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1.  Roles of nurse practitioners and family physicians in community health centres 
Canadian Family Physician  2014;60(11):1020-1027.
Abstract
Objective
To describe the models of practice used by nurse practitioners (NPs) and FPs in community health centres (CHCs), and to examine the roles of NPs and FPs in these models.
Design
Cross-sectional study using an organizational survey completed by managers of the CHC sites, as well as administrative data on patient sociodemographic characteristics and encounter activities.
Setting
A total of 21 CHCs (13 main sites and 8 satellite sites) operating in eastern Ontario during the period from December 1, 2006, to November 30, 2008.
Participants
A total of 44 849 patients, 53 full-time equivalent FPs, and 41 full-time equivalent NPs.
Main outcome measures
Family physicians’ and NPs’ models of practice, the sociodemographic characteristics and medical profiles of patients who were treated in each model of practice, and FPs’ and NPs’ use of time.
Results
Patients were attributed to 1 of 3 models of practice in CHCs based on the proportion of visits to FPs and NPs: FP care (53% of patients), NP care (29%), and shared care (18%). Patients who received care in the NP model of practice were younger and more likely to be female, be homeless, and not have postsecondary education. Patients who received care in the FP model of practice had more complex medical conditions (cardiovascular disease, mental illness, lung disease, and diabetes) and more annual visits. Patients who received care in the shared care model had intermediate profiles. Nurse practitioners performed more off-site care and walk-in visits. Family physicians and NPs spent a similar proportion of time performing various duties such as direct clinical care and administration tasks.
Conclusion
Although NPs mainly cared for their own patient panels (in the NP care model), they did share some patients with FPs and provide some care to patients under the FP model of practice. Patients who were cared for by FPs and NPs had quite different characteristics.
PMCID: PMC4229163  PMID: 25551130
2.  What is the impact of primary care model type on specialist referral rates? A cross-sectional study 
BMC Family Practice  2014;15:22.
Background
Several new primary care models have been implemented in Ontario, Canada over the past two decades. These practice models differ in team structure, physician remuneration, and group size. Few studies have examined the impact of these models on specialist referrals. We compared specialist referral rates amongst three primary care models: 1) Enhanced Fee-for-service, 2) Capitation- Non-Interdisciplinary (CAP-NI), 3) Capitation – Interdisciplinary (CAP-I).
Methods
We conducted a cross-sectional study using health administrative data from primary care practices in Ontario from April 1st, 2008 to March 31st, 2010. The analysis included all family physicians providing comprehensive care in one of the three models, had at least 100 patients, and did not have a prolonged absence (eight consecutive weeks). The primary outcome was referral rate (# of referrals to all medical specialties/1000 patients/year). A multivariable clustered Poisson regression analysis was used to compare referral rates between models while adjusting for provider (sex, years since graduation, foreign trained, time in current model) and patient (age, sex, income, rurality, health status) characteristics.
Results
Fee-for-service had a significantly lower adjusted referral rate (676, 95% CI: 666-687) than the CAP-NI (719, 95% confidence interval (CI): 705-734) and CAP-I (694, 95% CI: 681-707) models and the interdisciplinary CAP-I group had a 3.5% lower referral rate than the CAP-NI group (RR = 0.965, 95% CI: 0.943-0.987, p = 0.002). Female and Canadian-trained physicians referred more often, while female, older, sicker and urban patients were more likely to be referred.
Conclusions
Primary care model is significantly associated with referral rate. On a study population level, these differences equate to 111,059 and 37,391 fewer referrals by fee-for-service versus CAP-NI and CAP-I, respectively – a difference of $22.3 million in initial referral appointment costs. Whether a lower rate of referral is more appropriate or not is not known and requires further investigation. Physician remuneration and team structure likely account for the differences; however, further investigation is also required to better understand whether other organizational factors associated with primary care model also impact referral.
doi:10.1186/1471-2296-15-22
PMCID: PMC3933232  PMID: 24490703
Primary care; Specialist referral; Capitation; Primary care model
3.  An Overview of Practice Facilitation Programs in Canada: Current Perspectives and Future Directions 
Healthcare Policy  2013;8(3):58-67a.
Practice facilitation has proven to be effective in improving the quality of primary care. A practice facilitator is a health professional, usually external to the practice, who regularly visits the practice to provide support in change management that targets improvements in the delivery of care. Our environmental scan shows that several initiatives across Canada utilize practice facilitation as a quality improvement method; however, many are conducted in isolation as there is a lack of coordinated effort, knowledge translation and dissemination in this field across the country. We recommend that investments be made in capacity building, knowledge exchange and facilitator training, and that partnership building be considered a priority in this field.
PMCID: PMC3999561  PMID: 23968627
4.  Patient-reported access to primary care in Ontario 
Canadian Family Physician  2014;60(1):e24-e31.
