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1.  A cross-sectional, population-based study of HIV physicians and outpatient health care use by people with HIV in Ontario 
Background
People with HIV are living longer and their care has shifted towards the prevention and management of comorbidities. However, little is known about who is providing their care. Our objective was to characterize the provision of HIV care in Ontario by physician specialty.
Methods
We conducted a retrospective population-based observational study using linked administrative databases in Ontario, Canada, a single payer health care system. All Ontarians with HIV were identified using a validated case ascertainment algorithm. We examined office-based health care visits for this cohort between April 1, 2009 and March 31, 2012. Physician characteristics were compared between specialty groups. We stratified the frequency and distribution of physician care into three categories: (a) care by physician specialty (family physicians, internal medicine specialists, infectious disease specialists, and other specialists), (b) care based on physician caseload (low, medium or high categorized as ≤5, 6-49 or ≥50 HIV patients per physician), and (c) care that is related to HIV versus unrelated to HIV.
Results
Family physicians were older, graduated earlier, were more often female, and were the only group practicing in rural settings. Unlike other specialists, most family physicians (76.8%) had low-volume caseloads. There were 406,411 outpatient visits made by individuals with HIV; one-third were for HIV care. Family physicians provided the majority of care (53.6% of all visits and 53.9% of HIV visits). Internal medicine specialists provided 4.9% of all visits and 9.6% of HIV visits. Infectious disease specialists provided 12.5% of all visits and 32.7% of HIV visits. Other specialties provided 29.0% of visits; most of these (33.0%) were to psychiatrists.
Conclusions
The distribution of visits to physicians caring for HIV patients reveals different patterns of health care delivery by specialty and HIV caseload. Further research should delineate how specialties share care for this population and how different patterns relate to quality of care.
doi:10.1186/s12913-015-0723-5
PMCID: PMC4334842
Human immunodeficiency syndrome; Primary health care; Chronic disease; Comorbidity; Multimorbidity; Health services delivery
2.  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
4.  Quality of cardiovascular disease care in Ontario’s primary care practices: a cross sectional study examining differences in guideline adherence by patient sex 
BMC Family Practice  2014;15:123.
Background
Women are disproportionately affected by cardiovascular disease, often experiencing poorer outcomes following a cardiovascular event. Evidence points to inequities in processes of care as a potential contributing factor. This study sought to determine whether any sex differences exist in adherence to process of care guidelines for cardiovascular disease within primary care practices in Ontario, Canada.
Methods
This is a secondary analysis of pooled cross-sectional baseline data collected through a larger quality improvement initiative known as the Improved Delivery of Cardiovascular Care (IDOCC). Chart abstraction was performed for 4,931 patients from 84 primary care practices in Eastern Ontario who had, or were at high risk of, cardiovascular disease. Measures examining adherence to guidelines associated with nine areas of cardiovascular care (coronary artery disease, peripheral vascular disease (PVD), stroke/transient ischemic attack, chronic kidney disease, diabetes, dyslipidemia, hypertension, smoking cessation, and weight management) were collected. Multivariable logistic regression analysis was performed to evaluate sex differences, adjusting for age, physician remuneration, and rurality.
Results
Women were significantly less likely to have their lipid profiles taken (OR = 1.17, 95% CI 1.03-1.33), be prescribed lipid lowering medication for dyslipidemia (OR = 1.54, 95% CI 1.20-1.97), and to be prescribed ASA following stroke (OR = 1.56, 95% CI 1.39-1.75). Women with PVD were significantly less likely to be prescribed ACE inhibitors and/or angiotensin receptor blockers (OR = 1.74, 95% CI 1.25-2.41) and lipid lowering medications (OR = 1.95, 95% CI 1.46-2.62) or ASA (OR = 1.59, 95% CI 1.43-1.78). However, women were more likely to have two blood pressure measurements taken and to be referred to a dietician or weight loss program. Male patients with diabetes were less likely to be prescribed glycemic control medication (OR = 0.84, 95% CI 0.74-0.86).
