Meltem Tuna

Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational Factors

PURPOSE New approaches to chronic disease management emphasize the need to improve the delivery of primary care services to meet the needs of chronically ill patients. This study (1) assessed whether chronic disease management differed among 4 models of primary health care delivery and (2) identified which practice organizational factors were independently associated with high-quality care. METHODS We undertook a cross-sectional survey with nested qualitative case studies (2 practices per model) in 137 randomly selected primary care practices from 4 delivery models in Ontario Canada: fee for service, capitation, blended payment, and community health centers (CHCs). Practice and clinician surveys were based on the Primary Care Assessment Tool. A chart audit assessed evidence-based care delivery for patients with diabetes, congestive heart failure, and coronary artery disease. Intermediate outcomes were calculated for patients with diabetes and hypertension. Multiple linear regression identified those organizational factors independently associated with chronic disease management. RESULTS Chronic disease management was superior in CHCs. Clinicians in CHCs found it easier than those in the other models to promote high-quality care through longer consultations and interprofessional collaboration. Across the whole sample and independent of model, high-quality chronic disease management was associated with the presence of a nurse-practitioner. It was also associated with lower patient-family physician ratios and when practices had 4 or fewer full-time-equivalent family physicians. CONCLUSIONS The study adds to the literature supporting the value of nurse-practitioners within primary care teams and validates the contributions of Ontario’s CHCs. Our observation that quality of care decreased in larger, busier practices suggests that moves toward larger practices and greater patient-physician ratios may have unanticipated negative effects on processes of care quality.

Impact of remuneration and organizational factors on completing preventive manoeuvres in primary care practices

Background: Several jurisdictions attempting to reform primary care have focused on changes in physician remuneration. The goals of this study were to compare the delivery of preventive services by practices in four primary care funding models and to identify organizational factors associated with superior preventive care. Methods: In a cross-sectional study, we included 137 primary care practices in the province of Ontario (35 fee-for-service practices, 35 with salaried physicians [community health centres], 35 practices in the new capitation model [family health networks] and 32 practices in the established capitation model [health services organizations]). We surveyed 288 family physicians. We reviewed 4108 randomly selected patient charts and assigned prevention scores based on the proportion of eligible preventive manoeuvres delivered for each patient. Results: A total of 3284 patients were eligible for at least one of six preventive manoeuvres. After adjusting for patient profile and contextual factors, we found that, compared with prevention scores in practices in the new capitation model, scores were significantly lower in fee-for-service practices (β estimate for effect on prevention score = −6.3, 95% confidence interval [CI] −11.9 to −0.6) and practices in the established capitation model (β = −9.1, 95% CI −14.9 to −3.3) but not for those with salaried remuneration (β = −0.8, 95% CI −6.5 to 4.8). After accounting for physician characteristics and organizational structure, the type of funding model was no longer a statistically significant factor. Compared with reference practices, those with at least one female family physician (β = 8.0, 95% CI 4.2 to 11.8), a panel size of fewer than 1600 patients per full-time equivalent family physician (β = 6.8, 95% CI 3.1 to 10.6) and an electronic reminder system (β = 4.6, 95% CI 0.4 to 8.7) had superior prevention scores. The effect of these three factors was largely but not always consistent across the funding models; it was largely consistent across the preventive manoeuvres. Interpretation: No funding model was clearly associated with superior preventive care. Factors related to physician characteristics and practice structure were stronger predictors of performance. Practices with one or more female physicians, a smaller patient load and an electronic reminder system had superior prevention scores. Our findings raise questions about reform initiatives aimed at increasing patient numbers, but they support the adoption of information technology.

Getting it all done, Organizational factors linked with comprehensive primary care

BACKGROUND Comprehensiveness, a defining feature of primary care (PC) is associated with patient satisfaction and improved health status. This paper evaluates comprehensive services in fee-for-service (FFS), Health Service Organizations (HSOs), Family Health Networks (FHNs) and Community Health Centres (CHCs) payment models in Ontario. OBJECTIVES To assess how organizational models of PC differ in the delivery of comprehensive services and which organizational factors predict comprehensive PC delivery. METHODS Cross-sectional mixed-method study with nested qualitative case studies. SETTING PC practices in Ontario. PARTICIPANTS One hundred and thirty-seven PC practices (35 FFS, 32 HSO, 35 FHN and 35 CHC) and 358 providers. INSTRUMENTS Surveys based on the Primary Care Assessment Tool and qualitative interviews. OUTCOME MEASURES Comprehensiveness scores were calculated from practice report of clinical services offered in womens health, psychosocial counselling, procedural and diagnostic services. Confounding variables were calculated from provider and patient surveys. Performance at a model level was compared using analysis of variance. Multiple regressions then established factors independently associated with comprehensiveness. RESULTS CHCs offered significantly more comprehensive services (74%) than other models (61%-63%; P < 0.005). Thirty-five per cent of the variance in comprehensiveness was explained by a regression model that included the number of family physicians working at the practice, presence of other allied health providers, rurality and length of practice operation. CONCLUSIONS Practice size and diversity of providers seemed to partially explain the better performance of CHCs. Practice setting and, probably, practice maturity are significant drivers in the provision of comprehensive PC services. These factors warrant further examination in other PC environments.

