Category: PSI Spotlights

“This was my first successful grant as a new investigator, so it really jumpstarted my research career.… Getting that first grant and being able to do this research led to other opportunities, and I’m very grateful to PSI Foundation for their support.” – Dr. Selina Liu, Western University, Lawson Health Research Institute and St. Joseph’s Health Care, London, Ontario

Recent estimates from Diabetes Canada indicate that 5.7 million Canadians are living with diabetes. Many of these people do or will experience eye damage, called diabetic retinopathy, which is a major cause of vision loss. As a result, practice guidelines recommend that people with diabetes undergo screening for diabetic retinopathy once a year.

People with diabetes have their eye exams covered through OHIP, but they may face other barriers to getting an exam, such as simply remembering to make the appointment, taking additional time off work for the exam, and taking eye drops that make it difficult to see and drive for some time after the exam.

“Prior research showed that about 50% of people with diabetes in Ontario weren’t having their eyes checked regularly, and that’s a major problem. We know that diabetic retinopathy is the main cause of blindness in working-age adults in Canada and has a drastic effect on quality of life,” says Dr. Selina Liu, Assistant Professor, Department of Medicine at Western University, Associate Scientist at Lawson Health Research Institute and Endocrinologist, Centre for Diabetes, Endocrinology and Metabolism at St. Joseph’s Health Care London, Ontario. “Vision loss due to diabetic retinopathy is preventable through early detection and treatment. Developing strategies to improve retinopathy screening seemed to be a major area that deserved further research.”

One strategy uses a new technology to potentially make screening more accessible.

Non-mydriatic ultra-widefield (UWF) retinal imaging, which uses a specialized camera to take a wide-angle image of the retina, offers a few advantages over the usual screening methods used by optometrists. It only takes a few minutes and does not require eye drops, and images can be taken by trained staff and provided to an ophthalmologist to be read later. For these reasons, UWF imaging has potential to be incorporated into the regular diabetes clinic visits.

“What if we could integrate screening into a diabetes clinic visit?” says Dr. Liu. “If we could screen for retinopathy on the same day and in the same location where our patients are already coming for diabetes care, some of the barriers to getting screening done would be taken away.”

In 2016, Dr. Liu and a multidisciplinary team received funding from PSI Foundation for a randomized clinical trial called Clearsight to examine whether UWF imaging could detect more patients with eye disease that needed closer monitoring or treatment compared to usual screening.

“As a new investigator, embarking on a full 740-person randomized controlled trial was a bit daunting at first,” she says.  “But having funding from PSI Foundation was essential for this trial and gave me confidence as I went down this path.”

The research team recruited 740 patients with diabetes to participate in the trial, with half being screened through UWF imaging and half receiving usual care. The trial mimicked how screening is or could be done in a real-world setting: the patients enrolled in the UWF group were offered screening at the same clinic visit with the images read by an ophthalmologist later, while those receiving usual screening were responsible for making their own optometrist appointment. Patients in the UWF group were also still advised to visit their optometrist for usual screening, as per standard of care.

The team found that on-site screening significantly increased detection of diabetic eye disease that required either increased surveillance (more than annually) or referral to an ophthalmologist for further assessment. They also found that on-site screening resulted in significantly higher screening adherence than usual screening. The study did not look at patients’ vision outcomes as a result of the screening (since a much larger and longer trial would be required), but they expect that if more patients who require closer monitoring or ophthalmology referral are identified early, the rates of vision-threatening diabetic eye disease would ultimately decrease.

While the results were promising, screening with UWF imaging does come with significant costs, and Dr. Liu plans to complete a cost-effectiveness analysis of the imaging compared to usual screening. She is also undertaking research on other approaches to identify patients at risk of diabetic eye disease, including the use of artificial intelligence to read UWF images and the use of blood biomarkers for retinopathy screening.

Ultimately, she hopes that the Clearsight trial and other related work will provide evidence that can be incorporated into diabetes clinical practice guidelines to improve screening and vision care for people with diabetes, in Canada and worldwide.

