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Research ArticleOriginal Research

Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia

Lindsay Hedden, M. Ruth Lavergne, Kimberlyn M. McGrail, Michael R. Law, Ivy L. Bourgeault, Rita McCracken and Morris L. Barer
The Annals of Family Medicine March 2019, 17 (2) 116-124; DOI: https://doi.org/10.1370/afm.2366
Lindsay Hedden
1Centre for Clinical Epidemiology and Evaluation, Research Pavilion, Vancouver General Hospital, Vancouver, British Columbia, Canada
PhD
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  • For correspondence: lindsay.hedden@ubc.ca
M. Ruth Lavergne
2Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
PhD
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Kimberlyn M. McGrail
3Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
PhD
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Michael R. Law
3Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
PhD
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Ivy L. Bourgeault
4Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
PhD
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Rita McCracken
5Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
MD, PhD
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Morris L. Barer
3Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
PhD
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  • Figure 1
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    Figure 1

    Percentage of cohort providing home, long-term care, hospital, or emergency department visits by study year.

    ED = emergency department.

  • Figure 2
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    Figure 2

    Percentage of cohort providing after-hours care and on-call support by year.

    Note: Locations included patients’ homes, long-term care facilities, emergency departments and acute-care hospitals, diagnostic facilities, mental health centers, community location (eg, school), or other.

Tables

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    Table 1

    Physician Demographics

    CharacteristicAll Study Years
    (n = 6,531)
    2011-2012 by Area (n = 5,436)
    Rural
    (n = 871)
    Urban
    (n = 1,386)
    Metropolitan
    (n = 3,179)
    Total
    (n = 5,436)
    Sex, No. (%)a
     Female2,449 (37.5)312 (35.8)499 (36.0)1,249 (40.2)2,090 (38.4)
     Male4,082 (62.5)559 (64.8)887 (64.0)1,900 (59.8)3,346 (61.6)
    Age, mean (SD), yb…47.8 (11.2)50.9 (11.3)51.0 (11.6)50.6 (11.5)
    Age-group, No. (%), yc
     <35…115 (13.2)119 (8.6)310 (9.8)544 (10.0)
     35-<45…250 (28.7)289 (20.9)619 (19.5)1,158 (21.3)
     45-<55…248 (28.5)449 (32.4)1012 (31.8)1,709 (31.4)
     55-<65…196 (22.5)369 (26.6)827 (26.0)1,392 (25.6)
     ≥65…62 (7.1)160 (11.5)411 (12.9)633 (11.6)
    Trained internationally, No. (%)d1,913 (29.9)305 (35.7)427 (31.9)808 (26.1)1,550 (29.1)
    Average compensation, mean (SD), Can$
     Fee-for-service paymentse170,569 (140,779)197,595 (138,096)195,828 (128,348)190,046 (145,446)192,730 (138,096)
     APP paymentsf31,538 (57,049)44,942 (57,637)34,280 (60,347)31,647 (59,966)34,449 (59,872)
    Location of OOO visits provided, No. (%)
     Homeg3,627 (55.5)382 (43.9)580 (41.9)904 (28.4)1,866 (34.3)
     Long-term care facilityh3,629 (55.6)489 (56.1)791 (57.1)991 (31.2)2,271 (41.8)
     Emergency departmenti3,330 (51.0)594 (68.2)618 (44.6)574 (18.1)1,786 (32.9)
     Hospital (non-emergency)j5,123 (78.4)734 (84.3)1,022 (73.7)1,640 (51.6)3,396 (62.5)
    Provided OOO visits at any location, No. (%)k5,555 (85.1)802 (92.1)1,195 (86.2)2,100 (66.1)4,097 (75.4)
    After-hours contacts, No. (%)l4,190 (64.2)637 (74.7)716 (52.8)990 (32.7)2,343 (44.7)
    On-call participation, No. (%)m2,731 (41.8)568 (65.2)501 (36.2)540 (17.0)1,609 (29.6)
    • APP = alternative payment plan; OOO = out-of-office.

    • Note: Statistical tests for differences in outcome by type of area of practice location, 2011-2012 only (P <.05).

