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2.  Who gets a family physician through centralized waiting lists? 
BMC Family Practice  2015;16:10.
North American patients are experiencing difficulties in securing affiliations with family physicians. Centralized waiting lists are increasingly being used in Organisation for Economic Co-operation and Development countries to improve access. In 2011, the Canadian province of Quebec introduced new financial incentives for family physicians’ enrolment of orphan patients through centralized waiting lists, the Guichet d’accès aux clientèles orphelines, with higher payments for vulnerable patients. This study analyzed whether any significant changes were observed in the numbers of patient enrolments with family physicians’ after the introduction of the new financial incentives. Prior to then, financial incentives had been offered for enrolment of vulnerable patients only and there were no incentives for enrolling non-vulnerable patients. After 2011, financial incentives were also offered for enrolment of non-vulnerable patients, while those for enrolment of vulnerable patients were doubled.
A longitudinal quantitative analysis spanning a five-year period (2008–2013) was performed using administrative databases covering all patients enrolled with family physicians through centralized waiting lists in the province of Quebec (n = 494,697 patients). Mixed regression models for repeated-measures were used.
The number of patients enrolled with a family physician through centralized waiting lists more than quadrupled after the changes in financial incentives. Most of this increase involved non-vulnerable patients. After the changes, 70% of patients enrolled with a family physician through centralized waiting lists were non-vulnerable patients, most of whom had been referred to the centralized waiting lists by the physician who enrolled them, without first being registered in those lists or having to wait because of their priority level.
Centralized waiting lists linked to financial incentives increased the number of family physicians’ patient enrolments. However, although vulnerable patients were supposed to be given precedence, physicians favoured enrolment of healthier patients over those with greater health needs and higher assessed priority. These results suggest that introducing financial incentives without appropriate regulations may lead to opportunistic use of the incentive system with unintended policy consequences.
PMCID: PMC4328670  PMID: 25649074
Payment; Incentives; Centralized waiting lists; Registry; Enrolment; Vulnerable patients
3.  Effects of practice setting on GPs’ provision of care 
Canadian Family Physician  2014;60(10):e485-e492.
To define a physician classification system based on practice settings and to analyze the service provision associated with those classifications.
A cross-sectional, retrospective study.
Province of Quebec.
All GPs in Quebec in 2002 who had been practising for at least 2 years.
Main outcome measures
Practice setting variables were based on physician income in the different settings. Service provision was assessed using indicators related to continuity, comprehensiveness, accessibility, and productivity of services provided by the GPs. A multiple correspondence analysis with ascending hierarchical classification was conducted to construct the taxonomy of GPs based on their practice settings.
Our study produced 7 practice setting models. Two were essentially single-practice models. The 5 others combined several settings. Service provision varied from one model to another. Continuity was greater in the private practice model, in which older GPs were predominant, while accessibility was greater in multi-institutional practice models, in which younger GPs were more active.
To ensure balance between continuity, accessibility, and comprehensiveness in primary care services provided by GPs, it is important to consider the service provision associated with different practice models.
PMCID: PMC4196834  PMID: 25316763
4.  Impact of Québec’s healthcare reforms on the organization of primary healthcare (PHC): a 2003-2010 follow-up 
Healthcare reforms initiated in the early 2000s in Québec involved the implementation of new modes of primary healthcare (PHC) delivery and the creation of Health and Social Services Centers (HSSCs) to support it. The objective of this article is to assess and explain the degree of PHC organizational change achieved following these reforms.
We conducted two surveys of PHC organizations, in 2005 and 2010, in two regions of the province of Québec, Canada. From the responses to these surveys, we derived a measure of organizational change based on an index of conformity to an ideal type (ICIT). One set of explanatory variables was contextual, related to coercive, normative and mimetic influences; the other consisted of organizational variables that measured receptivity towards new PHC models. Multilevel analyses were performed to examine the relationships between ICIT change in the post-reform period and the explanatory variables.
Positive results were attained, as expressed by increase in the ICIT score in the post-reform period, mainly due to implementation of new types of PHC organizations (Family Medicine Groups and Network Clinics). Organizational receptivity was the main explanatory variable mediating the effect of coercive and mimetic influences. Normative influence was not a significant factor in explaining changes.
