Table 2 High-level description of each province: Primary care setting and COVID-19 context

Quebec

• In Quebec, there are 8.6 million residents, 85% of whom are registered with a family doctor [34]. Primary health care is regulated at the central and regional levels (16 regions). GPs are mainly paid on a fee-for-service or flat-rate basis, while the other professions are paid on an hourly basis. Most GP services are provided in Groupes de Médecine de Famille (GMF, Family Medicine Groups).

• Declared a state of emergency on March 13, 2020, and on that same day ordered the closure of all schools, post-secondary-educational institutions, and most daycares.

• Order in Council 223–2020 in Quebec [35] paused non-emergent and non-urgent procedures and treatments in clinics.

• March 14, 2020, the province reiterated that all residents over the age of 70 should stay at home as much as possible, except for things like medical appointments. It was also announced that the Régie de l’assurance maladie du Québec would cover the cost of health services offered virtually (including telephone) [36].

• For our period of data collection, Quebec experienced waves of COVID-19 that peaked in April/May 2020, January 2021, and April 2021. Throughout, the province has relied on a regional colour alert system, green (“vigilance”) being the lowest level of alert, and red (“maximum”) being the highest; each colour is associated with different restrictions and guidance related to social distancing, closures, private gatherings, visits to Long Term Care, etc.

Ontario

• In Ontario there are multiple primary care models, including Family Health Teams (which are often interdisciplinary), solo-practitioner and fee-for-service clinics, and Community Health Centers, that are compensated through a blended payment model (i.e., salaries based on roster size and additional fees for some services).

• State of emergency was declared on March 17th, 2020, and this coincided with population-level interventions to reduce spread (e.g., closures of schools and many businesses)

• Directive #2 for Health Care Providers in Ontario [37] resulted in pausing non-emergent and non-urgent procedures and treatments in clinics. Significant rise in positive case numbers during April/May 2020, January 2021, and April 2021.

• ‘Digital First’ approach in Ontario [38], formal policy announcements urging physicians to use virtual care whenever possible, and the introduction of billing codes to compensate for these visits (including telephone) [33].

• Local response by the 34 Ontario public health units differed depending on the case numbers and hospitalizations. For example, Ontario used a colour coded system to communicate the level of risk in each public health unit; green (“prevent”) being the lowest risk and with the lowest restrictions on activities, and grey (“lockdown”) reflecting the highest risk and indicating to return to the strict measures put in place during the first wave to reduce transmission.

• For our period of data collection, Ontario experienced waves of COVID-19 that peaked in April 2020, January 2021, April 2021, and September 2021.

Alberta

• In AB, primary care resides under Alberta Health (provincial Ministry of Health). Primary care clinics are owned and operated by family doctors, and most are members of a Primary Care Network (PCN), which essentially offers a multi-clinic collaboration to provide interdisciplinary programs and services based on agreed local priorities for the geographical area served. PCNs are a joint-venture agreement between physicians and Alberta Health Services (province’s single health authority) but governance and funding responsibility lie with the Ministry of Health. PCNs have been an essential component of transforming primary care in Alberta over the last two decades [39].

• State of emergency was declared on March 17th, 2020, and this was coupled with the closures of recreational facilities, and limitations on non-essential services; one day prior, on March 16th, all educational facilities were closed. Additional closures and restrictions for non-essential services were put in place two weeks later.

• March 18th, 2020, family doctors were asked to switch to primarily virtual care to reduce spread, and to bill using temporary virtual care codes (which were made permanent billing codes in June 2020) [40]. Alberta Health Services announcements paused non-urgent and non-emergent primary care in clinics.

• AB has experienced waves of COVID-19 that peaked in April 2020, December 2020, May 2021, and September 2021.