    • ↵a χ2 = 10.4, P = .006

    • ↵b F = 29.0, P <.0001

    • ↵c χ2 = 66.3, P <.0001 χ2

    • ↵d Frequency missing: 133; χ2 = 36.85, P <.0001

    • ↵e F = 17.0, P <.0001

    • ↵f F = 1.45, P = .2353

    • ↵g χ2 = 118.9, P <.0001

    • ↵h χ2 = 354.1, P <.0001

    • ↵i χ2 = 895.2, P <.0001

    • ↵j χ2 = 412.2, P <.0001

    • ↵k χ2 = 367.3, P <.0001

    • ↵l χ2 = 523.4, P <.0001

    • ↵m χ2 = 801.3, P <.0001

    • View popup
    Table 2

    Logistic Modeling Results for the Provision of Out-of-Office Care

    CharacteristicModel 1: Rural
    OR (95% CI)
    Model 2: Urban
    OR (95% CI)
    Model 3: Metropolitan
    OR (95% CI)
    Panel A: Any out–of-office care
    Sex (female)0.29 (0.21-0.40)a0.53 (0.43-0.66)a0.65 (0.59-0.72)a
    Year0.95 (0.88-1.03)0.92 (0.87-0.96)b0.94 (0.92-0.96)a
    Age, y
     35-<450.58 (0.33-1.03)0.92 (0.66-1.28)0.95 (0.83-1.09)
     45-<550.30 (0.17-0.52)a0.72 (0.52-1.00)c1.04 (0.91-1.19)
     55-<650.22 (0.13-0.40)a0.56 (0.40-0.79)b0.78 (0.68-0.90)b
     ≥650.08 (0.04-0.16)a0.24 (0.16-0.34)a0.39 (0.33-0.46)a
    Training (international)1.64 (1.20-2.24)c0.84 (0.70-1.00)0.98 (0.90-1.07)
    Proportion APP1.20 (0.71-2.03)7.22 (4.49-11.60)a1.47 (1.24-1.74)a
    Proportion female47.47 (15.68-143.70)a27.42 (11.77-63.87)a5.46 (3.89-7.65)a
    Proportion aged ≥65 y79.89 (24.36-261.94)a114.13 (54.11-240.69)a168.95 (121.50-234.93)a
    Proportion >1 Chronic ADGs72.68 (23.17-227.99)a56.99 (24.53-132.44)a14.46 (10.73-19.50)a
    Proportion low SES0.01 (0.01-0.03)a1.84 (0.79-4.29)0.22 (0.16-0.32)a
    Panel B: Home visits
    Sex (female)0.66 (0.53-0.82)b0.66 (0.55-0.79)a0.66 (0.58-0.75)a
    Year (continuous)0.93 (0.89-0.97)b0.91 (0.88-0.94)a0.92 (0.90-0.94)a
    Age, y
     35-<451.27 (0.99-1.61)1.03 (0.83-1.29)1.30 (1.09-1.55)c
     45-<551.50 (1.16-1.94)c1.23 (0.98-1.54)1.87 (1.57-2.23)a
     55-<651.64 (1.24-2.17)b1.27 (1.00-1.62)2.01 (1.68-2.41)a
     ≥650.68 (0.46-1.01)0.67 (0.50-0.90)c1.39 (1.12-1.72)c
    Training (international)0.97 (0.81-1.16)0.95 (0.82-1.10)0.94 (0.84-1.05)
    Proportion APP0.13 (0.08-0.19)a0.24 (0.18-0.33)a0.24 (0.20-0.29)a
    Proportion female2.46 (1.11-5.48)c3.54 (1.74-7.21)b1.90 (1.26-2.86)b
    Proportion aged ≥65 y18.52 (9.41-36.46)a43.81 (25.57-75.06)a12.34 (9.03-16.87)a
    Proportion >1 chronic ADGs2.15 (0.99-4.65)0.20 (0.10-0.39)a0.66 (0.46-0.94)c
    Proportion low SES0.26 (0.13-0.51)a0.92 (0.47-1.83)0.33 (0.21-0.51)a
    Panel C: Long-term care visits
    Sex (female)0.58 (0.46-0.75)a0.69 (0.57-0.84)b0.58 (0.46-0.75)a
    Year (continuous)0.98 (0.94-1.03)0.96 (0.93-1.00)c0.98 (0.94-1.03)
    Age, y