Changes were modest at the system level but important with regard to new forms of PHC organizations. The top-down decreed reform was a determining factor in initiating change whereas local coercive and normative influences did not play a major role. The exemplar role played by certain PHC organizations through mimetic influence was more important. Receptivity of individual organizations was both a necessary condition and a mediating factor in influencing change. This supports the view that a combination of top-down and bottom-up strategy is best suited for achieving substantial changes in PHC local organization.
PMCID: PMC4035759  PMID: 24886490
Primary healthcare organization; Healthcare reform; Organizational change; Family practice
5.  Primary Healthcare Solo Practices: Homogeneous or Heterogeneous? 
Introduction. Solo practices have generally been viewed as forming a homogeneous group. However, they may differ on many characteristics. The objective of this paper is to identify different forms of solo practice and to determine the extent to which they are associated with patient experience of care. Methods. Two surveys were carried out in two regions of Quebec in 2010: a telephone survey of 9180 respondents from the general population and a postal survey of 606 primary healthcare (PHC) practices. Data from the two surveys were linked through the respondent's usual source of care. A taxonomy of solo practices was constructed (n = 213), using cluster analysis techniques. Bivariate and multilevel analyses were used to determine the relationship of the taxonomy with patient experience of care. Results. Four models were derived from the taxonomy. Practices in the “resourceful networked” model contrast with those of the “resourceless isolated” model to the extent that the experience of care reported by their patients is more favorable. Conclusion. Solo practice is not a homogeneous group. The four models identified have different organizational features and their patients' experience of care also differs. Some models seem to offer a better organizational potential in the context of current reforms.
PMCID: PMC3913485  PMID: 24523964
6.  Reforming healthcare systems on a locally integrated basis: is there a potential for increasing collaborations in primary healthcare? 
Over the past decade, in the province of Quebec, Canada, the government has initiated two consecutive reforms. These have created a new type of primary healthcare – family medicine groups (FMGs) – and have established 95 geographically defined local health networks (LHNs) across the province. A key goal of these reforms was to improve collaboration among healthcare organizations. The objective of the paper is to analyze the impact of these reforms on the development of collaborations among primary healthcare practices and between these organisations and hospitals both within and outside administrative boundaries of the local health networks.
We surveyed 297 primary healthcare practices in 23 LHNs in Quebec’s two most populated regions (Montreal & Monteregie) in 2005 and 2010. We characterized collaborations by measuring primary healthcare practices’ formal or informal arrangements among themselves or with hospitals for different activities. These collaborations were measured based on the percentage of clinics that identified at least one collaborative activity with another organization within or outside of their local health network. We created measures of collaboration for different types of primary healthcare practices: first- and second-generation FMGs, network clinics, local community services centres (CLSCs) and private medical clinics. We compared their situations in 2005 and in 2010 to observe their evolution.
Our results showed different patterns of evolution in inter-organizational collaboration among different types of primary healthcare practices. The local health network reform appears to have had an impact on territorializing collaborations firstly by significantly reducing collaborations outside LHNs areas for all types of primary healthcare practices, including new type of primary healthcare and CLSCs, and secondly by improving collaborations among healthcare organizations within LHNs areas for all organizations. This is with the exception of private medical clinics, where collaborations decreased both outside and within LHNs.
Health system reforms aimed at creating geographically based networks influenced primary healthcare practices’ both among themselves (horizontal collaborations) and with hospitals (vertical collaborations). There is evidence of increased collaborations within defined geographic areas, particularly among new type of primary healthcare.
PMCID: PMC3750424  PMID: 23835105
Primary care; Network; Inter-organization collaboration
7.  Constructing Taxonomies to Identify Distinctive Forms of Primary Healthcare Organizations 
ISRN Family Medicine  2013;2013:798347.
Background. Primary healthcare (PHC) renewal gives rise to important challenges for policy makers, managers, and researchers in most countries. Evaluating new emerging forms of organizations is therefore of prime importance in assessing the impact of these policies. This paper presents a set of methods related to the configurational approach and an organizational taxonomy derived from our analysis. Methods. In 2005, we carried out a study on PHC in two health and social services regions of Quebec that included urban, suburban, and rural areas. An organizational survey was conducted in 473 PHC practices. We used multidimensional nonparametric statistical methods, namely, multiple correspondence and principal component analyses, and an ascending hierarchical classification method to construct a taxonomy of organizations. Results. PHC organizations were classified into five distinct models: four professional and one community. Study findings indicate that the professional integrated coordination and the community model have great potential for organizational development since they are closest to the ideal type promoted by current reforms. Conclusion. Results showed that the configurational approach is useful to assess complex phenomena such as the organization of PHC. The analysis highlights the most promising organizational models. Our study enhances our understanding of organizational change in health services organizations.