Conclusions
Sex disparities exist in the quality of cardiovascular care in Canadian primary care practices, which tend to favour men. Women with PVD have a particularly high risk of not receiving appropriate medications. Our findings indicate that improvements in care delivery should be made to address these issues, particularly with regard to the prescribing of recommended medications for women, and preventive measures for men.
doi:10.1186/1471-2296-15-123
PMCID: PMC4069341  PMID: 24938405
Sex equity; Primary care; Cardiovascular disease; Guideline adherence
5.  Providing high-quality care in primary care settings 
Canadian Family Physician  2014;60(5):e281-e289.
Abstract
Objective
To gain a deeper understanding of how primary care (PC) practices belonging to different models manage resources to provide high-quality care.
Design
Multiple-case study embedded in a cross-sectional study of a random sample of 37 practices.
Setting
Three regions of Quebec.
Participants
Health care professionals and staff of 5 PC practices.
Methods
Five cases showing above-average results on quality-of-care indicators were purposefully selected to contrast on region, practice size, and PC model. Data were collected using an organizational questionnaire; the Team Climate Inventory, which was completed by health care professionals and staff; and 33 individual interviews. Detailed case histories were written and thematic analysis was performed.
Main findings
The core common feature of these practices was their ongoing effort to make trade-offs to deliver services that met their vision of high-quality care. These compromises involved the same 3 areas, but to varying degrees depending on clinic characteristics: developing a shared vision of high-quality care; aligning resource use with that vision; and balancing professional aspirations and population needs. The leadership of the physician lead was crucial. The external environment was perceived as a source of pressure and dilemmas rather than as a source of support in these matters.
Conclusion
Irrespective of their models, PC practices’ pursuit of high-quality care is based on a vision in which accessibility is a key component, balanced by appropriate management of available resources and of external environment expectations. Current PC reforms often create tensions rather than support PC practices in their pursuit of high-quality care.
PMCID: PMC4020666  PMID: 24829023
6.  A cross-sectional, population-based study measuring comorbidity among people living with HIV in Ontario 
BMC Public Health  2014;14:161.
Background
As people diagnosed with HIV and receiving combination antiretroviral therapy are now living longer, they are likely to acquire chronic conditions related to normal ageing and the effects of HIV and its treatment. Comordidities for people with HIV have not previously been described from a representative population perspective.
Methods
We used linked health administrative data from Ontario, Canada. We applied a validated algorithm to identify people with HIV among all residents aged 18 years or older between April 1, 1992 and March 31, 2009. We randomly selected 5 Ontario adults who were not identified with HIV for each person with HIV for comparison. Previously validated case definitions were used to identify persons with mental health disorders and any of the following physical chronic diseases: diabetes, congestive heart failure, acute myocardial infarction, stroke, hypertension, asthma, chronic obstructive lung disease, peripheral vascular disease and end-stage renal failure. We examined multimorbidity prevalence as the presence of at least two physical chronic conditions, or as combined physical-mental health multimorbidity. Direct age-sex standardized rates were calculated for both cohorts for comparison.
Results
34.4% (95% confidence interval (CI) 33.6% to 35.2%) of people with HIV had at least one other physical condition. Prevalence was especially high for mental health conditions (38.6%), hypertension (14.9%) and asthma (12.7%). After accounting for age and sex differences, people with HIV had significantly higher prevalence of all chronic conditions except myocardial infarction and hypertension, as well as substantially higher multimorbidity (prevalence ratio 1.30, 95% CI 1.18 to 1.44) and combined physical-mental health multimorbidity (1.79, 95% CI 1.65 to 1.94). Prevalence of multimorbidity among people with HIV increased with age. The difference in prevalence of multimorbidity between the two cohorts was more pronounced among women.
Conclusion
People living with HIV in Ontario, especially women, had higher prevalence of comorbidity and multimorbidity than the general population. Quantifying this morbidity at the population level can help inform healthcare delivery requirements for this complex population.
doi:10.1186/1471-2458-14-161
PMCID: PMC3933292  PMID: 24524286
Human immunodeficiency syndrome; Primary health care; Chronic disease; Comorbidity; Multimorbidity
7.  Primary care quality improvement from a practice facilitator’s perspective 
BMC Family Practice  2014;15:23.
