Emily G Marshall

Emily G Marshall
Dalhousie University | Dal · Department of Family Medicine

PhD, MSc, BA

About

82
Publications
21,257
Reads
How we measure 'reads'
A 'read' is counted each time someone views a publication summary (such as the title, abstract, and list of authors), clicks on a figure, or views or downloads the full-text. Learn more
654
Citations
Citations since 2016
64 Research Items
540 Citations
2016201720182019202020212022020406080100120
2016201720182019202020212022020406080100120
2016201720182019202020212022020406080100120
2016201720182019202020212022020406080100120
Introduction
Prof. Marshall's mixed methods research examines primary healthcare from patient, provider, & system perspectives to address the quadruple aim: promoting population health, optimizing costs, enhancing patient experience, & supporting care team well-being. Foci include access, continuity, & comprehensiveness to improve equity & optimize outcomes across the life course. She leads several pan-Canadian studies (ie the PUPPY Study), and is the 2020 recipient of the NAPCRG Mid-Career Researcher Award.
Additional affiliations
July 2015 - present
Dalhousie University
Position
  • Professor (Associate)
Description
  • .
July 2009 - June 2015
Dalhousie University
Position
  • Professor (Assistant)
May 2007 - June 2009
University of British Columbia - Vancouver
Position
  • PostDoc Position
Education
September 2002 - June 2007
University of British Columbia - Vancouver
Field of study
  • Health Services Research

Publications

Publications (82)
Article
Full-text available
Background Many family medicine residency graduates indicate a desire to provide obstetric care, but a low proportion of family physicians (FPs) provide obstetric care within their practice. This suggests personal preference alone may not account for the low proportion of FPs who ultimately provide full obstetric care. If decisionmakers plan to aug...
Article
Full-text available
Background Family practice registered nurses co-managing patient care as healthcare professionals in interdisciplinary primary care teams have been shown to improve access, continuity of care, patient satisfaction, and clinical outcomes for patients with chronic diseases while being cost-effective. Currently, however, it is unclear how different fu...
Article
Background Timely access and attachment to a primary healthcare provider is associated with better population health outcomes. In Canada, community pharmacists are highly accessible and patients struggling to access a family physician or nurse practitioner (i.e., “unattached”) may seek care from a community pharmacist. Community pharmacists took on...
Article
Full-text available
Introduction Health system disruptions, caused by unexpected emergencies such as disease outbreaks, natural disasters, and cybercrimes, impact the delivery of routine preventative care. As comprehensive care providers, family physicians (FPs) devote significant time to prevention. However, without emergency and pandemic plans in place in primary ca...
Article
Full-text available
The COVID-19 response required family physicians (FPs) to adapt their practice to minimise transmission risks. Policy guidance to facilitate enacting public health measures has been generic and difficult to apply, particularly for FPs working with communities that experience marginalisation. Our objective was to explore the experiences of FPs servi...
Article
Full-text available
Objectives In Canada physician payment systems and associated billing data vary across provinces. We used linked billing data to develop comparable measures of family physician (FP) service volume, continuity, and comprehensiveness in each of four provinces, with the goal of describing changing patterns over time, relevant to workforce planning pol...
Article
Full-text available
Objectives Primary care attachment improves access, chronic disease prevention and management. Growing proportions of Canadians are unattached and registering with provincial primary care waitlists for family doctors or nurse practitioners. We compare emergency department utilization and hospitalization by waitlist registration status both before a...
Article
Purpose: Strong leadership in primary care is necessary to coordinate an effective pandemic response; however, descriptions of leadership roles for family physicians are absent from previous pandemic plans. This study aims to describe the leadership roles and functions family physicians played during the COVID-19 pandemic in Canada and identify su...
Article
Full-text available
Family physicians play important roles throughout all stages of a pandemic response; however, actionable descriptions outlining these roles are absent from current pandemic plans. Using a multiple case study design, we conducted a document analysis and interviewed 68 family physicians in four Canadian regions. We identified roles performed by famil...