     35-<451.16 (0.90-1.50)0.77 (0.62-0.96)c1.16 (0.90-1.50)
     45-<551.03 (0.78-1.36)0.82 (0.65-1.03)1.03 (0.78-1.36)
     55-<650.80 (0.59-1.09)0.74 (0.57-0.95)c0.80 (0.59-1.09)
     ≥650.47 (0.31-0.73)b0.42 (0.31-0.57)a0.47 (0.31-0.73)b
    Training (international)1.18 (0.95-1.45)1.16 (0.98-1.38)1.18 (0.95-1.45)
    Proportion APP0.13 (0.08-0.19)a0.27 (0.20-0.36)a0.13 (0.08-0.19)a
    Proportion female7.96 (3.34-18.94)a4.65 (2.36-9.14)a7.96 (3.34-18.94)a
    Proportion aged ≥65 y100.32 (45.47-221.36)a90.86 (51.98-158.82)a100.32 (45.47-221.36)a
    Proportion >1 chronic ADGs1.84 (0.80-4.22)0.53 (0.29-0.98)c1.84 (0.80-4.22)
    Proportion low SES0.19 (0.09-0.40)a7.46 (3.78-14.74)a0.19 (0.09-0.40)a
    Panel D: Emergency department visits
    Sex (female)0.49 (0.38-0.62)a0.53 (0.44-0.64)a0.59 (0.51-0.67)a
    Year0.95 (0.91-0.99)c0.96 (0.93-0.99)c0.93 (0.91-0.95)a
    Age, y
     35-<450.70 (0.53-0.93)c0.60 (0.48-0.75)a0.67 (0.58-0.78)a
     45-<550.56 (0.41-0.76)b0.44 (0.35-0.55)a0.58 (0.49-0.68)a
     55-<650.36 (0.26-0.50)a0.35 (0.27-0.44)a0.45 (0.38-0.54)a
     ≥650.18 (0.12-0.28)a0.20 (0.14-0.27)a0.30 (0.24-0.38)a
    Training (international)1.35 (1.08-1.68)c0.86 (0.73-1.01)0.89 (0.77-1.02)
    Proportion APP1.58 (1.10-2.29)c4.36 (3.30-5.77)a1.33 (1.14-1.57)b
    Proportion female1.98 (1.01-3.89)c0.89 (0.48-1.65)1.20 (0.85-1.69)
    Proportion aged ≥65 y0.42 (0.22-0.81)c0.59 (0.36-0.96)c0.61 (0.46-0.81)b
    Proportion >1 chronic ADGs3.79 (1.94-7.39)a4.05 (2.28-7.20)a3.93 (2.85-5.41)a
    Proportion low SES0.37 (0.20-0.67)c1.67 (0.87-3.19)0.53 (0.36-0.79)c
    Panel E: Hospital visits
    Sex (female)0.29 (0.22-0.37)0.58 (0.49-0.68)a0.67 (0.61-0.74)a
    Year (continuous)0.89 (0.84-0.94)b0.87 (0.84-0.90)a0.90 (0.88-0.92)a
    Age, y
     35-<450.73 (0.50-1.07)0.77 (0.60-0.98)c0.77 (0.67-0.87)a
     45-<550.47 (0.32-0.68)a0.56 (0.44-0.71)a0.90 (0.80-1.03)
     55-<650.31 (0.21-0.46)a0.56 (0.44-0.73)a0.64 (0.56-0.73)a
     ≥650.10 (0.06-0.17)a0.25 (0.19-0.33)a0.36 (0.31-0.42)a
    Training (international)1.05 (0.84-1.31)0.94 (0.82-1.07)1.04 (0.96-1.12)
    Proportion APP0.10 (0.07-0.15)a0.62 (0.47-0.81)b0.81 (0.69-0.95)c
    Proportion female106.55 (39.46-287.72)a38.00 (19.25-75.02)a18.77 (13.43-26.23)a
    Proportion aged ≥65 y21.90 (8.78-54.66)a12.11 (7.19-20.41)a37.81 (29.15-49.04)a
    Proportion >1 chronic ADGs260.50 (92.55-733.19)a49.72 (25.39-97.39)a14.89 (11.22-19.75)a
    Proportion low SES0.05 (0.02-0.10)a2.71 (1.42-5.17)c0.21 (0.15-0.30)a
    • ADG = aggregated diagnostic groupings; APP = alternative payment plan; OR = odds ratio; SES = socioeconomic status.