“We hope that having this study will provide the high-quality evidence that this approach can improve retinopathy screening and detection rates, and perhaps it could be implemented in clinical practice guidelines so that the diabetes clinic could be a one-stop shop for diabetes care, including eyes,” says Dr. Liu. “We have more work to do to get there, but we hope our work can influence changes to health policy and clinical practice in how screening for diabetic eye disease in Canada is performed.”

First Nations, Inuit and Métis people in Canada have poorer health outcomes than non-Indigenous people due to historical and ongoing systems of discrimination, and these disparities can start in childhood, with Inuit children experiencing higher rates of respiratory infections, iron deficiency anemia, and other conditions.

A team of researchers in Ottawa – home to the largest Inuit population in Canada outside of the traditional Inuit homeland of Inuit Nunangat – recently completed a study funded by the PSI Foundation that aims to arm caregivers of Inuit children with the knowledge they want and need to improve child health outcomes.

“Our colonial history, historical and ongoing systems of discrimination, and the unique challenges that Inuit people face when they have to move from the north to an urban Ottawa community result in a lot of cultural dissonance and tensions that are challenging for this community,” says Dr. Brian Hummel, currently a pediatric infectious disease fellow at the Children’s Hospital of Eastern Ontario (CHEO). “We wanted to better understand what those challenges are and what can be done to help support child health for this community.”

Recognizing the need for better knowledge sharing around child health, Dr. Hummel and co-investigator Dr. Daniel Bierstone, along with supervisor Dr. Radha Jetty, the physician lead for Inuit Child Health and the Nunavut Program at CHEO, partnered with the Inuuqatigiit Centre for Inuit Children, Youth and Families to better understand the experiences of caregivers of Inuit children related to child health.

Supported by a PSI Foundation Resident Research Grant, Dr. Hummel and the team conducted focus groups with 24 caregivers of Inuit children. In the focus groups, they discussed where caregivers go for child health knowledge, the topics they felt they needed more knowledge about, and how they prefer to learn about child health.

Dr. Hummel says that the qualitative approach to the study, as opposed to conducting a survey or other quantitative method, was essential to collecting data that would directly represent the voices of the caregivers.

“This approach allowed us to collect data that was more rich, raw and real, and it allowed Indigenous voices to be more directly represented in the research,” he says. “As non-Indigenous researchers, we viewed our role as being vessels to bring forward Indigenous insights, very much in the spirit of ‘never about us without us.’”

Knowledge-sharing programs should include both Indigenous and Western ways of knowing

In the focus groups, caregivers said they needed more support and information about parenting and development, adolescent mental and sexual health, common childhood illnesses, infant care and nutrition – topics where there can be tension between Indigenous and non-Indigenous ways of knowing.

Caregivers also said that they often turned to their families, friends, community members and Indigenous health services for child health information, largely because of previous negative experiences with Western medical institutions and lack of trust of these institutions.

While caregivers strongly preferred in-person knowledge-sharing sessions for their supportive environment and opportunity to build community, importantly, they identified that involving both Inuit Elders and health care providers in these sessions was important.

“One of the interesting themes that came out in the focus groups was this idea of synergy between Indigenous ways of knowing and Western medicine ways of knowing, and how those two things don’t need to compete with each other but can instead work synergistically together to support Inuit child health,” says Dr. Hummel. “There are things that are valued more in the cultural understandings of health, such as nutrition, child-rearing and development. But there were also things they valued about western medicine approaches.”

“Ultimately knowledge-sharing programs should include both Inuit and Western knowledge and traditions, while empowering families to engage in Indigenous child-rearing practices,” he adds.

The study is the first of its kind to explore caregivers’ perspectives on urban Inuit child health knowledge, and it has been presented at national pediatric and Indigenous health conferences and published in the peer-reviewed journal International Journal of Circumpolar Health. Dr. Hummel and the research team hope that these findings can now be used to help develop programs and other knowledge-sharing initiatives to benefit caregivers and ultimately improve Inuit children’s health.

As Dr. Hummel finishes his fellowship and moves to the next stage of his career, he plans to continue being involved in research and education on top of his clinical practice. And he says the PSI Resident Research Award has helped prepare him by giving him a rare opportunity to lead a larger project.

