AFTERMATH (Approaches For ThE pRioritization of patients in priMAry care post-COVID To reduce Health inequities)

Integrating Health & Social Care
In Progress
Chronic Diseases, Electronic Medical Records, Mental Disability, Prediction, Preventive Care, Primary Care, Social Determinants of Health


High quality primary care is the cornerstone of strong health systems. The COVID-19 pandemic has significantly altered primary care across Canada. Most offices and clinics rapidly shifted to virtual care, restricted in-person visits of closed their offices, and delayed routine monitoring and lab testing. It is likely health inequities in preventive care activities and chronic disease management widened, but the extent is unknown. AFTERMATH consists of two parts that will occur in tandem. In Part 1, we will use electronic medical records (EMR) data from all seven primary care Practice-Based Research Networks (PBRNs) in Ontario (>1.6 million patients) to examine the impact of the COVID-19 pandemic on gaps in preventive care activities and chronic disease status, including mental illness. In Part 2, we will conduct a pragmatic cluster of randomized control trial (cRCT) at the largest PBRN, focused on a population expected to have significant gaps in preventive care activities: adults living with mental illness and at a least one additional chronic disease.




Our goal is to improve quality of life, reduce gaps in preventive care activities and improve chronic disease management by supporting physicians with a newly developed EMR data driven dashboard plus tailored supports. Our project will result in new evidence on strategies to improve access to and reduce inequities in preventive. Findings will inform all future efforts to use EMR data driven improvements in primary care beyond the COVID-19 pandemic. If this intervention works, we will be able to rapidly disseminate and scale up in Canadian primary care, building on advances in processing and integrating EMR data into the workflow of clinicians and health organizations.


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