Abstract
Objective
To describe patient-reported access to primary health care across 4 organizational models of primary care in Ontario, and to explore how access is associated with patient, provider, and practice characteristics.
Design
Cross-sectional survey.
Setting
One hundred thirty-seven randomly selected primary care practices in Ontario using 1 of 4 delivery models (fee for service, established capitation, reformed capitation, and community health centres).
Participants
Patients included were at least 18 years of age, were not severely ill or cognitively impaired, were not known to the survey administrator, had consenting providers at 1 of the participating primary care practices, and were able to communicate in English or French either directly or through a translator.
Main outcome measures
Patient-reported access was measured by a 4-item scale derived from the previously validated adult version of the Primary Care Assessment Tool. Questions were asked about physician availability during and outside of regular office hours and access to health information via telephone. Responses to the scale were normalized, with higher scores reflecting greater patient-reported access. Linear regressions were used to identify characteristics independently associated with access to care.
Results
Established capitation model practices had the highest patient-reported access, although the difference in scores between models was small. Our multilevel regression model identified several patient factors that were significantly (P = .05) associated with higher patient-reported access, including older age, female sex, good-to-excellent self-reported health, less mental health disability, and not working. Provider experience (measured as years since graduation) was the only provider or practice characteristic independently associated with improved patient-reported access.
Conclusion
This study adds to what is known about access to primary care. The study found that established capitation models outperformed all the other organizational models, including reformed capitation models, independent of provider and practice variables save provider experience. This suggests that the capitation models might provide better access to care and that it might take time to realize the benefits of organizational reforms.
PMCID: PMC3994832  PMID: 24452575
5.  Delivery of primary health care to persons who are socio-economically disadvantaged: does the organizational delivery model matter? 
Background
As health systems evolve, it is essential to evaluate their impact on the delivery of health services to socially disadvantaged populations. We evaluated the delivery of primary health services for different socio-economic groups and assessed the performance of different organizational models in terms of equality of health care delivery in Ontario, Canada.
Methods
Cross sectional study of 5,361 patients receiving care from primary care practices using Capitation, Salaried or Fee-For-Service remuneration models. We assessed self-reported health status of patients, visit duration, number of visits per year, quality of health service delivery, and quality of health promotion. We used multi-level regressions to study service delivery across socio-economic groups and within each delivery model. Identified disparities were further analysed using a t-test to determine the impact of service delivery model on equity.
Results
Low income individuals were more likely to be women, unemployed, recent immigrants, and in poorer health. These individuals were overrepresented in the Salaried model, reported more visits/year across all models, and tended to report longer visits in the Salaried model. Measures of primary care services generally did not differ significantly between low and higher income/education individuals; when they did, the difference favoured better service delivery for at-risk groups. At-risk patients in the Salaried model were somewhat more likely to report health promotion activities than patients from Capitation and Fee-For-Service models. At-risk patients from Capitation models reported a smaller increase in the number of additional clinic visits/year than Fee-For-Service and Salaried models. At-risk patients reported better first contact accessibility than their non-at-risk counterparts in the Fee-For-Service model only.
Conclusions
Primary care service measures did not differ significantly across socio-economic status or primary care delivery models. In Ontario, capitation-based remuneration is age and sex adjusted only. Patients of low socio-economic status had fewer additional visits compared to those with high socio-economic status under the Capitation model. This raises the concern that Capitation may not support the provision of additional care for more vulnerable groups. Regions undertaking primary care model reforms need to consider the potential impact of the changes on the more vulnerable populations.
doi:10.1186/1472-6963-13-517
PMCID: PMC3927777  PMID: 24341530
Primary care; Health equity; Organizational models; Physician remuneration
6.  Family-centred care delivery 
Canadian Family Physician  2013;59(11):1202-1210.
Abstract
Objective
To determine whether models of primary care service delivery differ in their provision of family-centred care (FCC) and to identify practice characteristics associated with FCC.
Design
Cross-sectional study.
Setting
Primary care practices in Ontario (ie, 35 salaried community health centres, 35 fee-for-service practices, 32 capitation-based health service organizations, and 35 blended remuneration family health networks) that belong to 4 models of primary care service delivery.
Participants
A total of 137 practices, 363 providers, and 5144 patients.
Main outcome measures
Measures of FCC in patient and provider surveys were based on the Primary Care Assessment Tool. Statistical analyses were conducted using linear mixed regression models and generalized estimating equations.
Results
Patient-reported FCC scores were high and did not vary significantly by primary care model. Larger panel size in a practice was associated with lower odds of patients reporting FCC. Provider-reported FCC scores were significantly higher in community health centres than in family health networks (P = .035). A larger number of nurse practitioners and clinical services on-site were both associated with higher FCC scores, while scores decreased as the number of family physicians in a practice increased and if practices were more rural.
Conclusion
Based on provider and patient reports, primary care reform strategies that encourage larger practices and more patients per family physician might compromise the provision of FCC, while strategies that encourage multidisciplinary practices and a range of services might increase FCC.