PMCID: PMC4041222  PMID: 24959575
8.  Validation of Instruments to Evaluate Primary Healthcare from the Patient Perspective: Overview of the Method 
Healthcare Policy  2011;7(Spec Issue):31-46.
Patient evaluations are an important part of monitoring primary healthcare reforms, but there is little comparative information available to guide evaluators in the choice of instruments or to determine their relevance for Canada.
To compare values and the psychometric performances of validated instruments thought to be most pertinent to the Canadian context for evaluating core attributes of primary healthcare.
Among validated instruments in the public domain, we selected six: the Primary Care Assessment Survey (PCAS); the Primary Care Assessment Tool – Short Form (PCAT-S); the Components of Primary Care Index (CPCI); the first version of the EUROPEP (EUROPEP-I); the Interpersonal Processes of Care Survey, version II (IPC-II); and part of the Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS). We mapped subscales to operational definitions of attributes. All were administered to a sample of adult service users balanced by English/French language (in Nova Scotia and Quebec, respectively), urban/rural residency, high/low education and overall care experience. The sample was recruited from previous survey respondents, newspaper advertisements and community posters. We used common factor analysis to compare our factor resolution for each instrument to that of the developers.
Our sample of 645 respondents was approximately balanced by design variables, but considerable effort was required to recruit low-education and poor-experience respondents. Subscale scores are statistically different by excellent, average and poor overall experience, but interpersonal communication and respectfulness scores were the most discriminating of overall experience. We found fewer factors than did the developers, but when constrained to the number of expected factors, our item loadings were largely similar to those found by developers. Subscale reliability was equivalent to or higher than that reported by developers.
These instruments perform similarly in the Canadian context to their original development context, and can be used with confidence. Interpersonal and respectfulness scores are most discriminating of excellent, average or poor overall experience and are crucial dimensions of patient evaluations.
PMCID: PMC3399433  PMID: 23205034
9.  Relational Continuity from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments 
Healthcare Policy  2011;7(Spec Issue):124-138.
The operational definition of relational continuity is “a therapeutic relationship between a patient and one or more providers that spans various healthcare events and results in accumulated knowledge of the patient and care consistent with the patient's needs.”
To examine how well relational continuity is measured in validated instruments that evaluate primary healthcare from the patient's perspective.
645 adults with at least one healthcare contact in the previous 12 months responded to six instruments that evaluate primary healthcare. Five subscales map to relational continuity: the Primary Care Assessment Survey (PCAS, two subscales), the Primary Care Assessment Tool – Short Form (PCAT-S) and the Components of Primary Care Index (CPCI, two subscales). Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analysis examined fit to operational definition, and item response theory analysis examined item performance on common constructs.
All subscales load reasonably well on a single factor, presumed to be relational continuity, but the best model has two underlying factors corresponding to (1) accumulated knowledge of the patient and (2) relationship that spans healthcare events. Some items were problematic even in the best model. The PCAS Contextual Knowledge subscale discriminates best between different levels of accumulated knowledge, but this dimension is also captured well by the CPCI Accumulated Knowledge subscale and most items in the PCAT-S Ongoing Care subscale. For relationship-spanning events, the items' content captures concentration of care in one doctor; this is captured best by the CPCI Preference for Regular Provider subscale and, to a lesser extent, by the PCAS Visit-Based Continuity subscale and one relevant item in the PCAT-S Ongoing Care subscale. But this dimension correlates only modestly with percentage of reported visits to the personal doctor. The items function as yes/no rather than ordinal options, and are especially informative for poor concentration of care.
These subscales perform well for key elements of relational continuity, but do not capture consistency of care. They are more informative for poor relational continuity.
PMCID: PMC3399435  PMID: 23205040
10.  Accessibility from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments 
Healthcare Policy  2011;7(Spec Issue):94-107.
The operational definition of first-contact accessibility is “the ease with which a person can obtain needed care (including advice and support) from the practitioner of choice within a time frame appropriate to the urgency of the problem”; accommodation is “the way healthcare resources are organized to accommodate a wide range of patients' abilities to contact healthcare providers and reach healthcare services, that is to say telephone services, flexible appointment systems, hours of operation, and walk-in periods.”