“As residents, there aren’t a lot of funding opportunities for these kinds of larger projects,” he says. “PSI funding is really important for those of us who want to do larger projects to have these opportunities.”

A clinical trial funded by the PSI Foundation is changing the management of a rare genetic condition found in the Amish communities of southwestern Ontario. A research team led by Dr. Victoria Siu, a medical geneticist at London Health Science Centre and associate professor at Western University’s Schulich School of Medicine and Dentistry, found that histidine supplementation was effective in reducing the complications in children with the condition.

“The positive effects of histidine supplementation in patients with this condition open up the possibility of an inexpensive treatment to prevent loss of vision and hearing,” says Dr. Siu. “It’s very difficult to find funding for a clinical trial of a natural health product like histidine. We couldn’t have done this trial without PSI funding, and I’m very grateful.”

Dr. Siu began her career in London, Ontario, which is close to the majority of Ontario’s Amish and Mennonite communities, and she often sees patients from these communities as part of her practice.

In the early 2000s, she and her colleague, Dr. Tony Rupar, received funding from the PSI Foundation to lay the groundwork for a newborn and early childhood screening program in the Amish and Mennonite communities that would test for four treatable genetic disorders. In addition to helping identify children who could benefit from early treatment, the newborn screening program also helped Dr. Siu and other researchers examine the genetic conditions that affect this community.

“In a way, that grant was really seed funding for many other new discoveries,” she says. “The community, the public health nurses and midwives, started letting us know about other children with medical conditions, which enabled us to identify several new genes that caused some of these disorders in the community.”

More than 15 years after her first PSI grant, Dr. Siu received another PSI grant to examine a potential treatment for one such genetic disorder ­– HARS syndrome.

HARS syndrome is an extremely rare autosomal recessive genetic disorder, but it is much more common in the Amish community in southwestern Ontario where approximately one in five individuals in in the Amish community is a carrier of the gene and approximately one in 100 babies in the community are affected.

The HARS gene codes for an enzyme that links histidine to transfer RNA (tRNA), a process essential for protein translation. When this gene is mutated, the enzyme’s function is altered.

Affected children are often somewhat smaller than unaffected children, but are otherwise healthy and develop appropriately; however, when the child is infected with even common childhood viruses such as influenza or RSV, they often need hospitalization and can develop acute respiratory distress syndrome (ARDS). Following infection, their balance becomes unsteady, and their hearing and vision deteriorates. Historically, the mortality rate for affected children has been quite high due to ARDS. Children who do survive often need cochlear implants for their hearing and continue to lose their vision.

Children in histidine study stayed healthy through COVID-19 pandemic

With PSI funding, Dr. Siu and her research team examined 14 children with HARS ranging from one to 17 years old who were given a daily histidine supplement to determine whether it could be used to keep these children healthy and prevent further hearing and vision loss. Histidine is a relatively inexpensive supplement, costing around $100 a month for the oldest participants and much less for the younger children taking a lower dose.

Over the three-year study, the researchers monitored the children’s growth and overall health and periodically assessed the children’s vision and hearing.

The research team found that none of the children experienced any significant deterioration in their vision or hearing over the course of the study. And, importantly, the children also maintained overall good health during the study period, which took place during the COVID-19 pandemic.

The children were not vaccinated against COVID-19 and researchers found antibody levels in the blood indicating that they had been infected with SARS-CoV-2, yet none of the children were hospitalized.

“We saw that the children stayed healthy through this study period, and that was quite incredible to us because it was during the pandemic,” says Dr. Siu. “When these children had influenza, rhinovirus, RSV or any of those common viral illnesses, they have historically been hospitalized in the intensive care unit and needed to be ventilated, and some of them have died. We felt that for these children to stay healthy through COVID was really quite remarkable.”

With the study apparently showing the benefit of histidine supplementation in these children, management of HARS syndrome has already changed. The children are continuing to receive daily histidine supplementation and, when they are hospitalized with illness, they receive extra histidine and anti-inflammatory drugs and reduced fluids, all of which seem to reduce the risk of ARDS.