PMCID: PMC3828098  PMID: 24235195
7.  Practice size, financial sharing and quality of care 
Background
Although we are observing a general move towards larger primary care practices, surprisingly little is known about the influence of key components of practice organization on primary care. We aimed to determine the relationships between practice size, and revenue sharing agreements, and quality of care.
Methods
As part of a large cross sectional study, group practices were randomly selected from different primary care service delivery models in Ontario. Patient surveys and chart reviews were used to assess quality of care. Multilevel regressions controlled for patient, provider and practice characteristics.
Results
Positive statistically significant associations were found between the logarithm of group size and access, comprehensiveness, and disease prevention. Negative significant associations were found between logarithm group size and continuity. No differences were found for chronic disease management and health promotion. Practices that shared revenues were found to deliver superior health promotion compared to those who did not. Interacting group size with the presence of a revenue-sharing arrangement had a negative impact on health promotion.
Conclusions
Despite the limitations of our study, our findings have provided preliminary evidence of the tradeoffs inherent with increasing practice size. Larger group size is associated with better access and comprehensiveness but worse continuity of care. Revenue sharing in group practices was associated with higher health promotion compared to sharing only common costs. Further work is required to better inform policy makers and practitioners as to whether the pattern revealed in larger practices mitigates any of the previously reported benefits of continuity of primary care. We found few benefits of revenue sharing – even then the effect of revenue sharing on health promotion seemed diminished in larger practices.
doi:10.1186/1472-6963-13-446
PMCID: PMC3819507  PMID: 24165413
Group size; Quality measures; Revenue sharing
8.  Predictors of relational continuity in primary care: patient, provider and practice factors 
BMC Family Practice  2013;14:72.
Background
Continuity is a fundamental tenet of primary care, and highly valued by patients; it may also improve patient outcomes and lower cost of health care. It is thus important to investigate factors that predict higher continuity. However, to date, little is known about the factors that contribute to continuity. The purpose of this study was to analyse practice, provider and patient predictors of continuity of care in a large sample of primary care practices in Ontario, Canada. Another goal was to assess whether there was a difference in the continuity of care provided by different models of primary care.
Methods
This study is part of the larger a cross-sectional study of 137 primary care practices, their providers and patients. Several performance measures were evaluated; this paper focuses on relational continuity. Four items from the Primary Care Assessment Tool were used to assess relational continuity from the patient’s perspective.
Results
Multilevel modeling revealed several patient factors that predicted continuity. Older patients and those with chronic disease reported higher continuity, while those who lived in rural areas, had higher education, poorer mental health status, no regular provider, and who were employed reported lower continuity. Providers with more years since graduation had higher patient-reported continuity. Several practice factors predicted lower continuity: number of MDs, nurses, opening on weekends, and having 24 hours a week or less on-call. Analyses that compared continuity across models showed that, in general, Health Service Organizations had better continuity than other models, even when adjusting for patient demographics.
Conclusions
Some patients with greater health needs experience greater continuity of care. However, the lower continuity reported by those with mental health issues and those who live in rural areas is concerning. Furthermore, our finding that smaller practices have higher continuity suggests that physicians and policy makers need to consider the fact that ‘bigger is not always necessarily better’.
doi:10.1186/1471-2296-14-72
PMCID: PMC3688290  PMID: 23725212
Relational continuity; Primary care; Key predictors
9.  How Many Patients Should a Family Physician Have? Factors to Consider in Answering a Deceptively Simple Question 
Healthcare Policy  2012;7(4):26-34.
The ratio of patients to physicians has long been used as a tool for measuring and planning healthcare resources in Canada. Some current changes in primary care, such as enrolment of patients with physicians, make this ratio easier to calculate, while others, such as changing practice structure, make it more complex to interpret. Based on information gleaned from a review of the literature, we argue that before panel size can be used as an accountability measure for individual physicians or practices in primary care, we must understand its relationship to quality and outcomes at individual and population levels, as well as the contextual factors that affect it.
PMCID: PMC3359082  PMID: 23634160
10.  Patient poverty and workload in primary care 
Canadian Family Physician  2013;59(4):384-390.
Abstract
Objective
To determine if patient poverty is associated with increased workload for primary care providers (PCPs).
Design
Linkage of administrative data identifying patient poverty and comorbidity with survey data about the organizational structure of community health centres (CHCs).
Setting
Ontario’s 73 CHCs.
Participants
A total of 64 CHC sites (N = 63 included in the analysis).
Main outcome measures
Patient poverty was determined in 2 different ways: based on receipt of Ontario Drug Benefits (identifying recipients of welfare, provincial disability support, and low-income seniors’ benefits) or residence in low-income neighbourhoods. Patient comorbidities were determined through administrative diagnostic data from the CHCs and the Institute for Clinical Evaluative Sciences. Primary care workload was determined by examining PCP panel size (the number of patients cared for by a full-time-equivalent PCP during a 2-year interval).
