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.

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

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).

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.

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.

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

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

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.

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.

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).

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).

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)

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.

Background

Many industrialized nations have initiated reforms in the organization and delivery of primary care. In Ontario, Canada, salaried and capitation models have been introduced in an attempt to address the deficiencies of the traditional fee-for-service model. The Ontario setting therefore provides an opportunity to compare these funding models within a region that is largely homogeneous with respect to other factors that influence care delivery. We sought to compare the performance of the models across a broad array of dimensions and to understand the underlying practice factors associated with superior performance. We report on the methodology grounding this work.

Methods

Between 2004 and 2006 we conducted a cross-sectional mixed-methods study of the fee-for-service model, including family health groups, family health networks, community health centres and health service organizations. The study was guided by a conceptual framework for primary care organizations. Performance across a large number of primary care attributes was evaluated through surveys and chart abstractions. Nested case studies generated qualitative provider and patient data from 2 sites per model along with insights from key informants and policy-makers familiar with all models.

Results

The study recruited 137 practices. We conducted 363 provider surveys and 5361 patient surveys, and we performed 4108 chart audits. We also conducted interviews with 40 family physicians, 6 nurse practitioners, 24 patients and 8 decision-makers. The practice recruitment rate was 45%; it was lowest in fee-for-service practices (23%) and in family health networks (37%). A comparison with all Ontario practices in these models using health administrative data demonstrated that our sample was adequately representative. The patient participation (82%) and survey scale completion (93%) rates were high.

Conclusions

This article details our approach to performing a comprehensive evaluation of primary care models and may be a useful resource for researchers interested in primary care evaluation.

OBJECTIVE

To explore whether a home-based intermediate care program in a large Canadian city lowers the cost of care and to look at whether such home-based programs could be a solution to the increasing demands on Canadian hospitals.

DESIGN

Single-arm study with historical controls.

SETTING

Department of Family Medicine at the Ottawa Hospital (Civic campus) in Ontario.

PARTICIPANTS

Patients requiring hospitalization for acute care. Participants were matched with historical controls based on case-mix, most responsible diagnosis, and level of complexity.

INTERVENTIONS

Placement in the home-based intermediate care program. Daily home visits from the nurse practitioner and 24-hour access to care by telephone.

MAIN OUTCOME MEASURES

Multivariate regression models were used to estimate the effect of the program on 5 outcomes: length of stay in hospital, cost of care substituted for hospitalization (Canadian dollars), readmission for a related diagnosis, readmission for any diagnosis, and costs incurred by community home-care services for patients following discharge from hospital.

RESULTS

The outcomes of 43 hospital admissions were matched with those of 363 controls. Patients enrolled in the program stayed longer in hospital (coefficient 3.3 days, P < .001), used more community care services following discharge (coefficient $729, P = .007), and were more likely to be readmitted to hospital within 3 months of discharge (coefficient 17%, P = .012) than patients treated in hospital. Total substituted costs of home-based care were not significantly different from the costs of hospitalization (coefficient -$501, P = .11).

CONCLUSION

While estimated cost savings were not statistically significant, the limitations of our study suggest that we underestimated these savings. In particular, the economic inefficiencies of a small immature program and the inability to control for certain factors when selecting historical controls affected our results. Further research is needed to determine the economic effect of mature home-based programs.

OBJECTIVE

To examine the feasibility and efficacy of integrating home health monitoring into a primary care setting.

DESIGN

A mixed method was used for this pilot study. It included in-depth interviews, focus groups, and surveys.

SETTING

A semirural family health network in eastern Ontario comprising 8 physicians and 5 nurses caring for approximately 10 000 patients.

PARTICIPANTS

Purposeful sample of 22 patients chosen from the experimental group of 120 patients 50 years old or older in a larger randomized controlled trial (N = 240). These patients had chronic illnesses and were identified as being at risk based on objective criteria and physician assessment.

INTERVENTIONS

Between November 2004 and March 2006, 3 nurse practitioners and a pharmacist installed telehomecare units with 1 or more peripheral devices (eg, blood-pressure monitor, weight scale, glucometer) in patients’ homes. The nurse practitioners incorporated individualized instructions for using the unit into each patient’s care plan. Patients used the units every morning for collecting data, entering values into the system either manually or directly through supplied peripherals. The information was transferred to a secure server and was then uploaded to a secure Web-based application that allowed care providers to access and review it from any location with Internet access. The devices were monitored in the office on weekdays by the nurse practitioners.

MAIN OUTCOME MEASURES

Acceptance and use of the units, patients’ and care providers’ satisfaction with the system, and patients’ demographic and health characteristics.

RESULTS

All 22 patients, 12 men and 10 women with an average age of 73 years (range 60 to 88 years), agreed to participate. Most were retired, and a few were receiving community services. Common diagnoses included hypertension, diabetes, cardiovascular disease, and chronic obstructive pulmonary disease. All patients had blood pressure monitors installed, 11 had wired weight scales, 5 had glucometers, and 5 had pulse oximeters. The units were in place for 9 to 339 days. Three patients asked to have the systems removed early because they did not use them or found them inconvenient. The other patients and their informal caregivers found the technology user-friendly and useful. Health care providers were satisfied with the technology and found the equipment useful. They thought it might reduce the number of office visits patients made and help track long-term trends.

CONCLUSION

These pilot results demonstrate that telehomecare monitoring in a collaborative care community family practice is feasible and well used, and might improve access to and quality of care.

Background

Hospital in the home programs have been implemented in several countries and have been shown to be safe substitutions (alternatives) to in-patient hospitalization. These programs may offer a solution to the increasing demands made on tertiary care facilities and to surge capacity. We investigated the acceptance of this type of care provision with nurse practitioners as the designated principal home care providers in a family medicine program in a large Canadian urban setting.

Methods

Patients requiring hospitalization to the family medicine service ward, for any diagnosis, who met selection criteria, were invited to enter the hospital in the home program as an alternative to admission. Participants in the hospital in the home program, their caregivers, and the physicians responsible for their care were surveyed about their perceptions of the program. Nurse practitioners, who provided care, were surveyed and interviewed.

Results

Ten percent (104) of admissions to the ward were screened, and 37 patients participated in 44 home hospital admissions. Twenty nine patient, 17 caregiver and 38 provider surveys were completed. Most patients (88%–100%) and caregivers (92%–100%) reported high satisfaction levels with various aspects of health service delivery. However, a significant proportion in both groups stated that they would select to be treated in-hospital should the need arise again. This was usually due to fears about the safety of the program. Physicians (98%–100%) and nurse practitioners also rated the program highly. The program had virtually no negative impact on the physician workload. However nurse practitioners felt that the program did not utilize their full expertise.

Conclusion

Provision of hospital level care in the home is well received by patients, their caregivers and health care providers. As a new program, investment in patient education about program safety may be necessary to ensure its long term success. A small proportion of hospital admissions were screened for this program. Appropriate dissemination of program information to family physicians should help buy-in and participation. Nurse practitioners' skills may not be optimally utilized in this setting.