To compare how well accessibility is measured in validated subscales that evaluate primary healthcare from the patient's perspective.
645 adults with at least one healthcare contact in the previous 12 months responded to six instruments that evaluate primary healthcare with four subscales that measure accessibility: the Primary Care Assessment Survey (PCAS), the Primary Care Assessment Tool – Short Form (PCAT-S, two subscales) and the first version of the EUROPEP (EUROPEP-I). Scores were normalized to a 0-to-10 scale for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analysis examined fit to operational definition, and item response theory analysis examined item performance on common constructs.
The subscales demonstrate similar psychometric measures to those reported by developers. The PCAT-S First-Contact Utilization subscale does not fit the accessibility construct. The remaining three subscales load reasonably onto a single factor, presumed to be accessibility, but the best-fitting model has two factors: “timeliness of obtaining needed care” (PCAT-S First-Contact Access, some EUROPEP-I items) and “how resources are organized to accommodate clients” (PCAS Organizational Access and most of EUROPEP-I organization of care). Items in the PCAS and PCAT-S subscales have good discriminability.
Only three of the four subscales measure accessibility; all are appropriate for use in Canada. The PCAT-S First-Contact Access subscale is the best measure for first-contact accessibility, and PCAS Organizational Accessibility has good metric properties and measures for accommodation.
PMCID: PMC3399437  PMID: 23205038
11.  Respectfulness from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments 
Healthcare Policy  2011;7(Spec Issue):167-179.
Respectfulness is one measurable and core element of healthcare responsiveness. The operational definition of respectfulness is “the extent to which health professionals and support staff meet users' expectations about interpersonal treatment, demonstrate respect for the dignity of patients and provide adequate privacy.”
To examine how well respectfulness is captured in validated instruments that evaluate primary healthcare from the patient's perspective, whether or not their developers had envisaged these as representing respectfulness.
645 adults with at least one healthcare contact with their own regular doctor or clinic in the previous 12 months responded to six instruments, two subscales that mapped to respectfulness: the Interpersonal Processes of Care, version II (IPC-II, two subscales) and the Primary Care Assessment Survey (PCAS). Additionally, there were individual respectfulness items in subscales measuring other attributes in the Components of Primary Care Index (CPCI) and the first version of the EUROPEP (EUROPEP-I). Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analyses examined fit to operational definition.
Respectfulness scales correlate highly with one another and with interpersonal communication. All items load adequately on a single factor, presumed to be respectfulness, but the best model has three underlying factors corresponding to (1) physician's interpersonal treatment (eigenvalue=13.99), (2) interpersonal treatment by office staff (eigenvalue=2.13) and (3) respect for the dignity of the person (eigenvalue=1.16). Most items capture physician's interpersonal treatment (IPC-II Compassionate, Respectful Interpersonal Style, IPC-II Hurried Communication and PCAS Interpersonal Treatment). The IPC-II Interpersonal Style (Disrespectful Office Staff) captures treatment by staff, but only three items capture dignity.
Various items or subscales seem to measure respectfulness among currently available validated instruments. However, many of these items related to other constructs, such as interpersonal communication. Further studies should aim at developing more refined measures – especially for privacy and dignity – and assess the relevance of the broader concept of responsiveness.
PMCID: PMC3399438  PMID: 23205043
12.  Comprehensiveness of Care from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments 
Healthcare Policy  2011;7(Spec Issue):154-166.
Comprehensiveness relates both to scope of services offered and to a whole-person clinical approach. Comprehensive services are defined as “the provision, either directly or indirectly, of a full range of services to meet most patients' healthcare needs”; whole-person care is “the extent to which a provider elicits and considers the physical, emotional and social aspects of a patient's health and considers the community context in their care.” Among instruments that evaluate primary healthcare, two had subscales that mapped to comprehensive services and to the community component of whole-person care: the Primary Care Assessment Tool – Short Form (PCAT-S) and the Components of Primary Care Index (CPCI, a limited measure of whole-person care).
To examine how well comprehensiveness is captured in validated instruments that evaluate primary healthcare from the patient's perspective.
645 adults with at least one healthcare contact in the previous 12 months responded to six instruments that evaluate primary healthcare. Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation modelling) factor analysis examined fit to operational definition, and item response theory analysis examined item performance on common constructs.