Results
The CHCs with higher proportions of poor patients had smaller panel sizes. The smaller panel sizes were entirely explained by the medical comorbidity profile of the poor patients.
Conclusion
Poor patients generate a higher workload for PCPs in CHCs; however, this is principally because they are sicker than higher-income patients are. Further information is required about the spectrum of services used by poor patients in CHCs.
PMCID: PMC3625088  PMID: 23585609
11.  Access to primary health care for immigrants: results of a patient survey conducted in 137 primary care practices in Ontario, Canada 
BMC Family Practice  2012;13:128.
Background
Immigrants make up one fifth of the Canadian population and this number continues to grow. Adequate access to primary health care is important for this population but it is not clear if this is being achieved. This study explored patient reported access to primary health care of a population of immigrants in Ontario, Canada who were users of the primary care system and compared this with Canadian-born individuals; and by model of primary care practice.
Methods
This study uses data from the Comparison of Models of Primary Care Study (COMP-PC), a mixed-methods, practice-based, cross-sectional study that collected information from patients and providers in 137 primary care practices across Ontario, Canada in 2005-2006. The practices were randomly sampled to ensure an equal number of practices in each of the four dominant primary care models at that time: Fee-For-Service, Community Health Centres, and the two main capitation models (Health Service Organization and Family Health Networks). Adult patients of participating practices were identified when they presented for an appointment and completed a survey in the waiting room. Three measures of access were used, all derived from the patient survey: First Contact Access, First Contact Utilization (both based on the Primary Care Assessment Tool) and number of self-reported visits to the practice in the past year.
Results
Of the 5,269 patients who reported country of birth 1,099 (20.8%) were born outside of Canada. In adjusted analysis, recent immigrants (arrival in Canada within the past five years) and immigrants in Canada for more than 20 years were less likely to report good health compared to Canadian-born (Odds ratio 0.58, 95% CI 0.36,0.92 and 0.81, 95% CI 0.67,0.99). Overall, immigrants reported equal access to primary care services compared with Canadian-born. Within immigrant groups recently arrived immigrants had similar access scores to Canadian-born but reported 5.3 more primary care visits after adjusting for health status. Looking across models, recent immigrants in Fee-For-Service practices reported poorer access and fewer primary care visits compared to Canadian-born.
Conclusions
Overall, immigrants who were users of the primary care system reported a similar level of access as Canadian-born individuals. While recent immigrants are in poorer health compared with Canadian-born they report adequate access to primary care. The differences in access for recently arrived immigrants, across primary care models suggests that organizational features of primary care may lead to inequity in access.
doi:10.1186/1471-2296-13-128
PMCID: PMC3563569  PMID: 23272805
Primary health care; Access to health care; Immigrants; Canada
12.  Quality of cardiovascular disease care in Ontario, Canada: missed opportunities for prevention - a cross sectional study 
Background
Primary care plays a key role in the prevention and management of cardiovascular disease (CVD). We examined primary care practice adherence to recommended care guidelines associated with the prevention and management of CVD for high risk patients.
Methods
We conducted a secondary analysis of cross-sectional baseline data collected from 84 primary care practices participating in a large quality improvement initiative in Eastern Ontario from 2008 to 2010. We collected medical chart data from 4,931 patients who either had, or were at high risk of developing CVD to study adherence rates to recommended guidelines for CVD care and to examine the proportion of patients at target for clinical markers such as blood pressure, lipid levels and hemoglobin A1c.
Results
Adherence to preventive care recommendations was poor. Less than 10% of high risk patients received a waistline measurement, half of the smokers received cessation advice, and 7.7% were referred to a smoking cessation program. Gaps in care exist for diabetes and kidney disease as 54.9% of patients with diabetes received recommended hemoglobin-A1c screenings, and only 55.8% received an albumin excretion test. Adherence rates to recommended guidelines for coronary artery disease, hypertension, and dyslipidemia were high (>75%); however <50% of patients were at target for blood pressure or LDL-cholesterol levels (37.1% and 49.7% respectively), and only 59.3% of patients with diabetes were at target for hemoglobin-A1c.
Conclusions
There remain significant opportunities for primary care providers to engage high risk patients in prevention activities such as weight management and smoking cessation. Despite high adherence rates for hypertension, dyslipidemia, and coronary artery disease, a significant proportion of patients failed to meet treatment targets, highlighting the complexity of caring for people with multiple chronic conditions.
Trial Registration
NCT00574808
doi:10.1186/1471-2261-12-74
PMCID: PMC3477034  PMID: 22970753
Cardiovascular disease; Primary care; Diabetes; Evidence-based care; Preventive care; Quality of care
13.  Effect of nurse practitioner and pharmacist counseling on inappropriate medication use in family practice 
Canadian Family Physician  2012;58(8):862-868.