“Most clinical trials have big sponsors, and there’s really no place for a small trial like this. We also had additional costs for transportation and medical appointments because of the nature of working with this community,” says Dr. Siu. “The funding from PSI was very important and much appreciated as it  allowed us to do work that will make a difference for these children.”

“Learner-directed funding is critical to build skills in team leadership and direction and to create unique projects that tackle issues that learners themselves experience. I’m grateful to PSI for having the foresight to develop the next generation of scientists and education scientists in a deliberate way through the Resident Research Grants.” – Dr. Tavis Apramian

As both a learner and a researcher examining medical education, Dr. Tavis Apramian says he sometime felt as though he was navigating two worlds. During his residency in family medicine at McMaster University, he led research investigating how family medicine residents learn how to advance care planning conversations, with the goal of eventually improving education and training around this skill set.

“Studying medical education while acting as a learner is a little bit like living two lives at once,” says Dr. Apramian, now a palliative care fellow at the University of Toronto. “It helps me put some of the challenges I face into a broader systemic perspective, but it can also be challenging when I know that more evidence-based educational practices are available, but they might not be applied in a given situation.”

Dr. Apramian has long been interested in learning patient and physician stories and using storytelling to improve patient care. He studied English and biology at Carleton University and Narrative Medicine at Columbia University. He then focused his career on research and medicine, completing a PhD and MD at Western University.

When Dr. Apramian started his family medicine residency at McMaster University in 2019, he wanted to undertake research on medical education to try to affect positive change in how medicine is taught. He was specifically interested in how learners gain skills in advance care planning conversations, which require a complex skill set and are not typically taught in medical school.

Advance care planning conversations are often iterative conversations meant to help patients, typically with serious illness, understand the course of their disease, consider their values as they relate health care and make decisions about their future care.

Research has shown that fewer than 40% of family doctors regularly have these conversations with their patients with life-limiting illness, which suggests that residents may have limited opportunities to observe or participate in these conversations during a family medicine residency.

In 2020, Dr. Apramian received a PSI Resident Research Grant to investigate how family medicine residents learn to approach advance care planning. Working with Dr. Erin Gallagher as mentor and Dr. Michelle Howard as senior author, Dr. Apramian and the research team interviewed residents about their experiences to better understand if and how residents are learning these skills during their training and the factors that shape how they are taught these skills.

Residents face unique barriers to learning advanced care planning skills

Previous research has found that advance care planning conversations are challenging even for experienced physicians. These conversations are time-consuming and may take place over several appointments, and physicians often lack the time or flexibility in their schedules or access to clinical records to have these conversations effectively. In addition, physicians and patients often have cultural aversions to conversations about death and dying.

In the interviews led by Dr. Apramian’s team, residents described facing these same barriers, plus some specific to residency: lack of authority to shape clinic flow and schedules, short-term relationships with patients, navigating their preceptors’ clinical priorities, lack of encouragement from their preceptors, and limited opportunities to practice.

“The interviews demonstrated that the preferences and principles of family medicine preceptors affected how much time, energy, willingness and supervision that family medicine residents had to practice this skill set,” says Dr. Apramian. “These are really complex skills that require iterative and adaptive conversations. There’s certainly no training on advance care planning in medical schools, and little didactic or deliberate practice in the workplace once medical students reach residency, which is concerning.”

Importantly, the research team noted that, without this training in the primary care setting, many residents shifted to learning related skills during emergency department or internal medicine rotations through practising goals of care conversations, which are focused on an immediate clinical decision in a time of acute crisis.

“You can’t have conversations about values when patients are scared and uncomfortable and with physicians they don’t know or trust,” says Dr. Apramian. “I hope that what we found in our study will lead to more deliberate thinking about how to help residents practice the skill of building illness understanding and eliciting patients’ values in a family medicine setting.”

With the team now publishing and presenting the results, Dr. Apramian hopes that more awareness of the gaps in education will lead to changes in training that dedicate more time to practising this skill to increase future physicians’ comfort in leading these conversations and ultimately helping patients experience health care more aligned with their values. In his fellowship at the University of Toronto, he is planning to continue this research to examine advanced care planning in other clinical domains, including pain management.