Background
Practice facilitation has proven to be effective at improving care delivery. Practice facilitators are healthcare professionals who work with and support other healthcare providers. To the best of our knowledge, very few studies have explored the perspective of facilitators. The objective of this study was to gain insight into the barriers that facilitators face during the facilitation process and to identify approaches used to overcome these barriers to help practices move towards positive change.
Methods
We conducted semi-structured interviews with four practice facilitators who worked with 84 primary care practices in Eastern Ontario, Canada over a period of five years (2007–2012). The transcripts were analyzed independently by three members of the research team using an open coding technique. A qualitative data analysis using immersion/crystallization technique was applied to interpret the interview transcripts.
Results
Common barriers identified by the facilitators included accessibility to the practice (e.g., difficulty scheduling meetings, short meetings), organizational behaviour (team organization, team conflicts, etc.), challenges with practice engagement (e.g., lack of interest, lack of trust), resistance to change, and competing priorities. To help practices move towards positive change the facilitators had to tailor their approach, integrate themselves, be persistent with practices, and exhibit flexibility.
Conclusions
The consensus on redesigning and transforming primary care in North America and around the world is rapidly growing. Practice facilitation has been pivotal in materializing the transformation in the way primary care practices deliver care. This study provides an exclusive insight into facilitator approaches which will assist the design and implementation of small- and large-scale facilitation interventions.
doi:10.1186/1471-2296-15-23
PMCID: PMC3931473  PMID: 24490746
Practice facilitation; Practice facilitators; Cardiovascular health; Primary care; Quality improvement; Practice culture
8.  Fostering excellence 
Canadian Family Physician  2014;60(2):e105-e112.
Abstract
Problem addressed
A key priority in primary health care research is determining how to ensure the advancement of new family physician clinician investigators (FP-CIs). However, there is little consensus on what expectations should be implemented for new investigators to ensure the successful and timely acquisition of independent salary support.
Objective of program
Support new FP-CIs to maximize early career research success.
Program description
This program description aims to summarize the administrative and financial support provided by the C.T. Lamont Primary Health Care Research Centre in Ottawa, Ont, to early career FP-CIs; delineate career expectations; and describe the results in terms of research productivity on the part of new FP-CIs.
Conclusion
Family physician CI’s achieved a high level of research productivity during their first 5 years, but most did not secure external salary support. It might be unrealistic to expect new FP-CIs to be self-financing by the end of 5 years. This is a career-development program, and supporting new career FP-CIs requires a long-term investment. This understanding is critical to fostering and strengthening sustainable primary care research programs.
PMCID: PMC3922578  PMID: 24522688
9.  Improving Collaboration between Public Health and Family Health Teams in Ontario 
Healthcare Policy  2013;8(3):e93-e104.
Objectives:
To identify and explore areas where responsibilities may overlap between family health teams (FHTs) and public health units (PHUs); to identify facilitators or barriers to collaboration; and to identify priority areas for increased collaboration.
Design and context:
Cross-sectional mixed-methods study of FHTs and PHUs in Ontario, Canada, consisting of a postal survey, key informant interviews and a roundtable meeting.
Results:
The survey response rate was 46%. Direct client-based services such as giving immunizations, promoting prenatal health and nutrition, and counselling related to smoking cessation were identified as the top three areas of perceived overlap. The greatest interest in collaboration was expressed in the areas of emergency planning and preparedness, immunization, and prenatal health and nutrition. Good communication with a clear understanding of roles and functions was the most important facilitator, and lack of resources and absence of a clear provincial mandate and direction to collaborate were identified as significant barriers.
Conclusions:
Small, simple client-based projects of interest to both kinds of organization would be the best way to move forward in the short term. Improving communication between FHTs and PHUs, understanding of roles and functions, the use of shared or interoperable information systems and greater clarity from government on the ways in which these two key sectors of the healthcare system are intended to work together were identified as important for the success of increased collaboration.
PMCID: PMC3999554  PMID: 23968630
10.  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
11.  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
12.  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
13.  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
14.  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
15.  Decision making in family medicine 
Canadian Family Physician  2013;59(10):1084-1094.