Preprint
Background Many family medicine residency graduates indicate a desire to provide obstetric care, but a low proportion of family physicians provide obstetric care within their practice. This suggests personal preference alone may not account for the low proportion of FPs who ultimately provide full obstetric care. If decisionmakers plan to augment n...
Article
Full-text available
Following publication of the original article [1], the authors identified a typesetting error in the third paragraph of the ‘Patient experience outcomes via PREMS’ subsection under the ‘Results’. The sentence originally read: For instance, Cherkin et al. [57] reported higher satisfaction (p<0.0) and higher perceived knowledge (p<0.001) for patients...
Article
Full-text available
Background COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a healthcare system, particularly during a pandemic. We describe organizational innovations aiming to improve access to...
Article
Full-text available
Background Strong primary care systems have been associated with improved health equity. Primary care system reforms in Canada may have had equity implications, but these have not been evaluated. We sought to determine if changes in primary care service use between 1999/2000 and 2017/2018 differ by neighbourhood income in British Columbia. Methods...
Article
Full-text available
Background Globally, registered nurses (RNs) are increasingly working in primary care interdisciplinary teams. Although existing literature provides some information about the contributions of RNs towards outcomes of care, further evidence on RN workforce contributions, specifically towards patient-level outcomes, is needed. This study synthesized...
Article
Full-text available
Background Internationally, policy-makers and health administrators are seeking evidence to inform further integration and optimal utilization of registered nurses (RNs) within primary care teams. Although existing literature provides some information regarding RN contributions, further evidence on the impact of RNs towards quality and cost of care...
Article
Full-text available
Background Patient access to primary healthcare (PHC) is the foundation of a strong healthcare system and healthy populations. Attachment to a regular PHC provider, a key to healthcare access, has seen a decline in some jurisdictions. This study explored the consequences of unattachment from a patient perspective, an under-studied phenomenon to dat...
Preprint
Background Complaints about lack of access to family physicians (FPs) has led to concerns about the role recent physician graduates have had in changes in the supply of primary care services in Canada. This study investigates the impact of career stage, time period, and graduation cohort on family physician practice volume and continuity over two d...
Preprint
Full-text available
Background: Timely access and attachment to a primary healthcare provider is essential for population health outcomes. Patients without a family physician or nurse practitioner (“unattached”) or who cannot access their provider when needed may seek care from a community pharmacist. Community pharmacists are highly accessible in Canada and have a br...
Article
Full-text available
Introduction Access to a primary care provider is a key component of high-functioning healthcare systems. In Canada, 15% of patients do not have a regular primary care provider and are classified as ‘unattached’. In an effort to link unattached patients with a provider, seven Canadian provinces implemented centralised waitlists (CWLs). The effectiv...
Article
Full-text available
Primary care is the foundation of health care systems around the world. Physician autonomy means that governments rely on a limited selection of levers to implement reforms in primary care delivery, and these policies may impact the practice choices, intentions, and patterns of primary care physicians. Using a systematic search strategy to capture...
Article
Full-text available
Background Return-of-service (ROS) agreements require international medical graduates (IMGs) who accept medical residency positions in Canada to practice in specified geographic areas following completion of training. However, few studies have examined how ROS agreements influence career decisions. We examined IMG resident and early-career family p...
Preprint
Full-text available
Background Primary care (PC) attachment improves healthcare access and prevention and management of chronic conditions. Yet, growing proportions of Canadians are unattached, signing-up on provincial waitlists. Understanding variations in healthcare utilization during COVID-19, and among potentially vulnerable unattached patients, is needed. This st...
Article
Legislation on medical assistance in dying (MAiD) was enacted in Canada in 2016. There is limited research on the topic available from Atlantic Canada. This study provides early data on the uptake of MAiD in Nova Scotia based on analysis of administrative billing data. It presents the number of MAiD cases by year from 2017 through early 2020. It al...