    • ↵a P <.0001

    • ↵b P <.001

    • ↵c P <.05

    • View popup
    Table 3

    Logistic Modeling Results for the Provision of After-hours Care and On-call Participation

    CharacteristicModel 1: Rural
    OR (95% CI)
    Model 2: Urban
    OR (95% CI)
    Model 3:
    Metropolitan OR (95% CI)
    Panel A: Urgent After-Hours Care
    Sex (female)0.46 (0.35-0.59)a0.54 (0.45-0.65)a0.66 (0.58-0.75)a
    Year0.94 (0.90-0.98)c0.89 (0.86-0.91)a0.87 (0.85-0.89)a
    Age, y
     35-<450.77 (0.57-1.04)0.69 (0.55-0.86)c0.8 (0.69-0.92)c
     45-<550.75 (0.55-1.04)0.56 (0.44-0.71)a1.02 (0.88-1.18)
     55-<650.42 (0.30-0.59)a0.47 (0.37-0.61)a0.94 (0.80-1.10)
     ≥650.23 (0.15-0.36)a0.3 (0.22-0.41)a0.71 (0.59-0.86)b
    Training (international)1.22 (0.97-1.55)0.98 (0.83-1.15)0.86 (0.76-0.97)c
    Proportion APP0.41 (0.29-0.58)a0.89 (0.69-1.16)0.63 (0.54-0.73)a
    Proportion female6.43 (3.15-13.14)a3.67 (2.02-6.69)a2.82 (2.03-3.91)a
    Proportion aged ≥65 y5.5 (2.69-11.22)a2.66 (.64-4.30)a3.27 (2.51-4.27)a
    Proportion >1 chronic ADGs4.44 (2.18-9.04)a2.45 (1.40-4.28)c1.86 (1.39-2.50)a
    Proportion low SES0.24 (0.13-0.46)a1.71 (0.92-3.21)0.39 (0.27-0.57)a
    Panel B: On-call rota participation
    Sex (female)0.56 (0.43-0.73)a0.59 (0.48-0.72)a0.81 (0.70-0.94)c
    Year (continuous)0.93 (0.90-0.97)b0.96 (0.93-0.98)c0.93 (0.91-0.95)a
    Age, y
     35-<450.84 (0.66-1.07)0.78 (0.65-0.94)c0.73 (0.64-0.84)a
     45-<550.77 (0.58-1.01)0.63 (0.51-0.78)a0.67 (0.58-0.79)a
     55-<650.44 (0.33-0.60)a0.47 (0.37-0.59)a0.47 (0.40-0.56)a
     ≥650.16 (0.10-0.24)a0.3 (0.22-0.40)a0.32 (0.25-0.40)a
    Training (international)1.3 (1.03-1.64)c1.33 (1.12-1.59)c1.08 (0.93-1.26)
    Proportion APP5.51 (3.76-8.06)a4.35 (3.46-5.46)a2.16 (1.89-2.46)a
    Proportion female0.75 (0.39-1.44)1.39 (0.84-2.32)1.38 (1.04-1.84)c
    Proportion aged ≥65 y1.36 (0.71-2.60)1.29 (0.83-2.02)1.35 (1.04-1.74)c
    Proportion >1 chronic ADGs2.6 (1.41-4.83)c5.54 (3.45-8.89)a3.02 (2.29-3.99)a
    Proportion low SES0.45 (0.25-0.82)c3.18 (1.80-5.64)a0.77 (0.56-1.08)
    • ADG = aggregated diagnostic groupings; APP = alternative payment plan; OR = odds ratio; SES = socioeconomic status.

    • ↵a P <.0001

    • ↵b P <.001

    • ↵c P <.05

Additional Files

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  • Supplemental Table

    Supplemental Table

    Files in this Data Supplement:

    • Supplemental data: Table - PDF file
  • The Article in Brief

    Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia

    Lindsay Hedden , and colleagues

    Background Providing care outside of office hours and in alternative (non-office) locations (such as facilities for urgent after-hours care or long-term care), helps increase access and comprehensiveness of primary care. This study examines trends in and determinants of the provision of these services in a cohort of primary care physicians in British Columbia, Canada.

    What This Study Found During a six-year period, there was a significant decline in the provision of primary care services outside of regular office hours and at alternative locations. An analysis of physician-level payments for all primary care physicians practicing in British Columbia between 2006 and 2012 (n=6,531 physicians) found that the proportion of physicians providing care in non-office locations and after hours declined significantly in rural, urban, and metropolitan practice locations. Declines ranged from five percent for long-term care visits to 22 percent for after-hours care. Female physicians and those in the oldest age category had lower odds of providing care at alternative locations or in urgent after-hours care. Rural physicians had significantly higher odds of providing care in alternative locations and after hours compared to those practicing in metropolitan areas. The authors note that these declines occurred in the context of significant financial incentives intended to promote full-service family practice.

    Implications

    • This trend in provision of services points to increasing challenges in primary care accessibility, both within Canada and elsewhere, according to the authors.
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The Annals of Family Medicine: 17 (2)
The Annals of Family Medicine: 17 (2)
Vol. 17, Issue 2
March/April 2019
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Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia
Lindsay Hedden, M. Ruth Lavergne, Kimberlyn M. McGrail, Michael R. Law, Ivy L. Bourgeault, Rita McCracken, Morris L. Barer
The Annals of Family Medicine Mar 2019, 17 (2) 116-124; DOI: 10.1370/afm.2366

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Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia
Lindsay Hedden, M. Ruth Lavergne, Kimberlyn M. McGrail, Michael R. Law, Ivy L. Bourgeault, Rita McCracken, Morris L. Barer
The Annals of Family Medicine Mar 2019, 17 (2) 116-124; DOI: 10.1370/afm.2366
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Subjects

  • Person groups:
    • Vulnerable populations
  • Other research types:
    • Health services
    • Professional practice
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