Abstract
Objective
To compare the ability of users of 2 medical search engines, InfoClinique and the Trip database, to provide correct answers to clinical questions and to explore the perceived effects of the tools on the clinical decision-making process.
Design
Randomized trial.
Setting
Three family medicine units of the family medicine program of the Faculty of Medicine at Laval University in Quebec city, Que.
Participants
Fifteen second-year family medicine residents.
Intervention
Residents generated 30 structured questions about therapy or preventive treatment (2 questions per resident) based on clinical encounters. Using an Internet platform designed for the trial, each resident answered 20 of these questions (their own 2, plus 18 of the questions formulated by other residents, selected randomly) before and after searching for information with 1 of the 2 search engines. For each question, 5 residents were randomly assigned to begin their search with InfoClinique and 5 with the Trip database.
Main outcome measures
The ability of residents to provide correct answers to clinical questions using the search engines, as determined by third-party evaluation. After answering each question, participants completed a questionnaire to assess their perception of the engine’s effect on the decision-making process in clinical practice.
Results
Of 300 possible pairs of answers (1 answer before and 1 after the initial search), 254 (85%) were produced by 14 residents. Of these, 132 (52%) and 122 (48%) pairs of answers concerned questions that had been assigned an initial search with InfoClinique and the Trip database, respectively. Both engines produced an important and similar absolute increase in the proportion of correct answers after searching (26% to 62% for InfoClinique, for an increase of 36%; 24% to 63% for the Trip database, for an increase of 39%; P = .68). For all 30 clinical questions, at least 1 resident produced the correct answer after searching with either search engine. The mean (SD) time of the initial search for each question was 23.5 (7.6) minutes with InfoClinique and 22.3 (7.8) minutes with the Trip database (P = .30). Participants’ perceptions of each engine’s effect on the decision-making process were very positive and similar for both search engines.
Conclusion
Family medicine residents’ ability to provide correct answers to clinical questions increased dramatically and similarly with the use of both InfoClinique and the Trip database. These tools have strong potential to increase the quality of medical care.
PMCID: PMC3796978  PMID: 24130286
16.  Characteristics of primary care practices associated with high quality of care 
Background:
No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care.
Methods:
We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling.
Results:
The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0–35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8–14.4), presence of allied health professionals (15.3; 95% CI 5.4–25.2) and/or specialist physicians (19.6; 95% CI 8.3–30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0–12.4) and average organizational access to the practice (4.9; 95% CI 2.6–7.2). The number of physicians (1.2; 95% CI 0.6–1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1–2.5) were modestly associated with high-quality care.
Interpretation:
We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.
doi:10.1503/cmaj.121802
PMCID: PMC3761041  PMID: 23877669
17.  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
18.  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
19.  Family physician enabling attitudes: a qualitative study of patient perceptions 
BMC Family Practice  2013;14:8.
Background
Family physicians frequently interact with people affected by chronic diseases, placing them in a privileged position to enable patients to gain control over and improve their health. Soliciting patients’ perceptions about how their family physician can help them in this process is an essential step to promoting enabling attitudes among these health professionals. In this study, we aimed to identify family physician enabling attitudes and behaviours from the perspective of patients with chronic diseases.
Methods
We conducted a descriptive qualitative study with 30 patients, 35 to 75 years of age presenting at least one common chronic disease, recruited in primary care clinics in two regions of Quebec, Canada. Data were collected through in-depth interviews and were analyzed using thematic analysis.
Results
Family physician involvement in a partnership was perceived by participants as the main attribute of enablement. Promoting patient interests in the health care system was also important. Participants considered that having their situation taken into account maximized the impact of their physician’s interventions and allowed the legitimization of their feelings. They found their family physician to be in a good position to acknowledge and promote their expertise, and to help them maintain hope.