Dr. Apramian says that the funding from PSI Foundation was critical to his research and has helped him to build a research program focused on medical education and the dynamics between learners and their supervisors.

“Having my own funding allowed me to hire team members to move the research forward while doing my residency,” he says. “Getting this grant allowed the research to continue and improve over the course of my residency in a way that wouldn’t have otherwise been possible.”

Dr. Laureen Hachem has long been interested in neurosurgery and the potential of endogenous stem cells to repair spinal cord injuries. She started her research career in her last year of high school, volunteering in the lab of Dr. Charles Tator, a researcher and neurosurgeon at Toronto Western Hospital, and she continued working in Dr. Tator’s lab throughout her undergraduate and medical school education at the University of Toronto.

In 2017, she graduated from medical school and started the Toronto Neurosurgery Residency Program, which combines clinical and lab-based research training.

“When I’m on clinical service, I see questions or problems that I can critically analyze and think about how I would address them in a systematic, hypothesis-generating way,” says Dr. Hachem. “When I go back to the lab, I have an important perspective because I’ve seen what is relevant and feasible in the clinic, and the patient is always top of mind.”

In 2020, she started her PhD research, supervised by Dr. Tator and Dr. Michael Fehlings, continuing her studies of endogenous stem cell regeneration, with the aim of identifying therapies for spinal cord injury.

She had previously found that high levels of the neurotransmitter glutamate activate the AMPA receptor, which stimulates a response from endogenous stem cells. With a PSI Resident Research Grant, she began to look for clinically relevant methods to therapeutically activate AMPA receptors to stimulate endogenous stem cell regeneration, focusing on a class of drug called ampakines.

Ampakines bind to AMPA receptors to improve neuron signalling and have been used in neurodegenerative diseases, such as Alzheimer’s disease and Parkinson’s disease and in the setting of opioid-induced respiratory depression, and have been tested in clinical trials for some neuropsychiatric conditions. But until Dr. Hachem’s research, ampakines had not been examined for their potential in enhancing endogenous spinal cord stem cell regeneration.

Dr. Hachem says that PSI’s Resident Research Grant is a valuable tool for residents to develop their own research program and gain valuable skills early in their career.

“Because this grant funds residents as principal investigators who are asking the questions and leading the work, it gives residents ownership over the project,” she says. “It sets you up for the future in developing your career as a scientist and your own research program.”

Repurposed drug shows promise for neural stem cell regeneration

With PSI funding, Dr. Hachem used a clinically relevant rodent model of spinal cord injury to test whether an ampakine drug could stimulate the AMPA receptor to regenerate endogenous stem cells and restore function.

She found that the treatment increased the growth and division of endogenous neural stem cells and the production of beneficial growth factors, which was associated with increased neuron survival, reduced inflammation and improved functional recovery.

Dr. Hachem notes that other more invasive strategies – including stem cell transplantation – have been studied to repair spinal cord injuries, and while they show promise, her research is the first to show that ampakines have potential as a less invasive approach to regenerate neural stem cells.

“With this work, we’re trying to harness the body’s own regenerative potential with these stem cells. Since the discovery of these cells, it’s been a long-standing question of how we can actually use them to repair the spinal cord after injury, and this study is a critical step in answering that,” she says. “The relevance of the therapy and translation to the clinic is always top of mind, and ultimately the goal is to translate this drug and this approach of positively modulating these cells to patients in a clinical trial.”

With these first results, Dr. Hachem is continuing her research to understand the mechanisms at work, as well as examining the use of ampakines in chronic spinal cord injury. She plans to continue pursuing lab-based research along with clinical care to build a career that ultimately improves care for patients with spinal cord injury.

“Funding from PSI Foundation allowed me to do this first critical experiment to show the feasibility and efficacy of the drug, as well as optimize drug dosing, timing and duration, and this work paves the way for larger scale studies and ultimately clinical translation to patients,” says Dr. Hachem. “This line of research has really grown with me throughout my medical education. Looking forward in the future, I aim to have a career where I can integrate my research interests with my surgical practice.”