Abstract
Objective
To measure the effect of nurse practitioner and pharmacist consultations on the appropriate use of medications by patients.
Design
We studied patients in the intervention arm of a randomized controlled trial. The main trial intervention was provision of multidisciplinary team care and the main outcome was quality and processes of care for chronic disease management.
Setting
Patients were recruited from a single publicly funded family health network practice of 8 family physicians and associated staff serving 10 000 patients in a rural area near Ottawa, Ont.
Participants
A total of 120 patients 50 years of age or older who were on the practice roster and who were considered by their family physicians to be at risk of experiencing adverse health outcomes.
Intervention
A pharmacist and 1 of 3 nurse practitioners visited each patient at his or her home, conducted a comprehensive medication review, and developed a tailored plan to optimize medication use. The plan was developed in consultation with the patient and the patient’s doctor. We assessed medication appropriateness at the study baseline and again 12 to 18 months later.
Main outcome measures
We used the medication appropriateness index to assess medication use. We examined associations between personal characteristics and inappropriate use at baseline and with improvements in medication use at the follow-up assessment. We recorded all drug problems encountered during the trial.
Results
At baseline, 27.2% of medications were inappropriate in some way and 77.7% of patients were receiving at least 1 medication that was inappropriate in some way. At the follow-up assessments these percentages had dropped to 8.9% and 38.6%, respectively (P < .001). Patient characteristics that were associated with receiving inappropriate medication at baseline were being older than 80 years of age (odds ratio [OR] = 5.00, 95% CI 1.19 to 20.50), receiving more than 4 medications (OR = 6.64, 95% CI 2.54 to 17.4), and not having a university-level education (OR = 4.55, 95% CI 1.69 to 12.50).
Conclusion
We observed large improvements in the appropriate use of medications during this trial. This might provide a mechanism to explain some of the reductions in mortality and morbidity observed in other trials of counseling and advice provided by pharmacists and nurses.
Trial registration number
NCT00238836 (ClinicalTrials.gov).
PMCID: PMC3418988  PMID: 22893340
14.  Impact of remuneration and organizational factors on completing preventive manoeuvres in primary care practices 
Background:
Several jurisdictions attempting to reform primary care have focused on changes in physician remuneration. The goals of this study were to compare the delivery of preventive services by practices in four primary care funding models and to identify organizational factors associated with superior preventive care.
Methods:
In a cross-sectional study, we included 137 primary care practices in the province of Ontario (35 fee-for-service practices, 35 with salaried physicians [community health centres], 35 practices in the new capitation model [family health networks] and 32 practices in the established capitation model [health services organizations]). We surveyed 288 family physicians. We reviewed 4108 randomly selected patient charts and assigned prevention scores based on the proportion of eligible preventive manoeuvres delivered for each patient.
Results:
A total of 3284 patients were eligible for at least one of six preventive manoeuvres. After adjusting for patient profile and contextual factors, we found that, compared with prevention scores in practices in the new capitation model, scores were significantly lower in fee-for-service practices (β estimate for effect on prevention score = −6.3, 95% confidence interval [CI] −11.9 to −0.6) and practices in the established capitation model (β = −9.1, 95% CI −14.9 to −3.3) but not for those with salaried remuneration (β = −0.8, 95% CI −6.5 to 4.8). After accounting for physician characteristics and organizational structure, the type of funding model was no longer a statistically significant factor. Compared with reference practices, those with at least one female family physician (β = 8.0, 95% CI 4.2 to 11.8), a panel size of fewer than 1600 patients per full-time equivalent family physician (β = 6.8, 95% CI 3.1 to 10.6) and an electronic reminder system (β = 4.6, 95% CI 0.4 to 8.7) had superior prevention scores. The effect of these three factors was largely but not always consistent across the funding models; it was largely consistent across the preventive manoeuvres.
Interpretation:
No funding model was clearly associated with superior preventive care. Factors related to physician characteristics and practice structure were stronger predictors of performance. Practices with one or more female physicians, a smaller patient load and an electronic reminder system had superior prevention scores. Our findings raise questions about reform initiatives aimed at increasing patient numbers, but they support the adoption of information technology.
doi:10.1503/cmaj.110407
PMCID: PMC3273534  PMID: 22143227
15.  Age equity in different models of primary care practice in Ontario 
Canadian Family Physician  2011;57(11):1300-1309.
Abstract
Objective
To assess whether the model of service delivery affects the equity of the care provided across age groups.
Design
Cross-sectional study.
Setting
Ontario.
Participants
One hundred thirty-seven practices, including traditional fee-for-service practices, salaried community health centres (CHCs), and capitation-based family health networks and health service organizations.
Main outcome measures
To compare the quality of care across age groups using multilevel linear or logistic regressions. Health service delivery measures and health promotion were assessed through patient surveys (N = 5111), which were based on the Primary Care Assessment Tool, and prevention and chronic disease management were assessed, based on Canadian recommendations for care, through chart abstraction (N = 4 108).