Conclusions
From the patient’s perspective, their partnership with their family physician is the most important aspect of enablement.
doi:10.1186/1471-2296-14-8
PMCID: PMC3556105  PMID: 23305144
Power (psychology); Enablement; Patient-centred care; Family practice; Primary health care; Chronic disease
20.  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
21.  Primary Care Reform: Can Quebec's Family Medicine Group Model Benefit from the Experience of Ontario's Family Health Teams? 
Healthcare Policy  2011;7(2):e122-e135.
Canadian politicians, decision-makers, clinicians and researchers have come to agree that reforming primary care services is a key strategy for improving healthcare system performance. However, it is only more recently that real transformative initiatives have been undertaken in different Canadian provinces. One model that offers promise for improving primary care service delivery is the family medicine group (FMG) model developed in Quebec. A FMG is a group of physicians working closely with nurses in the provision of services to enrolled patients on a non-geographic basis. The objectives of this paper are to analyze the FMG's potential as a lever for improving healthcare system performance and to discuss how it could be improved. First, we briefly review the history of primary care in Quebec. Then we present the FMG model in relation to the four key healthcare system functions identified by the World Health Organization: (a) funding, (b) generating human and technological resources, (c) providing services to individuals and communities and (d) governance. Next, we discuss possible ways of advancing primary care reform, looking particularly at the family health team (FHT) model implemented in the province of Ontario. We conclude with recommendations to inspire other initiatives aimed at transforming primary care.
PMCID: PMC3287954  PMID: 23115575
22.  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
23.  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
24.  Assessing methods for measurement of clinical outcomes and quality of care in primary care practices 
Purpose
To evaluate the appropriateness of potential data sources for the population of performance indicators for primary care (PC) practices.
Methods
This project was a cross sectional study of 7 multidisciplinary primary care teams in Ontario, Canada. Practices were recruited and 5-7 physicians per practice agreed to participate in the study. Patients of participating physicians (20-30) were recruited sequentially as they presented to attend a visit. Data collection included patient, provider and practice surveys, chart abstraction and linkage to administrative data sets. Matched pairs analysis was used to examine the differences in the observed results for each indicator obtained using multiple data sources.
Results
Seven teams, 41 physicians, 94 associated staff and 998 patients were recruited. The survey response rate was 81% for patients, 93% for physicians and 83% for associated staff. Chart audits were successfully completed on all but 1 patient and linkage to administrative data was successful for all subjects. There were significant differences noted between the data collection methods for many measures. No single method of data collection was best for all outcomes. For most measures of technical quality of care chart audit was the most accurate method of data collection. Patient surveys were more accurate for immunizations, chronic disease advice/information dispensed, some general health promotion items and possibly for medication use. Administrative data appears useful for indicators including chronic disease diagnosis and osteoporosis/ breast screening.
Conclusions
Multiple data collection methods are required for a comprehensive assessment of performance in primary care practices. The choice of which methods are best for any one particular study or quality improvement initiative requires careful consideration of the biases that each method might introduce into the results. In this study, both patients and providers were willing to participate in and consent to, the collection and linkage of information from multiple sources that would be required for such assessments.
doi:10.1186/1472-6963-12-214
PMCID: PMC3431283  PMID: 22824551
Performance measurement; Primary care; Quality of care; Evaluation
25.  Estimating patient demographic profiles from practice location 
Canadian Family Physician  2012;58(4):414-419.
Abstract
Objective
To test the accuracy of imputing a practice population’s average socioeconomic characteristics (such as average education levels and average income) using census data centred on the location of the practice.
Design
Comparison of census data with survey data collected in primary care offices.
Setting
Ontario.
Participants
A cross-sectional sample of patients from 116 urban practices.
Main outcome measures
Patient data were compared with census data at different levels of aggregation using mean absolute relative error (ARE), median ARE, and Spearman rank correlations.
Results
A total of 4413 patient surveys were collected. Differences between patient profiles and census data were large. Most mean AREs were clustered between 0.70 and 0.80, and median AREs were as high as 1.67. Correlations were low (ρ = 0.02) to moderate (ρ = 0.48). These results held across both levels of aggregation.
Conclusion
The use of imputation techniques based on practice location is inadvisable, given the large differences that were observed.
PMCID: PMC3325457  PMID: 22611611

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