Screening women for intimate partner violence (IPV), which includes physical, sexual, and emotional violence, may not seem to fall under the scope of an orthopedic or fracture clinic. But orthopedic surgeons and researchers who recently led an international study on IPV prevalence among orthopedic patients explain that the fracture clinic can actually be a good setting to address this issue.

“In the fracture clinic, you often see patients with injuries frequently during the first few weeks to months. Follow-up often continues for months and sometimes longer,” says Dr. Brad Petrisor, an orthopedic surgeon and professor at McMaster’s Department of Surgery. “You get multiple snapshots over the course of the year after their injury, so this is a major opportunity to ask about and understand intimate partner violence in people’s lives.”

Dr. Petrisor, Dr. Sheila Sprague, Associate Professor in the Department of Surgery, Dr. Kim Madden, Assistant Professor in the Department of Surgery, Dr. Mohit Bhandari, Chair of the Department of Surgery, along with a large multi-disciplinary team, are leading a research program that is generating more awareness of IPV among orthopedic specialists and equipping them to address it with their patients.

As part of her PhD thesis, Dr. Sprague led one of the early studies of IPV among orthopedic patients, the PRAISE (Prevalence of abuse and intimate partner violence surgical evaluation) study. The research team examined the prevalence of IPV among 3,000 women attending orthopedic fracture clinics in Canada, the US, the Netherlands, Denmark and India. They found that one in six women had experienced IPV in the year before the injury, and one in three had experienced IPV in their lifetime. The study was published in The Lancet in 2013.

In 2015, Dr. Petrisor and Dr. Sprague received funding from PSI Foundation to expand on those results with the PRAISE-2 study, which examined reporting rates of IPV among orthopedic patients during the first year following the injury and how IPV affects outcomes such as return to function, complications from the injury and health-related quality of life.

The team assessed IPV disclosures and clinical outcomes of 250 women from Canada, the Netherlands, Spain and Finland at the first visit to the orthopedic fracture clinic and at one, three, six and 12 months after the first visit.
They found that 33% of the patients disclosed IPV during their first visit, and an additional 12.4% who did not disclose IPV at the first visit did disclose IPV at some point during the 12-month follow up.

The team also found that women who disclosed IPV were slower to return to their pre-injury level of function, experienced more complications from their injury and had lower health-related quality of life during the follow-up period. The results were published in the Journal of Bone and Joint Surgery, the field’s most prestigious journal.

“These kinds of statistics can help inform education so that surgeons know to ask about IPV, not just once but at each visit, because you could be missing a significant number of people who could be helped,” says Dr. Sprague. “And knowing that patients who experience IPV have a more difficult recovery is helpful so that the surgeon can intervene earlier with referrals to appropriate services.”

The research team’s work over the last decade has helped to change the perspective of orthopedic specialists from viewing IPV as outside their scope of practice to feeling better equipped to help patients experiencing IPV. They have published papers in top journals and delivered presentations at major orthopedic trauma meetings, and their work has led to positional statements by the Canadian Orthopedic Association recognizing IPV as a significant determinant of morbidity and mortality.

Importantly, Dr. Sprague, Dr. Bhandari, and their colleagues have used the results from the research program to develop a program called EDUCATE, an open access website for orthopedic surgeons and fracture clinic staff that provides knowledge and skills to assist women who are victims of IPV. By the end of 2021, the EDUCATE program had trained more than 150 health care professionals, and they hope to eventually broaden the program to include more health care fields.

“It teaches them how to optimize their fracture clinic and how to ask about IPV. And it also describes the resources that are available and referrals that health care providers can give,” says Dr. Sprague.

As a practising surgeon, Dr. Petrisor says that the research program has changed his own approach with patients.

“When we started this program of research, there was a lot of discomfort among orthopedic surgeons: how do you ask people about IPV, how can the environment in the fracture clinic be conducive to asking about it, and if a patient discloses, what do I do about it?” says Dr. Petrisor. “Knowing that more than one third of women in the clinic disclose IPV has definitely changed my approach in how I interact with patients. In the same way we ask about smoking, alcohol or drugs without judgment, we can ask about IPV and know what to do after a disclosure.”