Predictors of relational continuity in primary care: patient, provider and practice factors

BackgroundContinuity 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.MethodsThis 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.ResultsMultilevel 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.ConclusionsSome 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’.

An evaluation of gender equity in different models of primary care practices in Ontario

BackgroundThe World Health Organization calls for more work evaluating the effect of health care reforms on gender equity in developed countries. We performed this evaluation in Ontario, Canada where primary care models resulting from reforms co-exist.MethodsThis cross sectional study of primary care practices uses data collected in 2005-2006. Healthcare service models included in the study consist of fee for service (FFS) based, salaried, and capitation based. We compared the quality of care delivered to women and men in practices of each model. We performed multi-level, multivariate regressions adjusting for patient socio-demographic and economic factors to evaluate vertical equity, and adjusting for these and health factors in evaluating horizontal equity. We measured seven dimensions of health service delivery (e.g. accessibility and continuity) and three dimensions of quality of care using patient surveys (n = 5,361) and chart abstractions (n = 4,108).ResultsHealth service delivery measures were comparable in women and men, with differences ≤ 2.2% in all seven dimensions and in all models. Significant gender differences in the health promotion subjects addressed were observed. Female specific preventive manoeuvres were more likely to be performed than other preventive care. Men attending FFS practices were more likely to receive influenza immunization than women (Adjusted odds ratio: 1.75, 95% confidence intervals (CI) 1.05, 2.92). There was no difference in the other three prevention indicators. FFS practices were also more likely to provide recommended care for chronic diseases to men than women (Adjusted difference of -11.2%, CI -21.7, -0.8). A similar trend was observed in Community Health Centers (CHC).ConclusionsThe observed differences in the type of health promotion subjects discussed are likely an appropriate response to the differential healthcare needs between genders. Chronic disease care is non equitable in FFS but not in capitation based models. We recommend that efforts to monitor and address gender based differences in the delivery of chronic disease management in primary care be pursued.

Measuring Burden of Unhealthy Behaviours Using a Multivariable Predictive Approach: Life Expectancy Lost in Canada Attributable to Smoking, Alcohol, Physical Inactivity, and Diet

Background Behaviours such as smoking, poor diet, physical inactivity, and unhealthy alcohol consumption are leading risk factors for death. We assessed the Canadian burden attributable to these behaviours by developing, validating, and applying a multivariable predictive model for risk of all-cause death. Methods A predictive algorithm for 5 y risk of death—the Mortality Population Risk Tool (MPoRT)—was developed and validated using the 2001 to 2008 Canadian Community Health Surveys. There were approximately 1 million person-years of follow-up and 9,900 deaths in the development and validation datasets. After validation, MPoRT was used to predict future mortality and estimate the burden of smoking, alcohol, physical inactivity, and poor diet in the presence of sociodemographic and other risk factors using the 2010 national survey (approximately 90,000 respondents). Canadian period life tables were generated using predicted risk of death from MPoRT. The burden of behavioural risk factors attributable to life expectancy was estimated using hazard ratios from the MPoRT risk model. Findings The MPoRT 5 y mortality risk algorithms were discriminating (C-statistic: males 0.874 [95% CI: 0.867–0.881]; females 0.875 [0.868–0.882]) and well calibrated in all 58 predefined subgroups. Discrimination was maintained or improved in the validation cohorts. For the 2010 Canadian population, unhealthy behaviour attributable life expectancy lost was 6.0 years for both men and women (for men 95% CI: 5.8 to 6.3 for women 5.8 to 6.2). The Canadian life expectancy associated with health behaviour recommendations was 17.9 years (95% CI: 17.7 to 18.1) greater for people with the most favourable risk profile compared to those with the least favourable risk profile (88.2 years versus 70.3 years). Smoking, by itself, was associated with 32% to 39% of the difference in life expectancy across social groups (by education achieved or neighbourhood deprivation). Conclusions Multivariable predictive algorithms such as MPoRT can be used to assess health burdens for sociodemographic groups or for small changes in population exposure to risks, thereby addressing some limitations of more commonly used measurement approaches. Unhealthy behaviours have a substantial collective burden on the life expectancy of the Canadian population.