Over one-quarter of respondents had missing responses on services offered or doctor's knowledge of the community. The subscales did not load on a single factor; comprehensive services and community orientation were examined separately. The community orientation subscales did not perform satisfactorily. The three comprehensive services subscales fit very modestly onto two factors: (1) most healthcare needs (from one provider) (CPCI Comprehensive Care, PCAT-S First-Contact Utilization) and (2) range of services (PCAT-S Comprehensive Services Available). Individual item performance revealed several problems.
Measurement of comprehensiveness is problematic, making this attribute a priority for measure development. Range of services offered is best obtained from providers. Whole-person care is not addressed as a separate construct, but some dimensions are covered by attributes such as interpersonal communication and relational continuity.
PMCID: PMC3399439  PMID: 23205042
13.  Interpersonal Communication from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments 
Healthcare Policy  2011;7(Spec Issue):108-123.
The operational definition of interpersonal communication is “the ability of the provider to elicit and understand patient concerns, to explain healthcare issues and to engage in shared decision-making if desired.”
To examine how well interpersonal communication is captured in validated instruments that evaluate primary healthcare from the patient's perspective.
645 adults with at least one healthcare contact in the previous 12 months responded to instruments that evaluate primary healthcare. Eight subscales measure interpersonal communication: the Primary Care Assessment Survey (PCAS, two subscales); the Components of Primary Care Index (CPCI, one subscale); the first version of the EUROPEP (EUROPEP-I); and the Interpersonal Processes of Care Survey, version II (IPC-II, four subscales). Scores were normalized for descriptive comparison. Exploratory and confirmatory (structural equation) factor analysis examined fit to operational definition, and item response theory analysis examined item performance.
Items not pertaining to interpersonal communication were removed from the EUROPEP-I. Most subscales are skewed positively. Normalized mean scores are similar across subscales except for IPC-II Patient-Centred Decision-Making and IPC-II Hurried Communication. All subscales load reasonably well on a single factor, presumed to be interpersonal communication. The best model has three underlying factors corresponding to eliciting (eigenvalue = 26.56), explaining (eigenvalue = 2.45) and decision-making (eigenvalue = 1.34). Both the PCAS Communication and the EUROPEP-I Clinical Behaviour subscales capture all three dimensions. Individual subscales within IPC-II measure each sub-dimension.
The operational definition is well reflected in the available measures, although shared decision-making is poorly represented. These subscales can be used with confidence in the Canadian context to measure this crucial aspect of patient-centred care.
PMCID: PMC3399440  PMID: 23205039
14.  Management Continuity from the Patient Perspective: Comparison of Primary Healthcare Evaluation Instruments 
Healthcare Policy  2011;7(Spec Issue):139-153.
Management continuity, operationally defined as “the extent to which services delivered by different providers are timely and complementary such that care is experienced as connected and coherent,” is a core attribute of primary healthcare. Continuity, as experienced by the patient, is the result of good care coordination or integration.
To provide insight into how well management continuity is measured in validated coordination or integration subscales of primary healthcare instruments.
Relevant subscales from the Primary Care Assessment Survey (PCAS), the Primary Care Assessment Tool – Short Form (PCAT-S), the Components of Primary Care Instrument (CPCI) and the Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS) were administered to 432 adult respondents who had at least one healthcare contact with a provider other than their family physician in the previous 12 months. Subscales were examined descriptively, by correlation and factor analysis and item response theory analysis. Because the VANOCSS elicits coordination problems and is scored dichotomously, we used logistic regression to examine how evaluative subscales relate to reported problems.
Most responses to the PCAS, PCAT-S and CPCI subscales were positive, yet 83% of respondents reported having one or more problems on the VANOCSS Overall Coordination subscale and 41% on the VANOCSS Specialist Access subscale. Exploratory factor analysis suggests two distinct factors. The first (eigenvalue=6.98) is coordination actions by the primary care physician in transitioning patient care to other providers (PCAS Integration subscale and most of the PCAT-S Coordination subscale). The second (eigenvalue=1.20) is efforts by the primary care physician to create coherence between different visits both within and outside the regular doctor's office (CPCI Coordination subscale). The PCAS Integration subscale was most strongly associated with lower likelihood of problems reported on the VANOCSS subscales.
Ratings of management continuity correspond only modestly to reporting of coordination problems, possibly because they rate only the primary care physician, whereas patients experience problems across the entire system. The subscales were developed as measures of integration and provider coordination and do not capture the patient's experience of connectedness and coherence.
