Jean-Frédéric Lévesque

Patient-centred access to health care: conceptualising access at the interface of health systems and populations

BackgroundAccess is central to the performance of health care systems around the world. However, access to health care remains a complex notion as exemplified in the variety of interpretations of the concept across authors. The aim of this paper is to suggest a conceptualisation of access to health care describing broad dimensions and determinants that integrate demand and supply-side-factors and enabling the operationalisation of access to health care all along the process of obtaining care and benefiting from the services.MethodsA synthesis of the published literature on the conceptualisation of access has been performed. The most cited frameworks served as a basis to develop a revised conceptual framework.ResultsHere, we view access as the opportunity to identify healthcare needs, to seek healthcare services, to reach, to obtain or use health care services, and to actually have a need for services fulfilled. We conceptualise five dimensions of accessibility: 1) Approachability; 2) Acceptability; 3) Availability and accommodation; 4) Affordability; 5) Appropriateness. In this framework, five corresponding abilities of populations interact with the dimensions of accessibility to generate access. Five corollary dimensions of abilities include: 1) Ability to perceive; 2) Ability to seek; 3) Ability to reach; 4) Ability to pay; and 5) Ability to engage.ConclusionsThis paper explains the comprehensiveness and dynamic nature of this conceptualisation of access to care and identifies relevant determinants that can have an impact on access from a multilevel perspective where factors related to health systems, institutions, organisations and providers are considered with factors at the individual, household, community, and population levels.

Operational Definitions of Attributes of Primary Health Care: Consensus Among Canadian Experts

PURPOSE In 2004, we undertook a consultation with Canadian primary health care experts to define the attributes that should be evaluated in predominant and proposed models of primary health care in the Canadian context. METHOD Twenty persons considered to be experts in primary health care or recommended by at least 2 peers responded to an electronic Delphi process. The expert group was balanced between clinicians (principally family physicians and nurses), academics, and decision makers from all regions in Canada. In 4 iterative rounds, participants were asked to propose and modify operational definitions. Each round incorporated the feedback from the previous round until consensus was achieved on most attributes, with a final consensus process in a face-to-face meeting with some of the experts. RESULTS Operational definitions were developed and are proposed for 25 attributes; only 5 rate as specific to primary care. Consensus on some was achieved early (relational continuity, coordination-continuity, family-centeredness, advocacy, cultural sensitivity, clinical information management, and quality improvement process). The definitions of other attributes were refined over time to increase their precision and reduce overlap between concepts (accessibility, quality of care, interpersonal communication, community orientation, comprehensiveness, multidisciplinary team, responsiveness, integration). CONCLUSION This description of primary care attributes in measurable terms provides an evaluation lexicon to assess initiatives to renew primary health care and serves as a guide for instrument selection.

Emergency Department Visits and Primary Care Among Adults With Chronic Conditions

Background:An emergency department (ED) visit may be a marker for limited access to primary medical care, particularly among those with ambulatory care sensitive chronic conditions (ACSCC). Objectives:In a population with universal health insurance, to examine the relationships between primary care characteristics and location of last general physician (GP) contact (in an ED vs. elsewhere) among those with and without an ACSCC. Research Design:A cross-sectional survey using data from 2 cycles of the Canadian Community Health Survey carried out in 2003 and 2005. Subjects:The study sample comprised Québec residents aged ≥18 who reported at least one GP contact during the previous 12 months, and were not hospitalized (n = 33,491). Measures:The primary outcome was place of last GP contact: in an ED versus elsewhere. Independent variables included the following: lack of a regular physician, perceived unmet healthcare needs, perceived availability of health care, number of contacts with doctors and nurses, and diagnosis of an ACSCC (hypertension, heart disease, chronic respiratory disease, diabetes). Results:Using multiple logistic regression, with adjustment for sociodemographic, health status, and health services variables, lack of a regular GP and perceptions of unmet needs were associated with last GP contact in an ED; there was no interaction with ACSCC or other chronic conditions. Conclusions:Primary care characteristics associated with GP contact in an ED rather than another site reflect individual characteristics (affiliation with a primary GP and perceived needs) rather than the geographic availability of healthcare, both among those with and without chronic conditions.