Article
Full-text available
Background: Although focused practice within family medicine may be increasing globally, there is limited research on the factors contributing to decisions to focus practice. Aim: We aimed to examine the factors influencing resident and early-career family physician choices of focused practice across three Canadian provinces. Design and setting...
Preprint
Full-text available
Background COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a health care system, particularly during a pandemic. We describe organizational innovations aiming to improve access t...
Article
Full-text available
Background Visa trainees (international medical graduates [IMG] who train in Canada under a student or employment visa) are expected to return home after completing their training. We examine the retention patterns of visa trainee residents funded by Canadian (regular ministry and other), foreign, or mixed sources. Methods We linked data from the...
Article
Abstract Objective: To understand physician acceptance of new patients, specifically the use of “meet and greets”; and to explore FPs’ rationale, beliefs, and processes regarding these appointments. Design Exploratory qualitative interviews. Setting: Nova Scotia. Participants: A purposive sample of 12 FPs who had previously participated in the...
Preprint
Full-text available
Background Patient access to primary healthcare (PHC) is the foundation of a strong healthcare system and healthy populations. Attachment to a regular PHC provider, a key to healthcare access, has seen a decline in some jurisdictions. This study explored the consequences of unattachment from a patient perspective, an under-studied phenomenon to dat...
Article
Full-text available
Introduction: Given the recurrent risk of respiratory illness-based pandemics, and the important roles family physicians play during public health emergencies, the development of pandemic plans for primary care is imperative. Existing pandemic plans in Canada, however, do not adequately incorporate family physicians' roles and perspectives. This p...
Preprint
Full-text available
Background Patient access to primary healthcare (PHC) is the foundation of a strong healthcare system and healthy populations. Attachment to a regular PHC provider, a key to healthcare access, has seen a decline in some jurisdictions. This study explored the consequences of unattachment from a patient perspective, an under-studied phenomenon to dat...
Article
Full-text available
Objective: To examine the degree to which Canadian consensus guideline recommendations for annual comprehensive preventive care assessments of adults with intellectual and developmental disabilities (IDD) are being taken up by Nova Scotia family physicians since the introduction of incentive billing codes; and to discuss the importance of complete...
Preprint
Full-text available
Background: Although focused practice within family medicine may be increasing globally, there is limited research on the factors contributing to decisions to focus practice. We aimed to examine the factors influencing resident and early-career family physician choices of focused practice across three Canadian provinces. Methods: We analyzed a subs...
Article
Access to a regular primary care provider is essential to quality care. In Canada, where 15% of patients are unattached (i.e., without a regular provider), centralized waiting lists (CWLs) help attach patients to a primary care provider (family physician or nurse practitioner). Previous studies reveal mechanisms needed for CWLs to work, but focus m...
Article
Background: The COVID-19 pandemic significantly disrupted primary care in Canada, with many walk-in clinics and family practices initially closing or being perceived as inaccessible, pharmacies remaining open with restrictions on patient interactions, rapid uptake of virtual care, and reduced referrals for lab tests, diagnostics, and specialist ca...
Preprint
BACKGROUND The COVID-19 pandemic has significantly disrupted primary care in Canada, with many walk-in clinics and family practices initially closing or being perceived as inaccessible; pharmacies remaining open with restrictions on patient interactions; rapid uptake of virtual care; and reduced referrals for lab tests, diagnostics, and specialist...
Preprint
Full-text available
Background: The COVID-19 pandemic significantly disrupted primary care in Canada, with many walk-in clinics and family practices initially closing or being perceived as inaccessible, pharmacies remaining open with restrictions on patient interactions, rapid uptake of virtual care, and reduced referrals for lab tests, diagnostics, and specialist car...
Article
Introduction Canadians report persistent problems accessing primary care despite an increasing per-capita supply of primary care physicians (PCPs). There is speculation that PCPs, especially those early in their careers, may be working less and/or choosing to practice in focused clinical areas rather than comprehensive family medicine. Objectives...