PMCID: PMC3399442  PMID: 23205041
15.  An Overview of Confirmatory Factor Analysis and Item Response Analysis Applied to Instruments to Evaluate Primary Healthcare 
Healthcare Policy  2011;7(Spec Issue):79-92.
This paper presents an overview of the analytic approaches that we used to assess the performance and structure of measures that evaluate primary healthcare; six instruments were administered concurrently to the same set of patients. The purpose is (a) to provide clinicians, researchers and policy makers with an overview of the psychometric methods used in this series of papers to assess instrument performance and (b) to articulate briefly the rationale, the criteria used and the ways in which results can be interpreted. For illustration, we use the case of instrument subscales evaluating accessibility. We discuss (1) distribution of items, including treatment of missing values, (2) exploratory and confirmatory factor analysis to identify how items from different subscales relate to a single underlying construct or sub-dimension and (3) item response theory analysis to examine whether items can discriminate differences between individuals with high and low scores, and whether the response options work well. Any conclusion about the relative performance of instruments or items will depend on the type of analytic technique used. Our study design and analytic methods allow us to compare instrument subscales, discern common constructs and identify potentially problematic items.
PMCID: PMC3399444  PMID: 23205037
16.  Canadian Experts' Views on the Importance of Attributes within Professional and Community-Oriented Primary Healthcare Models 
Healthcare Policy  2011;7(Spec Issue):21-30.
The aim of this study was to rate the importance of primary healthcare (PHC) attributes in evaluations of PHC organizational models in Canada.
Using the Delphi process, we conducted a consensus consultation with 20 persons recognized by peers as Canadian PHC experts, who rated the importance of PHC attributes within professional and community-oriented models of PHC.
Attributes rated as essential to all models were designated core attributes: first-contact accessibility, comprehensiveness of services, relational continuity, coordination (management) continuity, interpersonal communication, technical quality of clinical care and clinical information management. Overall, while all were important, non-core attributes – except efficiency/productivity – were rated as more important in community-oriented than in professional models. Attributes rated as essential for community-oriented models were equity, client/community participation, population orientation, cultural sensitivity and multidisciplinary teams.
Evaluation tools should address core attributes and be customized in accordance with the specific organizational models being evaluated to guide health reforms.
PMCID: PMC3399445  PMID: 23205033
17.  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
18.  Emerging organisational models of primary healthcare and unmet needs for care: insights from a population-based survey in Quebec province 
BMC Family Practice  2012;13:66.
Reform of primary healthcare (PHC) organisations is underway in Canada. The capacity of various types of PHC organizations to respond to populations’ needs remains to be assessed. The main objective of this study was to evaluate the association of PHC affiliation with unmet needs for care.
Population-based survey of 9205 randomly selected adults in two regions of Quebec, Canada. Outcomes Self-reported unmet needs for care and identification of the usual source of PHC.
Among eligible adults, 18 % reported unmet needs for care in the last six months. Reasons reported for unmet needs were: waiting times (59 % of cases); unavailability of usual doctor (42 %); impossibility to obtain an appointment (36 %); doctors not accepting new patients (31 %). Regression models showed that unmet needs were decreasing with age and was lower among males, the least educated, and unemployed or retired. Controlling for other factors, unmet needs were higher among the poor and those with worse health status. Having a family doctor was associated with fewer unmet needs. People reporting a usual source of care in the last two-years were more likely to report unmet need for care. There were no differences in unmet needs for care across types of PHC organisations when controlling for affiliation with a family physician.
Reform models of primary healthcare consistent with the medical home concept did not differ from other types of organisations in our study. Further research looking at primary healthcare reform models at other levels of implementation should be done.
PMCID: PMC3431245  PMID: 22748060
Primary care; Unmet needs for care; Primary healthcare organization; Vulnerability
19.  A Global Approach to Evaluation of Health Services Utilization: Concepts and Measures 
Healthcare Policy  2011;6(4):e106-e117.
Health services utilization has been the object of many books and papers in the literature. Measures associated with utilization are often a function of volume of services. The objective of this paper is to present a comprehensive approach to the evaluation of health services utilization and of associated measures, using databases. Based on the theoretical framework of Starfield (1998), we analyze health services utilization with the help of indicators that are not directly linked to volume but that indirectly provide an estimate, while also documenting the qualitative aspects of utilization. The indicators mark accessibility, continuity, comprehensiveness and productivity of care. Once the concepts have been defined, we propose their operationalization using the databases. We then present the advantages of multidimensional conceptualization of health services utilization through a simultaneous analysis of these indicators. Researchers and decision-makers in public health and health planning have much to gain from this innovative multidimensional approach, which presents a dynamic conceptualization of health services utilization based on health administrative data.
