journey. The installation disseminated quantitative findings and engaged the general public in contemplating and co‐creating around the subject of death—outputs of which were used to inform subsequent qualitative research, while recruiting an interested audience as research participants. Conclusion: This study presents an innovative extension of our previous research‐to‐public methodology, representing a paradigmatic shift towards creative knowledge exchange and bidirectional meaning making within health services research. Patient Public Contribution: The public's role as co‐creators is foundational to the research‐to‐public‐to‐research feedback loop methodology. Those with lived experience—bereaved caregivers and patient partners—were also embedded throughout both the research and design processes, ensuring accessibility, relevance, and emotional resonance. Blending personal knowledge and public perspective, The Terminal Diner foregrounded the essential role of patient and public contributions in co‐creating meaningful, responsive, and inclusive health services research.

Background: Continuity of care (COC) measurements that reflect relational continuity have been used as quality indicators, yet their applicability near the end of life may be limited. Modified continuity indices—UPC-Team (Usual Provider of Care) and BB-Team (Bice-Boxerman)—were developed to reflect escalating care needs and capture associations with patient-centered outcomes. Objectives: To measure associations between the modified COC indices, UPC-Team, and BB-Team during the last year of life and end-of-life (EOL) health care outcomes. Methods: Retrospective cohort study of adults who died between January 1, 2018, and December 31, 2022, with advanced chronic obstructive pulmonary disease and/or heart failure prevalent ≥2 years before death, using health administrative data from Ontario, Canada. Multivariate regressions measured associations between the indices and days spent in community during the last 30 and 14 days of life, and place of death. Results: Among 175,323 included individuals (median age at death=80; 55.4% male), the median number of community days was 23 and 10 in the last 30 and 14 days of life; 56.5% died in a health care institution. Higher UPC-Team and BB-Team scores were associated with increased odds of institutional deaths and fewer community days. Conclusions: Higher continuity scores were associated with increased odds of institutional death and fewer days spent in the community, suggesting limited utility of these modified indices in predicting favorable EOL health care outcomes. Findings highlight the need for future research to incorporate all aspects of continuity (ie, relational, informational, and management) to better capture care coordination in this context.

Background: Family physicians (FP) are critical in providing outpatient end-of-life (EOL) care, yet most continuity measures do not consider temporal changes in visits. The relative variance index (RVI), which measures visit interval variation, has not been applied to the EOL context. Aim: To measure the association between outpatient FP visit regularity & acute care use in the last month of life. Design: Retrospective cohort study using linked population-level health administrative data. FP visit regularity was measured using the RVI, calculated from outpatient visits during the last two years of life (excluding the last month). Outcomes included hospitalizations, emergency department (ED) visits in the last month of life & acute care setting deaths. Setting: Adults with cardiorespiratory conditions who died in Ontario, Canada, between 2017 & 2019. Results: Patients' (N = 151 030) median age at 2-years before death was 80, 55% were male, & had a median of 9 FP outpatient visits in the last two years of life. Higher FP RVI scores were associated with increased hospitalizations (IRR [95% CI]: 1.07 [1.05,1.10]), ED visits (1.06 [1.03, 1.08]) & acute care deaths (OR [95% CI]: 1.30 [1.26, 1.35]). Sensitivity analyses identified that RVI scores varied across different look-back periods, while sensitivity model performances remained stable when adjusting for specialist visit regularity. Conclusions: Higher outpatient FP visit regularity was associated with increased EOL acute care use, despite low visit regularity during the last two years of life. However, the RVI's sensitivity to observation period lengths limits its utility as an EOL care-quality indicator.

Objectives: To develop and describe the performance of two modified relational continuity of care indices for adults with organ failure nearing the end of life, addressing limitations of existing indices that penalise multispecialty physician care. Design: Population-based retrospective study. Setting: Linked routinely collected health administrative databases in Ontario, Canada. Participants: Adults aged ≥19 years who died between 1 January 2018 and 31 December 2022, with kidney failure on dialysis, advanced chronic obstructive pulmonary disease and/or heart failure. Primary and secondary outcome measures: We adapted the Usual Provider of Care (UPC) and Bice-Boxerman Continuity of Care (BB) indices to avoid penalising multispecialty physician care, resulting in the UPC-Team and BB-Team indices. Indices were calculated for the last 2 years of life (truncating the last month) using outpatient physician visits. Correlation coefficients were produced between the unmodified indices, the modified indices and outpatient healthcare utilisation. Results: The cohort included 199 035 individuals, with a median age of 79 years (P25, P75: 70, 86); 55.5% were male. The median modified continuity scores were higher than the unmodified scores (UPC=0.44 (0.32, 0.61), UPC-Team=0.79 (0.67, 0.89); BB=0.24 (0.15, 0.40), BB-Team=0.75 (0.52, 0.95)). The modified indices shared weaker correlations with outpatient healthcare use (ie, number of visits or specialists involved), compared with the unmodified indices. Conclusions: The UPC-Team and BB-Team indices do not penalise patients for receiving multispecialty physician care, compared with the unmodified UPC and BB indices. The modified indices demonstrated more consistency in measuring continuity across patients with varying degrees of medical complexity and less correlation with outpatient healthcare use. Use of these indices is suggested to capture different aspects of relational continuity in the context of multispecialty care nearing the end of life.

