Summary

Primary care reform has been a major policy initiative across a number of Canadian provinces with the goal of creating a “Medical Home” model for all citizens including children and youth. While differences in the organization of care exist both across and within these jurisdictions, goals are care which is accessible, continuous, comprehensive, compassionate, coordinated, family-centered and culturally effective. This module has attempted to summarize how the Medical Home is organized for children and youth and what is known about how these goals are being met. However, what became clear during the course of this project is that there are limited data, especially on measures of effective care, available for most provinces and territories. Standard measures of childhood immunization coverage, arguably the most cost-effective intervention in primary care for children, are not readily available for all provinces/territories. While hospitalization data are of high quality and readily available through the Canadian Institute for Health Information, there are important limitations to how well these track primary care quality as outlined in those sections. Finally, the variation in care delivery within any province or territory means that provincial-level measures may obscure important variations at a more local level.

However, our analyses of national survey data do suggest a few conclusions around access to primary care physicians. These include differences across provinces, notably low levels of reported access in Quebec and the Territories and generally the highest levels in Ontario and the Maritime provinces. Further work should continue to track access to care with more recent data. Our related work suggests that Quebec has put a number of financial incentives in place to improve primary care access for mothers and young children.¹ Access in the Territories is difficult to assess as the national survey questions asked about physicians whereas many citizens of the Territories receive their care from nurse practitioners. National surveys will need to adapt to the more complex ecosystem of primary care. While the differences in access to care by socio-economic status were generally small, the older data from the 2006 Aboriginal Peoples Survey indicated approximately 11% of both Inuit and off-reserve First Nations children and youth had difficulty accessing healthcare. However, it is important to note that these survey indicators, as well as most of the other data that we report do not include First Nations children living on reserves and the systems of care that are provided by the federal government.

Our analyses of indicators of the effectiveness of primary care yielded varying results. Overall, in comparison to similar US data, rates of acute ambulatory care sensitive admissions are very similar with the exception of gastroenteritis and dehydration. The higher rates in Canada are likely related to a less consistent approach to funding of the rotavirus vaccine, for which there is strong evidence of cost-effectiveness. This variable funding may explain in part the inter-provincial variation in these admissions. All indicators showed ambulatory care sensitive condition admissions to be most common in the lowest income children and least common in the highest income ones, although there was variation in the extent and patterns of the socio-economic gradients across the provinces.

Complementary to findings on the “Medical Home’, we investigated the “Dental Home.” Our findings suggest larger differences in access to dental rather than primary care by socio-economic status and important differences in access as well as outcomes in the Territories. This is despite the governments of Nunavut and the Northwest Territories providing complete coverage for registered First Nations and Inuit children and most provinces having special dental programs that target low income children. This speaks to the need to for increased attention to equity issues around access to both prevention and treatment services.

We included other healthcare services and screening interventions relevant to child and youth health that while not always delivered within primary care, could be considered a “primary” healthcare service. For these, we reviewed the evidence base for their effectiveness and described public funding across provinces and territories as a proxy for access. We could not find any population-based data on actual use of services across these jurisdictions. For some screening services, such as newborn hearing, the evidence both for the effectiveness and cost effectiveness is so strong, that the lack of programs in some provinces needs to be addressed. For other services, such as universal developmental screening, there isn’t strong evidence to guide program development and for vision screening there are so many different programs across the provinces that without good outcomes data on whether there are children with visual impairment who are falling through the cracks, it is difficult to draw conclusions around the current state. If anything, the natural experiment of different approaches across provinces could be seen as an opportunity for a pragmatic evaluation to guide further program and policy development. However, this will require a Pan-Canadian data strategy to facilitate such evaluation.  Finally, the area of universal funding and access to medications for children is one where there has been little research but some evidence of potential harm without universal access. Policy change in this area will be important but likely part of a larger national conversation around pharmacare.² The Canadian Paediatric Society has recently added paediatric drugs and therapeutics to its list of strategic priorities.

¹P Li, S Gandhi, A Chien, M Barwick , E Cohen, M Brownell, S Glazer, J J Reisman, , A Guttmann Primary care for children and youth in Canada in the context of reform and incentives, submitted manuscript.

²Morgan, S.G., D. Martin, MA Gagnon, B Mintzes, J.R. Daw, and J. Lexchin. (2015) Pharmacare 2020: The future of drug coverage in Canada. Vancouver, Pharmaceutical Policy Research Collaboration, University of British Columbia.