This paper was originally published in French, in the journal Pratiques et Organisation des Soins 2011 42(1): 11–18.
PMCID: PMC3107120  PMID: 22548101
20.  Mapping the coverage of attributes in validated instruments that evaluate primary healthcare from the patient perspective 
BMC Family Practice  2012;13:20.
Primary healthcare in developed countries is undergoing important reforms, and these require evaluation strategies to assess how well the population's expectations are being met. Although numerous instruments are available to evaluate primary healthcare (PHC) from the patient perspective, they do not all measure the same range of constructs. To analyze the extent to which important PHC attributes are covered in validated instruments measuring quality of care from the patient perspective.
We systematically identified validated instruments from the literature and by consulting experts. Using a Delphi consensus-building process, Canadian PHC experts identified and operationally defined 24 important PHC attributes. One team member mapped instrument subscales to these operational definitions; this mapping was then independently validated by members of the research team and conflicts were resolved by the PHC experts.
Of the 24 operational definitions, 13 were evaluated as being best measured by patients, 10 by providers, three by administrative databases and one by chart audits (some being best measured by more than one source). Our search retained 17 measurement tools containing 118 subscales. After eliminating redundancies, we mapped 13 unique measurement tools to the PHC attributes. Accessibility, relational continuity, interpersonal communication, management continuity, respectfulness and technical quality of clinical care were the attributes widely covered by available instruments. Advocacy, management of clinical information, comprehensiveness of services, cultural sensitivity, family-centred care, whole-person care and equity were poorly covered.
Validated instruments to evaluate PHC quality from the patient perspective leave many important attributes of PHC uncovered. A complete assessment of PHC quality will require adjusting existing tools and/or developing new instruments.
PMCID: PMC3353250  PMID: 22423617
Primary healthcare; Quality of healthcare; Qualitative analysis; Measurement instruments
21.  Availability of Healthcare Resources, Positive Ratings of the Care Experience and Extent of Service Use: An Unexpected Relationship 
Healthcare Policy  2011;6(3):46-56.
Two main avenues are advocated to improve the capability of healthcare systems to satisfy the public's needs and expectations: more resources and better organization. This paper sheds some light on this debate. It assesses the extent to which patients' positive rating of their healthcare experience and the extent to which they use services are related to the availability of healthcare resources. Findings indicate that patients' evaluations of their care experience and use of services were higher when the availability of resources was either limited or average. In no case were positive ratings of services and greater use of them associated with greater resource availability. Thus, simply adding resources runs the risk of diminishing, rather than improving, users' healthcare experience.
PMCID: PMC3082387  PMID: 22294991
22.  Evaluation of the implementation of an integrated primary care network for prevention and management of cardiometabolic risk in Montréal 
BMC Family Practice  2011;12:126.
The goal of this project is to evaluate the implementation of an integrated and interdisciplinary program for prevention and management of cardiometabolic risk (PCMR). The intervention is based on the Chronic Care Model. The study will evaluate the implementation of the PCMR in 6 of the 12 health and social services centres (CSSS) in Montréal, and the effects of the PCMR on patients and the practice of their primary care physicians up to 40 months following implementation, as well as the sustainability of the program. Objectives are: 1-to evaluate the effects of the PCMR and their persistence on patients registered in the program and the practice of their primary care physicians, by implementation site and degree of exposure to the program; 2-to assess the degree of implementation of PCMR in each CSSS territory and identify related contextual factors; 3-to establish the relationships between the effects observed, the degree of PCMR implementation and the related contextual factors; 4-to assess the impact of the PCMR on strengthening local services networks.
The evaluation will use a mixed design that includes two complementary research strategies. The first strategy is similar to a quasi-experimental "before-after" design, based on a quantitative approach; it will look at the program's effects and their variations among the six territories. The effects analysis will use data from a clinical database and from questionnaires completed by participating patients and physicians. Over 3000 patients will be recruited. The second strategy corresponds to a multiple case study approach, where each of the six CSSS constitutes a case. With this strategy, qualitative methods will set out the context of implementation using data from semi-structured interviews with program managers. The quantitative data will be analyzed using linear or multilevel models complemented with an interpretive approach to qualitative data analysis.