Cardiovascular Disease Population Risk Tool (CVDPoRT): predictive algorithm for assessing CVD risk in the community setting. A study protocol

Introduction Recent publications have called for substantial improvements in the design, conduct, analysis and reporting of prediction models. Publication of study protocols, with prespecification of key aspects of the analysis plan, can help to improve transparency, increase quality and protect against increased type I error. Valid population-based risk algorithms are essential for population health planning and policy decision-making. The purpose of this study is to develop, evaluate and apply cardiovascular disease (CVD) risk algorithms for the population setting. Methods and analysis The Ontario sample of the Canadian Community Health Survey (2001, 2003, 2005; 77 251 respondents) will be used to assess risk factors focusing on health behaviours (physical activity, diet, smoking and alcohol use). Incident CVD outcomes will be assessed through linkage to administrative healthcare databases (619 886 person-years of follow-up until 31 December 2011). Sociodemographic factors (age, sex, immigrant status, education) and mediating factors such as presence of diabetes and hypertension will be included as predictors. Algorithms will be developed using competing risks survival analysis. The analysis plan adheres to published recommendations for the development of valid prediction models to limit the risk of overfitting and improve the quality of predictions. Key considerations are fully prespecifying the predictor variables; appropriate handling of missing data; use of flexible functions for continuous predictors; and avoiding data-driven variable selection procedures. The 2007 and 2009 surveys (approximately 50 000 respondents) will be used for validation. Calibration will be assessed overall and in predefined subgroups of importance to clinicians and policymakers. Ethics and dissemination This study has been approved by the Ottawa Health Science Network Research Ethics Board. The findings will be disseminated through professional and scientific conferences, and in peer-reviewed journals. The algorithm will be accessible electronically for population and individual uses. Trial registration number ClinicalTrials.gov NCT02267447.

One- and five-year risk of death and cardiovascular complications for hospitalized patients with hyperglycemia without diagnosed diabetes: An observational study.

BACKGROUND Hyperglycemia is recognized as an important threat to the health of patients, independent of diabetes status. However, no long-term follow-up study of patients with in-hospital elevated glucose without diabetes has been conducted. OBJECTIVE To compare 1- and 5-year risk of death and cardiovascular (CV) complications in patients with a diagnosis of diabetes versus those without a diabetes diagnosis DESIGN Retrospective cohort study. METHODS Risk of all-cause death and CV complications (acute myocardial infarction [AMI], congestive heart failure [CHF], cardiovascular disease [CVD], peripheral vascular disease [PVD], and end-stage renal disease [ESRD]) in those diagnosed with diabetes versus those with different glycemia categories was determined using competing risk models. SETTING/PATIENTS All adult patients from a tertiary hospital discharged alive between 1996 and 2008 from any service except psychiatry or obstetrics. RESULTS Compared to patients with diagnosed diabetes, patients with peak serum glucose level >200 mg/dL had significantly higher 1-year risk (hazard ratio [HR]: 1.31, 95% confidence interval [CI]: 1.20-1.43) and 5-year risk (HR: 1.13, 95% CI: 1.06-1.22) of death but a decreased 1-year risk of hospitalization for CHF (HR: 0.71, 95% CI: 0.62-0.81), PVD (HR: 0.20, 95% CI: 0.18-0.24), or ESRD (HR: 0.73, 95% CI: 0.6-0.89). There was no risk difference for AMI (HR: 0.96, 95% CI: 0.78-1.18) or CVD (HR: 0.79, 95% CI: 0.61-1.0). CONCLUSIONS Although it is unclear whether hospitalized patients with elevated peak serum glucose have early diabetes or their hyperglycemia reflects hospital stress or another comorbidity, in-hospital hyperglycemia is an important clinical indicator, carrying a higher 1- and 5-year mortality risk than those with diagnosed diabetes.

Delivery of primary health care to persons who are socio-economically disadvantaged: does the organizational delivery model matter?

BackgroundAs 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.MethodsCross 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.ResultsLow 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.ConclusionsPrimary 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.

Predicting stroke risk based on health behaviours: development of the stroke population risk tool (SPoRT).

Background Health behaviours, important factors in cardiovascular disease, are increasingly a focus of prevention. We appraised whether stroke risk can be accurately assessed using self-reported information focused on health behaviours. Methods Behavioural, sociodemographic and other risk factors were assessed in a population-based survey of 82 259 Ontarians who were followed for a median of 8.6 years (688 000 person-years follow-up) starting in 2001. Predictive algorithms for 5-year incident stroke resulting in hospitalization were created and then validated in a similar 2007 survey of 28 605 respondents (median 4.2 years follow-up). Results We observed 3 236 incident stroke events (1 551 resulting in hospitalization; 1 685 in the community setting without hospital admission). The final algorithms were discriminating (C-stat: 0.85, men; 0.87, women) and well-calibrated (in 65 of 67 subgroups for men; 61 of 65 for women). An index was developed to summarize cumulative relative risk of incident stroke from health behaviours and stress. For men, each point on the index corresponded to a 12% relative risk increase (180% risk difference, lowest (0) to highest (9) scores). For women, each point corresponded to a 14% relative risk increase (340% difference, lowest (0) to highest (11) scores). Algorithms for secondary stroke outcomes (stroke resulting in death; classified as ischemic; excluding transient ischemic attack; and in the community setting) had similar health behaviour risk hazards. Conclusion Incident stroke can be accurately predicted using self-reported information focused on health behaviours. Risk assessment can be performed with population health surveys to support population health planning or outside of clinical settings to support patient-focused prevention.