Results
Older individuals reported better health service delivery in all models. This age effect ranged from 1.9% to 5.7%, and was larger in the 2 capitation-based models. Individuals aged younger than 30 years attending CHCs had more features of disadvantage (ie, living below the poverty line and without high school education) and were more likely than older individuals to report discussing at least 1 health promotion subject at the index visit. These differences were deemed an appropriate response to greater needs in these younger individuals. The prevention score showed an age-sex interaction in all models, with adherence to recommended care dropping with age for women. These results are largely attributable to the fact that maneuvers recommended for younger women are considerably more likely to be performed than other maneuvers. Chronic disease management scores showed an inverted U relationship with age in fee-for-service practices, family health networks, and health service organizations but not in CHCs.
Conclusion
The salaried model might have an organizational structure that is more conducive to providing appropriate care across age groups. The thrust toward adopting capitation-based payment is unlikely to have an effect on age disparities.
PMCID: PMC3215613  PMID: 22084464
16.  Comparison of primary care models in the prevention of cardiovascular disease - a cross sectional study 
BMC Family Practice  2011;12:114.
Background
Primary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models.
Methods
This is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practice's adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models.
Results
The percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management.
Conclusions
This study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice.
Trial Registration
ClinicalTrials.gov: NCT00574808
doi:10.1186/1471-2296-12-114
PMCID: PMC3215648  PMID: 22008366
17.  Improved delivery of cardiovascular care (IDOCC) through outreach facilitation: study protocol and implementation details of a cluster randomized controlled trial in primary care 
Background
There is a need to find innovative approaches for translating best practices for chronic disease care into daily primary care practice routines. Primary care plays a crucial role in the prevention and management of cardiovascular disease. There is, however, a substantive care gap, and many challenges exist in implementing evidence-based care. The Improved Delivery of Cardiovascular Care (IDOCC) project is a pragmatic trial designed to improve the delivery of evidence-based care for the prevention and management of cardiovascular disease in primary care practices using practice outreach facilitation.
Methods
The IDOCC project is a stepped-wedge cluster randomized control trial in which Practice Outreach Facilitators work with primary care practices to improve cardiovascular disease prevention and management for patients at highest risk. Primary care practices in a large health region in Eastern Ontario, Canada, were eligible to participate. The intervention consists of regular monthly meetings with the Practice Outreach Facilitator over a one- to two-year period. Starting with audit and feedback, consensus building, and goal setting, the practices are supported in changing practice behavior by incorporating chronic care model elements. These elements include (a) evidence-based decision support for providers, (b) delivery system redesign for practices, (c) enhanced self-management support tools provided to practices to help them engage patients, and (d) increased community resource linkages for practices to enhance referral of patients. The primary outcome is a composite score measured at the level of the patient to represent each practice's adherence to evidence-based guidelines for cardiovascular care. Qualitative analysis of the Practice Outreach Facilitators' written narratives of their ongoing practice interactions will be done. These textual analyses will add further insight into understanding critical factors impacting project implementation.
Discussion
This pragmatic, stepped-wedge randomized controlled trial with both quantitative and process evaluations demonstrates innovative methods of implementing large-scale quality improvement and evidence-based approaches to care delivery. This is the first Canadian study to examine the impact of a large-scale multifaceted cardiovascular quality-improvement program in primary care. It is anticipated that through the evaluation of IDOCC, we will demonstrate an effective, practical, and sustainable means of improving the cardiovascular health of patients across Canada.
Trial Registration
ClinicalTrials.gov: NCT00574808
doi:10.1186/1748-5908-6-110
PMCID: PMC3197547  PMID: 21952084
19.  Community orientation in primary care practices 
Canadian Family Physician  2010;56(7):676-683.
ABSTRACT
OBJECTIVE
To determine which of 4 organizational models of primary care in Ontario were more community oriented.
DESIGN
Cross-sectional investigation using practice and provider surveys derived from the Primary Care Assessment Tool, with nested qualitative case studies (2 practices per model).
SETTING
Thirty-five fee-for-service family practices (including family health groups), 32 health service organizations, 35 family health networks, and 35 community health centres (CHCs) in Ontario.
PARTICIPANTS
A total of 137 practices and 363 providers.
MAIN OUTCOME MEASURES
Community orientation (CO) was assessed from the perspectives of the practices and the providers working in them. Practice CO scores reflect activities that practices use to reach out to their communities, assess the needs of their communities, and monitor or evaluate the effectiveness of their programs and services. The self-rated provider CO score reflects providers’ participation in home visits and their perceptions of their own degree of CO.
RESULTS
At the practice level, CHCs had significantly higher CO scores than the other models did (P < .001 for most differences); in fact, the other models rarely reported meaningful levels of CO. Self-rated provider CO scores were also higher in CHCs, but were present in other models as well.