Article
Full-text available
Context Many health systems have centralized waiting lists (CWLs), but there is limited evidence on CWL effectiveness and how to design and implement them. Aim To understand how CWLs’ design and implementation influence their use and effect on access to healthcare. Methods We conducted a realist review (n = 21 articles), extracting context-interv...
Article
Objective: To examine how FP and practice characteristics relate to the provision of home visits. Design: Census survey linked to administrative billing data. Setting: Nova Scotia, 2014 to 2015. Participants: Respondents to the family physician practice survey (N = 740; 84.5% response rate), the FP provider survey (N = 677; 56.7% response ra...
Article
Background: As the Canadian population ages, there is a need to improve long-term care (LTC) services. An increased understanding of the positive work experiences of LTC staff may help attract more human health resources to LTC. Objective: To describe the perceptions of the roles and work of nurses and care assistants in LTC from interprofession...
Article
Full-text available
Background: Acceptance to a family practice is key to access and continuity of care. While Canadian patients increasingly report not being able to acquire acceptance to a family practice, little is known about the association between requiring opioids and acceptance. We aim to determine the proportion of family physicians who would accept new pati...
Article
Full-text available
Introduction Canadians report persistent problems accessing primary care despite an increasing per-capita supply of primary care physicians (PCPs). There is speculation that PCPs, especially those early in their careers, may now be working less and/or choosing to practice in focused clinical areas rather than comprehensive family medicine, but litt...
Article
Objectives: Many older adults in long-term care (LTC) experience acute health crises but are at high risk of transfer distress and in-hospital morbidity and mortality. Residents often complete advance directives (ADs) regarding future care wishes, including directives for hospital transfers. This study aims to estimate the prevalence of, and adher...
Article
Full-text available
Canada has the lowest rate of attachment to primary care providers among OECD countries, which makes access and continuity of care problematic. To address this important issue, seven Canadian provinces have implemented centralized waiting lists (CWLs) for unattached patients in primary care. Introduced at different times, no two provinces' CWLs are...
Article
Full-text available
Open access article available from http://cmajopen.ca/content/7/1/E124.full Background: Family medicine residents choose among a range of practice options as they enter the physician workforce. We describe the demographic and personal characteristics of Canadian family medicine residents and examine differences in the intentions of residents from...
Article
Full-text available
Research indicates that trans people face a number of barriers to healthcare, including challenges in finding healthcare providers (HCPs) who are knowledgeable about, and sensitive to, trans identity and health issues. These and other barriers contribute to this population's under-usage of healthcare services and, in turn, their poor overall health...
Article
Background: Strategies have been developed for use in primary care to identify patients at risk of declining health and dying, yet little is known about the perceptions of doing so or the broader implications and impacts. Aim: To explore the acceptability and implications of using a primary care-based electronic medical record algorithm to help...
Article
Full-text available
Background Falls and the resulting complications are common among frail older adults. We aimed to explore risk factors and potential prevention strategies for falls in elderly residents of Long-Term Care Facilities (LTCF). Methods This was a cross sectional study design using data from the Care by Design (CBD) study, within Nova Scotia’s Capital D...
Article
Introduction: Centralized waiting lists (CWLs) are one solution to reduce the problematic number of patients without a regular primary care provider. This article describes different models of CWLs for unattached patients implemented in seven Canadian provinces and identifies common issues in the implementation of these CWLs. Methods: Logic models...
Article
p> OBJECTIVES: To determine whether socio-economic status (SES) and presence of a chronic condition are associated with the response a prospective patient receives when seeking a family physician (FP). METHODS: Scripted telephone calls (indicating higher or lower SES and presence or absence of a chronic condition) were made to all 327 FP offices i...
Article
Full-text available
The addition of nurse practitioners (NPs) in primary healthcare (PHC) is intended to improve accessibility. This study compared access to NP services in consultative, dyad and multiprofessional team structures in Nova Scotia. Accessibility indicators included NP appointment wait times, after-hours coverage and acceptance of new patients. Secondary...
