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Not your average PUPPY: Research to support better primary care during a pandemic

Posted by Canadian Institutes of Health Research on November 16, 2020 in News

If you ask a Canadian about our health care system, you'll likely get an opinion—and a story.

"Countless surveys have shown that Canadians value our universal health care system and that they see it as a public good, as something we should all care about," explains Dr. Emily Gard Marshall, an Associate Professor in the Department of Family Medicine at Dalhousie University. "But that doesn't mean it's perfect exactly as it is. We also recognize that there are challenges, there are differences across provinces and territories, and there are things that we would like to improve."

She notes, for example, that many Canadians know someone who does not have access to a family practice, where they'd like to have a family physician or nurse practitioner to follow their care. The issue has become so widespread that seven provinces have instituted centralized wait-lists for people who are "unattached", a term used to describe patients without regular primary care providers. The provinces use different strategies to manage those wait-lists—for everything from prioritizing patients based on greatest need to offering financial incentives to care providers—but it's not clear which of those approaches is most effective.

"That's where research comes in," says Dr. Marshall. "We need research evidence to make sure that the decisions we make about the health care system are the best ones. The system isn't static. We can change it. But there's a lot to consider as we try to make all these provincial systems and levels of care as effective as possible, so the research helps us figure out what the best mix of approaches could be."  

Earlier this year, Dr. Marshall was set to tackle some of the much needed research on those primary care wait-lists. But then—as was the case with so many things in our lives—the COVID-19 pandemic arrived and changed everything.

"We were on the cusp of interviewing a bunch of stakeholders about making improvements to primary care, but it wouldn't have made sense to do that anymore—at least not without also asking about how the pandemic has changed things for them," she recalls. "So, we had to take a step back to think about how we could redesign the study within a new COVID-19 reality, and then we also wanted to take a hard look at the changes the pandemic brought to primary care. We had the people and the enthusiasm in place, but we still had to pivot quite quickly to address a number of new things."

This pivot led Dr. Marshall and her team to launch a new year-long project called the PUPPY Study (also known as Problems Coordinating and Accessing Primary Care for Attached and Unattached Patients in a Pandemic Year), which will focus on Nova Scotia, Ontario, and Quebec. Through a series of interviews and surveys, the team will gather information about the different experiences of patients, primary care providers (including family doctors, nurse practitioners, and pharmacists), and policy makers.

"There were a lot of drastic changes that happened very rapidly across the primary care landscape this year," explains Dr. Marshall. "Virtual doctor appointments suddenly became available, but many walk-in clinics closed or drastically changed triage practices and pharmacies had to limit patient interactions to adhere to public health safety measures. This means that there were changes to the way people could access care and changes to the way people could provide care, so we want to hear about that. What worked? What didn't? And what might be worth keeping if we tweak it just a little bit?" 

The patient experience is also a central feature of the research. Patient partners are included as full members of the research team for the PUPPY Study, which means they discuss approaches for patient recruitment, provide feedback on draft surveys and interview guides, co-author papers, and ultimately help share the research findings in ways that will be meaningful for different audiences.

"As someone who has been both an attached and unattached patient, as well as a health care advocate for many family members, I feel like I have seen many sides of the health care system," says Ms. Sarah Peddle, one of the patient partners for the study and Manager of the Service Learning Program in Dalhousie Medical School's Global Health Office. "I have friends and family members who have needed care this year, and I have witnessed firsthand the stress and anxiety that has been added to accessing that care because of COVID-19. I see the potential for this research to shape health policy and practice, so I'm glad that it will include the patient voice—in part through stories like mine."

Ms. Ana Correa, who is also a patient partner on the team, agrees. "I think involving patients can take research in a new direction," she says. "Their voices have to matter to the research in order to make that research matter to them."

Bringing all of these perspectives together will help the team understand gaps in primary care access and the associated experiences, and they will supplement that information by looking at provincial administrative billing data and the primary care wait-lists in each participating province. The two data sets are actually compatible in those provinces, so the team will be able to look at the trajectories of attached and unattached patients to see how they accessed care before the pandemic, during the pandemic restrictions, and after the restrictions are lifted.

"With unattached patients, for example, how did they handle getting their prescriptions filled during the height of the pandemic restrictions? Did they go without? Did they end up visiting an emergency department? We will be able to trace these details in the data," Dr. Marshall explains. "We're looking at unattached and attached patients who have specific conditions, as well. The data will help us get a sense of how people living with diabetes, mental health issues, or congestive heart failure, for example, have accessed care throughout the pandemic period."

Finally, the team plans to conduct a policy scan to see how each province enacted new policies to meet the needs of its citizens. Combining this scan with the interviews, surveys, and provincial data will give the PUPPY Study team an incredibly comprehensive overview of the state of primary care in each participating province. With this rich data in hand, the team hopes to find ways to strengthen primary care during and beyond the COVID-19 pandemic.

"It's complex, but it's exciting," says Dr. Marshall. "Everyone involved genuinely and wholeheartedly wants to make things better, and I love that research gives us a way to bring stakeholders together to do that."