Objectives: To compare primary care for depression among patients detected in the first 21 months of the SARS-CoV-2 pandemic to patients detected pre-pandemic, and examine whether depression care was associated with patient characteristics. Design: Retrospective pre–post study using de-identified data from electronic medical record data from the Canadian Primary Care Sentinel Surveillance Network (CPCSSN). Setting: Primary care clinics enrolled in CPCSSN from 1 January 2018 to 31 December 2021. Population: Patients with a valid CPCSSN case definition of depression detected between 01 January 2018 and 31 December 2021 were included in the cohort and categorised by detection date (pre-pandemic or during Canadian pandemic waves). Outcome measures: Primary care encounters, psychotropic prescriptions and selective serotonin reuptake inhibitor (SSRI) prescriptions were observed at 3 and 12 months post-detection. Multivariable regression evaluated associations between patients’ depression detection timing and depression care, adjusting for age, sex, rurality, neighbourhood deprivation quintile, province, number of observable comorbidities and pre-detection psychotropic use. Results: 91 453 patients with depression were identified, of whom 53% were detected pre-pandemic. Patients detected during the pandemic were younger and less comorbid than those detected pre-pandemic. Proportions of patients with any encounter, psychotropic prescriptions and SSRI prescriptions were higher for patients detected during every pandemic wave compared with patients detected pre-pandemic. The adjusted incidence rate ratios (aIRRs) of number of encounters (aIRR=1.15; 95% CI 1.13 to 1.17), psychotropics (aIRR=1.11, 95% CI 1.09 to 1.13) and SSRIs prescribed (aIRR=1.12; 95% CI 1.10 to 1.15) within 3 months of detection were higher among patients detected during the first pandemic wave compared with those detected pre-pandemic. Socio-demographic characteristics had weaker associations with outcomes compared with timing of detection. Results were similar within 12 months of detection. Conclusion: Overall, primary care for depression was maintained during the pandemic despite challenging circumstances. Increases in paediatric encounter rates and increased prescribing in younger adults warrant further investigation to understand the factors driving these patterns. Trial registration number: ClinicalTrials.gov NCT05813652 .

Background: Family physicians play an important role in coordinating care for medically complex patients, especially during the end-of-life (EOL) period. While continuity of care (COC) is a routinely measured care quality indicator, the influence of geographic proximity to family physicians on EOL COC has not been studied in the Canadian context. Existing research has focused on rurality indicators instead of individual-level proximity measures. Objectives: This study objectives are to: (1) measure the association between patients’ geographic proximity to their family physician and COC during the patients’ last year of life; and (2) measure the association between geographic proximity and the number of days spent in the community and palliative homecare services referral in the last year of life, and place of death. Methods: We will conduct a population-level retrospective cohort study using linked health administrative data from ICES in Ontario, Canada, of adults who died between January 1, 2021, and December 31, 2024. Geographic proximity to the rostered family physician will be calculated in the shortest travel distance and time from the patient’s residence to the physicians primary practice location, considering road, transit, and walking infrastructure. COC will be measured using three indices: Usual Provider of Care, Modified Bice-Boxerman, and Relative Variance indices, based on outpatient visits in the last year of life. EOL outcomes will include days spent in the community, referral to palliative home care, and place of death. Multivariate regression will measure associations between proximity and outcomes, adjusting for relevant patient-level characteristics. Expected outcomes: We hypothesize that patients living closer to their family physician will experience higher COC and improved healthcare outcomes at the end of life. Findings have the potential to inform health policy and planning aimed at improving equitable geographic access to family medicine during the late stages of life.