CONCLUSION
Primary care providers in Ontario give themselves high ratings for CO; however, indicators of CO activity at the practice level were found to a significantly higher degree in CHCs than in the other models.
PMCID: PMC2922817  PMID: 20631283
21.  An evaluation of gender equity in different models of primary care practices in Ontario 
BMC Public Health  2010;10:151.
Background
The World Health Organization calls for more work evaluating the effect of health care reforms on gender equity in developed countries. We performed this evaluation in Ontario, Canada where primary care models resulting from reforms co-exist.
Methods
This cross sectional study of primary care practices uses data collected in 2005-2006. Healthcare service models included in the study consist of fee for service (FFS) based, salaried, and capitation based. We compared the quality of care delivered to women and men in practices of each model. We performed multi-level, multivariate regressions adjusting for patient socio-demographic and economic factors to evaluate vertical equity, and adjusting for these and health factors in evaluating horizontal equity. We measured seven dimensions of health service delivery (e.g. accessibility and continuity) and three dimensions of quality of care using patient surveys (n = 5,361) and chart abstractions (n = 4,108).
Results
Health service delivery measures were comparable in women and men, with differences ≤ 2.2% in all seven dimensions and in all models. Significant gender differences in the health promotion subjects addressed were observed. Female specific preventive manoeuvres were more likely to be performed than other preventive care. Men attending FFS practices were more likely to receive influenza immunization than women (Adjusted odds ratio: 1.75, 95% confidence intervals (CI) 1.05, 2.92). There was no difference in the other three prevention indicators. FFS practices were also more likely to provide recommended care for chronic diseases to men than women (Adjusted difference of -11.2%, CI -21.7, -0.8). A similar trend was observed in Community Health Centers (CHC).
Conclusions
The observed differences in the type of health promotion subjects discussed are likely an appropriate response to the differential healthcare needs between genders. Chronic disease care is non equitable in FFS but not in capitation based models. We recommend that efforts to monitor and address gender based differences in the delivery of chronic disease management in primary care be pursued.
doi:10.1186/1471-2458-10-151
PMCID: PMC2856534  PMID: 20331861
22.  Methods for a study of Anticipatory and Preventive multidisciplinary Team Care in a family practice 
Canadian Family Physician  2010;56(2):e73-e83.
BACKGROUND
T o examine the methodology used to evaluate whether focusing the work of nurse practitioners and a pharmacist on frail and at-risk patients would improve the quality of care for such patients.
DESIGN
Evaluation of methodology of a randomized controlled trial including analysis of quantitative and qualitative data over time and analysis of cost-effectiveness.
SETTING
A single practice in a rural area near Ottawa, Ont.
PARTICIPANTS
A total of 241 frail patients, aged 50 years and older, at risk of experiencing adverse health outcomes.
INTERVENTION
At-risk patients were randomly assigned to receive Anticipatory and Preventive Team Care (from their family physicians, 1 of 3 nurse practitioners, and a pharmacist) or usual care.
MAIN OUTCOME MEASURES
The principal outcome for the study was the quality of care for chronic disease management. Secondary outcomes included other quality of care measures and evaluation of the program process and its cost-effectiveness. This article examines the effectiveness of the methodology used. Quantitative data from surveys, administrative databases, and medical records were supplemented with qualitative information from interviews, focus groups, work logs, and study notes.
CONCLUSION
Three factors limit our ability to fully demonstrate the potential effects of this team structure. For reasons outside our control, the intervention duration was shorter than intended; the practice’s physical layout did not facilitate interactions between the care providers; and contamination of the intervention effect into the control arm cannot be excluded. The study used a randomized design, relied on a multifaceted approach to evaluating its effects, and used several sources of data.
TRIAL REGISTRATION NUMBER
NCT00238836 (CONSORT).
PMCID: PMC2821256  PMID: 20154234
23.  Cost-effectiveness of Anticipatory and Preventive multidisciplinary Team Care for complex patients 
Canadian Family Physician  2010;56(1):e20-e29.
OBJECTIVE
To evaluate the cost-effectiveness of Anticipatory and Preventive Team Care (APTCare).
DESIGN
Analysis of data drawn from a randomized controlled trial.
SETTING
A family health network in a rural area near Ottawa, Ont.
PARTICIPANTS
Patients 50 years of age or older at risk of experiencing adverse health outcomes. Analysis of cost-effectiveness was performed for a subsample of participants with at least 1 of the chronic diseases used in the quality of care (QOC) measure (74 intervention and 78 control patients).
INTERVENTIONS
At-risk patients were randomly assigned to receive usual care from their family physicians or APTCare from a collaborative team.
MAIN OUTCOME MEASURES
Cost-effectiveness and the net benefit to society of the APTCare intervention.