Article
Full-text available
Introduction People are living longer; however, they are not necessarily experiencing good health and well-being as they age. Many older adults live with multiple chronic conditions (MCC), and complex health issues, which adversely affect their day-to-day functioning and overall quality of life. As a result, they frequently rely on the support of f...
Article
Full-text available
Objectives: Polypharmacy is both common and harmful for frail residents of long-term care facilities (LTCF). We aimed to study rates of polypharmacy and potentially inappropriate medications (PIMs) before and after the implementation of a new model of coordinated primary care in LTCF, 'Care by Design (CBD)'. Methods: This was an observational be...
Article
Trans individuals are less healthy than the general population in part because of their avoidance and underutilisation of healthcare. Using qualitative research methods, the objective of this study was to explore the barriers trans adults encounter when pursuing primary and emergency care in Nova Scotia, Canada. Findings reveal that trans adults of...
Article
Background.: Family physicians (FPs) are expected to take on new patients fairly and equitably and to not discriminate based on medical or social history. 'Meet and greet' appointments are initial meetings between physicians and prospective patients to establish fit between patient needs and provider scope of practice. The public often views these...
Article
Full-text available
Introduction There is little evidence on how primary care providers (PCPs) model their practices in Nova Scotia (NS), Canada, what services they offer or what accessibility is like for the average patient. This study will create a database of all family physicians and primary healthcare nurse practitioners in NS, including information about accessi...
Article
Full-text available
Introduction: Care by Design™ (CBD) (Canada), a model of coordinated team-based primary care, was implemented in long-term care facilities (LTCFs) in Halifax, Nova Scotia, Canada, to improve access to and continuity of primary care and to reduce high rates of transfers to emergency departments (EDs). Methods: This was an observational time serie...
Article
Full-text available
To compare system and clinical outcomes before and after an extended care paramedic (ECP) program was implemented to better address the emergency needs of long-term care (LTC) residents. Data were collected from emergency medical services (EMS), hospital, and ten LTC facility charts for two five-month time periods, before and after ECP implementati...
Article
Full-text available
Abstract Problem addressed: A recently implemented model of care in long-term care facilities (LTCFs) called Care by Design addresses concerns about a previously uncoordinated care system, a reduction in family physician services, and high rates of ambulance transports to emergency departments. Objective of program: Care by Design is designed to i...
Article
Full-text available
Most older adults living in long-term care facilities (LTCF) are frail and have complex care needs. Holistic understanding of residents' health status is key to providing good care. Comprehensive Geriatric Assessment (CGA) is a valid assessment method which aims to embrace complexity. Here we aimed to study a CGA that has been modified for use in l...
Article
Full-text available
A Long-Term Care—Comprehensive Geriatric Assessment (LTC-CGA) Tool: Improving Care for Frail Older Adults? Emily G. Marshall, Barry S. Clarke, Nirupa Varatharasan, Melissa K. Andrew Abstract Background Most older adults living in long-term care facilities (LTCF) are frail and have complex care needs. Holistic understanding of residents’ health s...
Article
Problem addressed A recently implemented model of care in long-term care facilities (LTCFs) called Care by Design addresses concerns about a previously uncoordinated care system, a reduction in family physician services, and high rates of ambulance transports to emergency departments. Objective of program Care by Design is designed to increase acce...
Article
The use of financial incentives provided to primary care physicians who achieve target management or clinical outcomes has been advocated to support the fulfillment of care recommendations for patients with diabetes. This article explores the characteristics of incentive models implemented in the context of universal healthcare systems in the Unite...
Article
Abstract Objective. An extended-care paramedic (ECP) program was implemented to provide emergency assessment and care on site to long-term care (LTC) residents suffering acute illness or injury. A single paramedic works collaboratively with physicians, LTC staff, patient, and family to develop care plans to address acute situations, often avoiding...
Article
Full-text available
Prior to the implementation of a new model of care in long-term care facilities in the Capital District Health Authority, Halifax, Nova Scotia, residents entering long-term care were responsible for finding their own family physician. As a result, care was provided by many family physicians responsible for a few residents leading to care coordinati...