Our study will identify contextual factors associated with the effectiveness, successful implementation and sustainability of such a program. The contextual information will enable us to extrapolate our results to other contexts with similar conditions.
Trial registration NCT01326130
PMCID: PMC3282661  PMID: 22074614
23.  Does Receiving Clinical Preventive Services Vary across Different Types of Primary Healthcare Organizations? Evidence from a Population-Based Survey 
Healthcare Policy  2010;6(2):67-84.
To measure the association between primary healthcare (PHC) organizational types and patient coverage for clinical preventive services (CPS).
Study conducted in Quebec (2005), including a population-based survey of patients' experience of care (N=4,417) and a survey of PHC clinics.
Outcome measures:
Patient-reported CPS delivery rates and CPS coverage scores. Multiple logistic regressions used to assess factors associated with higher probability of receiving CPS.
CPS delivery rates were higher among patients with a regular source of PHC. Higher CPS score was associated with having a public (OR 1.79; 95% CI 1.35—2.37) or mixed (OR 1.22; 95% CI 1.01—1.48) type of organization as source of PHC compared to a private one, and having had a high number of visits to the regular source of PHC in the past two years (≤6: OR 1.83; 95% CI 1.41—2.38) compared to a single visit.
Public and mixed PHC organizations seem to perform better. CPS delivery is strongly associated with having a regular source of care.
PMCID: PMC3016636  PMID: 22043224
24.  The Continuing Saga of Emergency Room Overcrowding: Are We Aiming at the Right Target? 
Healthcare Policy  2010;5(3):27-39.
Emergency room utilization in Canada is considerably higher than in other industrialized countries. Despite significant investments, recurrent emergency room crises persist. Focusing particularly on the situation in Quebec, this paper examines the evolution of Canada's and Quebec's healthcare systems over the past 40 years and identifies the key developments that resulted in today's problems and the challenges that must be addressed. In this historical overview, we argue that emergency room problems arise from past decisions that gave hospitals a predominant role in the healthcare system and partly modified their original mission, as well as from counterproductive funding modalities. Other decisions have also weakened primary care services, which are strongly focused on acute health problems and are poorly coordinated with the rest of the system. Symptomatic remedies have only eased the pressure on emergency rooms, but the real solution is more complex and must address the historical residues that are paralyzing our healthcare system.
PMCID: PMC2831731  PMID: 21286266
25.  Assessing the evolution of primary healthcare organizations and their performance (2005-2010) in two regions of Québec province: Montréal and Montérégie 
BMC Family Practice  2010;11:95.
The Canadian healthcare system is currently experiencing important organizational transformations through the reform of primary healthcare (PHC). These reforms vary in scope but share a common feature of proposing the transformation of PHC organizations by implementing new models of PHC organization. These models vary in their performance with respect to client affiliation, utilization of services, experience of care and perceived outcomes of care.
In early 2005 we conducted a study in the two most populous regions of Quebec province (Montreal and Montérégie) which assessed the association between prevailing models of primary healthcare (PHC) and population-level experience of care. The goal of the present research project is to track the evolution of PHC organizational models and their relative performance through the reform process (from 2005 until 2010) and to assess factors at the organizational and contextual levels that are associated with the transformation of PHC organizations and their performance.
This study will consist of three interrelated surveys, hierarchically nested. The first survey is a population-based survey of randomly-selected adults from two populous regions in the province of Quebec. This survey will assess the current affiliation of people with PHC organizations, their level of utilization of healthcare services, attributes of their experience of care, reception of preventive and curative services and perception of unmet needs for care. The second survey is an organizational survey of PHC organizations assessing aspects related to their vision, organizational structure, level of resources, and clinical practice characteristics. This information will serve to develop a taxonomy of organizations using a mixed methods approach of factorial analysis and principal component analysis. The third survey is an assessment of the organizational context in which PHC organizations are evolving. The five year prospective period will serve as a natural experiment to assess contextual and organizational factors (in 2005) associated with migration of PHC organizational models into new forms or models (in 2010) and assess the impact of this evolution on the performance of PHC.
The results of this study will shed light on changes brought about in the organization of PHC and on factors associated with these changes.
PMCID: PMC3014883  PMID: 21122145

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