Factors predicting patient use of the emergency department: a retrospective cohort study

Background: Many studies have shown the tendency for people without a regular care provider or primary physician to make greater use of emergency departments. We sought to determine the effects of three aspects of care provided by primary physicians (physician specialty, continuity of care and comprehensiveness of care) on their patients’ use of the emergency department. Methods: Using provincial administrative databases, we created a cohort of 367 315 adults aged 18 years and older. Participants were residents of urban areas of Quebec. Affiliation with a primary physician, the specialty of this physician (i.e., family physician v. specialist), continuity of care (as measured using the Usual Provider Continuity index) and comprehensiveness of care (i.e., number of complete annual examinations) were measured among participants (n = 311 701) who had visited a physician three or more times during a two-year baseline period. We used multivariable negative binomial regression to investigate the relationships between measures of care and the number of visits to emergency departments during a 12-month follow-up period. Results: Among participants under 65 years of age, emergency department use was higher for those not affiliated than for those affiliated with a family physician (incidence rate ratio [IRR] 1.11, 95% confidence interval [CI] 1.05–1.16) or a specialist (IRR 1.10, 95% CI 1.04–1.17). Among patients aged 65 years and older, having a specialist primary physician, as opposed to a family physician, predicted increased use of the emergency department (IRR 1.13, 95% CI 1.09–1.17). Greater continuity of care with a family physician predicted less use of the emergency department only among participants who made 25 or more visits to a physician during the baseline period. Greater continuity of care with a specialist predicted less use of the emergency department overall, particularly among participants with intermediate numbers of multimorbidities and admissions to hospital. Greater comprehensiveness of care by family physicians predicted less use of the emergency department. Interpretation: Efforts to increase the proportion of adults affiliated with a family physician should target older adults, people who visit physicians more frequently and people with multiple comorbidities and admissions to hospital.

Assessing the evolution of primary healthcare organizations and their performance (2005-2010) in two regions of Québec province: Montréal and Montérégie

BackgroundThe 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.ObjectivesIn 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.Methods/DesignThis 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.DiscussionThe results of this study will shed light on changes brought about in the organization of PHC and on factors associated with these changes.

Association between nutrition and the evolution of multimorbidity: The importance of fruits and vegetables and whole grain products

BACKGROUND & AIMS Multimorbidity is a common health status. The impact of nutrition on the development of multimorbidity remains to be determined. The aim of this study is to determine the association between foods, macronutrients and micronutrients and the evolution of multimorbidity. METHODS Data from 1020 Chinese who participated in the Jiangsu longitudinal Nutrition Study (JIN) were collected in 2002 (baseline) and 2007 (follow-up). Three-day weighted food records and status for 11 chronic diseases was determined using biomedical measures (hypertension, diabetes, hypercholesterolemia and anemia) or self-reports (coronary heart disease, asthma, stroke, cancer, fracture, arthritis and hepatitis). Participants were divided in six categories of stage of evolution of multimorbidity. Association of foods, macronutrients and micronutrients at baseline with stages in the evolution of multimorbidity were determined. Data were adjusted for age, sex, BMI, marital status, sedentary lifestyle, smoking status, annual income, education and energy intake. RESULTS The prevalence of multimorbidity increased from 14% to 34%. A high consumption of fruit and vegetables (p < 0.05) and grain products other than rice and wheat (p < 0.001) were associated with healthier stages in the evolution of multimorbidity. The consumption of grain products other than rice and wheat was highly correlated with dietary fibers (r = 0.77, p < 0.0001), iron (r = 0.46, p < 0.0001), magnesium (r = 0.49, p < 0.0001) and phosphorus (r = 0.57, p < 0.0001) intake which were also associated with healthier stages. CONCLUSION This study provides the first evidence of an association between nutrition and evolution towards multimorbidity. More precisely, greater consumption of fruits and vegetable and whole grain products consumption appear to lower the risk of multimorbidity.