Background: In Canada, primary care manages most diabetes care. The COVID-19 pandemic disrupted primary care, reducing access to care and monitoring. Objectives: We aim to describe changes in diabetes monitoring during the first 21 months of the pandemic, patients’ experiences with these changes, and impact on HbA1c and blood pressure (BP) control. Methods: We conducted a two-phase mixed methods study: (i) A retrospective pre-post cohort study using de-identified electronic medical record data to compare HbA1c and BP measurement frequency and results in diabetic patients prepandemic (22 June 2018 to 12 March 2020) and during the pandemic (13 March 2020 to 3 December 2021); (ii) A qualitative descriptive analysis using semistructured interviews to understand patient experiences navigating diabetes care during the pandemic. Results: The cohort included 84 617 patients with validated diabetes case definition. Proportion of patients with <1 HbA1c test increased by 10% during the pandemic. For those with ≥1 test, mean HbA1c remained unchanged [mean (SD) HbA1cPre: 7.2 (1.3); HbA1cDuring: 7.2 (1.3); P = .51]. Proportion of patients with <1 BP measurement increased by 23%. For those with ≥1 measurement, mean BP remained clinically similar [mean (SD) sBPPre: 131.8 (13.7); sBPDuring: 132.9 (15.2); P < .01. Mean dBPPre: 74.9 (8.6); dBPDuring: 75.1 (9.1); P = .63]. Nineteen participants were interviewed, discussing virtual care, challenges with self-monitoring, and self-management strategies. Conclusions: Mean HbA1c and BP values remained clinically stable during the pandemic despite reductions in monitoring frequency, likely due to continuity of care and patient self-management. Future research should evaluate a de-intensified frequency of diabetes monitoring and address care gaps.

Background: People with heart failure (HF) are treated by multiple physician specialties as they approach the end of life (EOL). Patterns of physician involvement and health outcomes are not well understood. Elucidation of care patterns for this population may identify opportunities to minimize fragmentation and improve EOL continuity. This study describes categories of outpatient physician care patterns in the last year of life for people with HF and how EOL acute care use varies by category. Methods and Results: We conducted a retrospective cohort study of 65 625 adults with HF (median age, 83 [interquartile range, 74–89] years; 44.2% women; 86.9% urban residents) who died between 2017 and 2019 in Ontario, Canada, using health administrative data. Individuals were categorized according to different combinations of outpatient care providers in the last year of life: (1) primary care, palliative care, and relevant specialties (25.9%); (2) primary care and palliative care (5.4%); (3) primary care and relevant specialties (40.8%); (4) primary care (18.6%); and (5) specialty care (9.3%). Primary care physicians maintained involvement throughout the last year of life, while the proportion of monthly palliative care encounters increased near death. People who had palliative care involvement had the lowest rates of hospitalization and acute care deaths compared with those without palliative care involvement. Conclusions: People with HF receive most outpatient care from primary care physicians and palliative care physicians at the EOL. Multiple specialties are involved, highlighting the patients' medical complexity. Findings may help inform ways to measure relational continuity at the EOL for patients with HF.

Background: The COVID@Home Clinical Care Pathway (the Pathway) was developed and implemented as an evidence-based remote monitoring clinical care pathway for the integrated management of coronavirus disease 2019 (COVID-19) in the province of Ontario, Canada. We examine its effectiveness and rapid large-scale implementation. Methods: Using a prospective longitudinal study design, we used electronic medical record clinical data, provider and patient surveys, web analytics, healthcare and provincial utilization, and government holdings data to evaluate reach, effectiveness, adoption, implementation, and maintenance outcomes, including patient mortality and health equity. Results: The Pathway was widely accessed (19 474 Ontario unique users), contributed 28 816 oxygen saturation monitors, and achieved coverage across income levels and geography. Two-thirds of patients had > 1 encounter, monitored for a median of 4 days (Range: 1–57). Fifty percent of patients had > 1 chronic condition. Patients receiving Pathway care were less likely to die by 0.44% (20/4556), two times lower compared to the total mortality of a population-based representative patient cohort over a parallel time period in Ontario of 0.86% (1820/212 326, P = .0023). Patients were very satisfied with their care, and felt care was accessible, safe, and clear. Providers were very satisfied with the Pathway resources and reported strengthened relationships across the health system. Conclusions: Primary care (PC) rapidly implemented a clinical care pathway during the COVID-19 crisis. The Pathway demonstrated the beneficial role and effectiveness of PC when patients are provided with timely, accessible, and comprehensive care. Public health responses should explicitly collaborate with PC to address population health.