“It can be hard for physicians who practice in the community to get research off the ground because they don’t have access to traditional funding streams… I look at the community setting as a real-life lab for doing research, and it’s so beneficial to have funding from PSI that supports physicians in this setting.” – Dr. Kamila Premji

Dr. Kamila Premji, a family physician practising in Ottawa, has been interested in research throughout medical school and residency—with a particular interest in health care policy and access to primary care. Now a PhD candidate in Family Medicine at Western University, she has had the opportunity during her training to lead research that has provided important information about challenges with Ontario’s current system of physician compensation.

“I have been able to use my clinical practice experience in the community, see what my patients were struggling with and look for answers to those problems,” she says. “Research was such a natural path to explore those interests and make a difference in health care policy to help improve access to care.”

Dr. Premji had been working at her community practice for a few years when she decided to pursue a master’s degree, which would give her the skills to undertake more rigorous research, and soon transitioned into the PhD stream.

Early in her graduate training, Dr. Premji was part of a team led by Dr. Richard Glazier that examined whether the physician access bonus led to better patient care.

Ontario introduced the access bonus in 2004 as part of several pay-for-performance incentives in primary care. The access bonus is meant to reward family physicians who organize their practices to be more accessible by providing higher bonuses to physicians whose patients seek less external care, such as walk-in or after-hours clinics. Emergency department visits and specialists are not counted as external care.

However, the access bonus has been a controversial incentive, particularly because patients in urban and rural communities have different access to external health care services. With patients in rural communities often relying on emergency departments, it results in bonuses that may not accurately reflect whether physicians are making their practices more accessible.

“The access bonus creates all kinds of unintended consequences for the way services are delivered, and it can even impact the patient-physician relationship at times,” she says. “It’s such a big part of the dominant payment model in Ontario, so it seemed like something that warranted further exploration.”

In 2019, the team including Dr. Premji published a study that linked administrative data about patients’ health care use with their physicians’ access bonuses. The study found that physicians who earned the highest access bonuses were more likely to practice in rural or small urban areas and have higher proportions of patients with less complex health care needs; but these physicians did not necessarily offer more after-hours care, and their patients had higher rates of emergency room use.

PSI Research Trainee Award project suggests access bonus is not working as intended

Dr. Premji wanted to examine the results in the urban setting more closely, as well as consider a different measure of patient access. With a PSI Research Trainee Award, Dr. Premji and the team examined the access bonus for physicians in large, medium and small urban centres from the perspective of whether it improved patients’ experiences and perceptions of access.

“This is such an important part of understanding what the access bonus payment does from a patient perspective,” she says. “From their perspective, are patients experiencing a better level of service and access with this bonus? Is the bonus doing what it is meant to do?”

The team used data from the Health Care Experiences Survey, a patient experience survey conducted quarterly and funded by the Ontario Ministry of Health, and health administrative data from ICES. They were able to link patients with their physicians and family health teams and find associations between patient perceptions of access and their physicians’ bonuses.

The team found that in large and medium urban centres, where walk-in clinics and after-hours care are easily accessed, patient-reported experiences of access were positively associated with their physician’s access bonus. But this association did not hold in small urban centres, and as in the previous study, higher bonuses did not actually mean that patients experienced better access to their physicians.

“In large and medium urban centres, the higher the bonus, the more satisfied patients were with their access, which suggests that the bonus may be motivating physicians and clinics to organize their services in a way that improves the patient’s experience of access,” she says. “But the availability of resources and patients’ choices are still driving the bonus and having more of an impact, and these are out of physicians’ control.”

The results of both studies suggest that the access bonus is not necessarily doing what it is meant to do and may need to be redesigned to account for the differences in geography and patient experience. The results were published in the Canadian Medical Association Journal in November 2021 and have been presented to stakeholders including the Ontario Medical Association and the Ontario Ministry of Health.

The PSI Research Trainee Award concluded in 2020, but Dr. Premji is continuing research in primary care access while she finishes her PhD and cares for her patients.

“I find myself more alert to what my patients are experiencing that could be answered through policy solutions and through research. These areas fuel each other,” she says. “My clinical care fuels my curiosity, and my interest in research leads me to do these projects that then may have an impact on my patients.”