Increases in Emergency Department Occupancy Are Associated With Adverse 30-day Outcomes

OBJECTIVES The associations between emergency department (ED) crowding and patient outcomes have not been investigated comprehensively in different types of ED. The study objective was to examine the associations of changes over time in ED occupancy with patient outcomes in a sample of EDs that vary by size and location. A secondary objective was to explore whether the relationship between ED occupancy and patient outcomes differed by ED characteristics (size/type and medical and nursing staffing ratios). METHODS Using linked administrative databases, the authors constructed a cohort of 677,475 patients who visited one of 42 hospital EDs with complete data for 2005 on ED bed and waiting room occupancy. Crowding was measured with the relative occupancy ratio separately for ED bed and waiting room patients, defined as the ratio of ED occupancy on the day of the index ED visit to the average annual occupancy at that same ED. Multivariable logistic regression (adjusting for patient and ED characteristics) was used to analyze 30-day outcomes: mortality, return ED visits, and hospital admission at the first return ED visit. RESULTS After adjustment for ED and patient characteristics, a 10% increase in ED bed relative occupancy ratio was associated with 3% increases in death and hospital admission at a return visit. A 10% increase in ED waiting room crowding was associated with a small decrease in return visits. There was a stronger association between bed crowding and mortality among larger EDs. CONCLUSIONS In Quebec EDs, increases in bed occupancy are associated with an increase in the rates of 30-day adverse outcomes, even after adjustment for patient and ED characteristics. The results raise important concerns about the quality of care during periods of ED crowding.

An exploration of rural-urban differences in healthcare-seeking trajectories: implications for measures of accessibility.

Comparing accessibility between urban and rural areas requires measurement instruments that are equally discriminating in each context. Through focus groups we explored and compared care-seeking trajectories to understand context-specific accessibility barriers and facilitators. Rural care-seekers rely more on telephone access and experience more organizational accommodation but have fewer care options. Urban care-seekers invoke the barrier of distance more frequently. Four consequences of accessibility problems emerged across settings which could be used for valid comparisons of access: having to restart the care-seeking process, abandoning it, using emergency services for primary care, and health deterioration due to delay.

Measuring the prevalence of chronic diseases using population surveys by pooling self-reported symptoms, diagnosis and treatments: results from the World Health Survey of 2003 for South Asia

ObjectivesMeasuring disease prevalence poses challenges in countries where information systems are poorly developed. Population surveys soliciting information on self-reported diagnosis also have limited capacity since they are influenced by informational and recall biases. Our aim is to propose a method to assess the prevalence of chronic disease by combining information on self-reported diagnosis, self-reported treatment and highly suggestive symptoms.MethodsAn expanded measure of prevalence was developed using data from the World Health Survey for Bangladesh, India and Sri Lanka. Algorithms were constructed for six chronic diseases.ResultsThe expanded measures of chronic disease increase the prevalence estimates. Prevalence varies across socio-demographic characteristics, such as age, education, socioeconomic status (SES), and country. Finally, the association, as also risk factor, between chronic disease status and poor self-rated health descriptions increases significantly when one takes into account highly suggestive symptoms of diseases.ConclusionsOur expanded measure of chronic disease could form a basis for surveillance of chronic diseases in countries where health information systems have been poorly developed. It represents an interesting trade-off between the bias associated with usual surveillance data and costs.

Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries

Context A key aim of reforms to primary health care (PHC) in many countries has been to enhance interprofessional teamwork. However, the impact of these changes on practitioners has not been well understood. Objective To assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in PHC practices. Design Collaborative synthesis of 12 mixed methods studies. Setting Primary care practices undergoing transformational change in three countries: Australia, Canada, and the USA, including three Canadian provinces (Alberta, Ontario, and Quebec). Methods We conducted a synthesis and secondary analysis of 12 qualitative and quantitative studies conducted by the authors in order to understand the impacts and how they were influenced by local context. Results There was a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions. These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups. Conclusion The variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level. The same characteristic could have both positive and negative influence on different aspects (eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice). Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level.