RESULTS
Costs not directly associated with delivery of the intervention were similar in the 2 arms: $9121 and $9222 for the APTCare and control arms, respectively. Costs directly associated with the program were $3802 per patient for a total cost per patient of $12 923 and $9222, respectively (P = .033). A 1% improvement in QOC was estimated to cost $407 per patient. Analysis of the net benefit to society in absolute dollars found a breakeven threshold of $750 when statistical significance was required. This implies that society must place a value of at least $750 on a 1% improvement in QOC in order for the intervention to be socially worthwhile. By any of the metrics used, the APTCare intervention was not cost-effective, at least not in a population for which baseline QOC was high.
CONCLUSION
Although our calculations suggest that the APTCare intervention was not cost-effective, our results need the following caveats. The costs of such a newly introduced intervention are bound to be higher than those for an established, up-and-running program. Furthermore, it is possible that some benefits of the secondary preventive measures were not captured in this limited 12- to 18-month study or were simply not measured.
TRIAL REGISTRATION NUMBER
NCT00238836 (CONSORT).
PMCID: PMC2809192  PMID: 20090057
24.  Randomized controlled trial of Anticipatory and Preventive multidisciplinary Team Care 
Canadian Family Physician  2009;55(12):e76-e85.
ABSTRACT
OBJECTIVE
T o examine whether quality of care (QOC) improves when nurse practitioners and pharmacists work with family physicians in community practice and focus their work on patients who are 50 years of age and older and considered to be at risk of experiencing adverse health outcomes.
DESIGN
Randomized controlled trial.
SETTING
A family health network with 8 family physicians, 5 nurses, and 11 administrative personnel serving 10 000 patients in a rural area near Ottawa, Ont.
PARTICIPANTS
Patients 50 years of age and older at risk of experiencing adverse health outcomes (N = 241).
INTERVENTIONS
At-risk patients were randomly assigned to receive usual care from their family physicians or Anticipatory and Preventive Team Care (APTCare) from a collaborative team composed of their physicians, 1 of 3 nurse practitioners, and a pharmacist.
MAIN OUTCOME MEASURES
Quality of care for chronic disease management (CDM) for diabetes, coronary artery disease, congestive heart failure, and chronic obstructive pulmonary disease.
RESULTS
Controlling for baseline demographic characteristics, the APTCare approach improved CDM QOC by 9.2% (P < .001) compared with traditional care. The APTCare intervention also improved preventive care by 16.5% (P < .001). We did not observe significant differences in other secondary outcome measures (intermediate clinical outcomes, quality of life [Short-Form 36 and health-related quality of life scales], functional status [instrumental activities of daily living scale] and service usage).
CONCLUSION
Additional resources in the form of collaborative multidisciplinary care teams with intensive interventions in primary care can improve QOC for CDM in a population of older at-risk patients. The appropriateness of this intervention will depend on its cost-effectiveness.
TRIAL REGISTRATION NUMBER NCT00238836 (CONSORT)
PMCID: PMC2793206  PMID: 20008582
25.  Health promotion activity in primary care: performance of models and associated factors 
Open Medicine  2009;3(3):149-164.
Background
Lifestyle behaviours have significant health and economic consequences. Primary care providers play an important role in promoting healthy behaviours. We compared the performance of primary care models in delivering health promotion and identified practice factors associated with its delivery.
Methods
Surveys were conducted in 137 randomly selected primary care practices in 4 primary care models in Ontario, Canada: 35 community health centres, 35 fee-for-service practices, 35 family health networks and 32 health service organizations. A total of 4861 adult patients who were visiting their family practice participated in the study. Qualitative nested case studies were also conducted at 2 practices per model. A 7-item question was used to evaluate health promotion. The main outcome was whether at least 1 of the 7 health promotion items was discussed at the survey visit. Multilevel logistic regressions were used to compare the models and determine performance-related practice factors.
Results
The rate of health promotion was significantly higher in community health centres than in the other models (the unadjusted difference ranged between 8% and 13%). This finding persisted after controlling for patient and family physician profiles. Factors independently positively associated with health promotion were as follows: reason for visit (for a general checkup: adjusted odds ratio [AOR] 3.34, 95% confidence interval [CI] 2.81–3.97; for care for a chronic disease: AOR 2.03, 95% CI 1.69–2.43), patients having and seeing their own provider (for those not: AOR 0.58, 95% CI 0.43–0.78), number of nurses in the practice (AOR 1.07, 95% CI 1.02–1.12), percentage of female family physicians (AOR 1.38, 95% CI 1.15–1.66), smaller physician panel size (AOR 0.92, 95% CI 0.85–1.01) and longer booking interval (AOR 1.03, 95% CI 1.01–1.04). Providers in interdisciplinary practices viewed health promotion as an integral part of primary care, whereas other providers emphasized the role of relational continuity in effective health promotion.
Conclusion
We have identified several attributes associated with health promotion delivery. These results may assist practice managers and policy-makers in modifying practice attributes to improve health promotion in primary care.
PMCID: PMC3090121  PMID: 21603049

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