Raynald Pineault

Practice Features Associated With Patient-Reported Accessibility, Continuity, and Coordination of Primary Health Care

PURPOSE On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict accessibility, continuity, and coordination of care as experienced by patients. METHODS Primary health care clinics were selected by stratified random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on first-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic. RESULTS One hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). First-contact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their office. CONCLUSIONS The way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.

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.

Randomized clinical trial of one-day surgery. Patient satisfaction, clinical outcomes, and costs.

One hundred and eighty-two patients undergoing tubal ligation, hernia repair, or meniscectomy were randomly assigned to either one-day or inpatient surgery. The studys objective is to compare these two modes of care with regard to patient satisfaction, clinical outcomes, and costs of the episode of care. A significantly higher proportion of one-day patients than their hospitalized counterparts found their stay to be too short and would prefer hospitalization as an alternative. Clinical outcomes were comparable in both groups. One-day tubal ligation and hernia repair were found to be cost-efficient and averaged hospital savings of

Investigating the correlation between hospital of primary treatment and the survival of women with breast cancer.

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Structural and Political Models of Analysis of the Introduction of an Innovation in Organizations: The Case of the Change in the Method of Payment of Physicians in Long-Term Care Hospitals

115.00 more than inpatient care. Meniscectomy deviated from this trend in that treatment costs were significantly higher for one-day surgery patients. Analysis of personal and physician costs did not show any significant difference between the two modes of care.

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

To understand the relation between hospital of initial treatment and the survival of women with breast cancer, the authors investigated the characteristics of the treatment center that were related most to outcome.

The effect of prepaid group practice on physicians' utilization behavior.

This article presents the results of a study on the introduction of sessional fees remuneration for physicians working in Quebec long-term care hospitals. More generally, this research was concerned with the determinants of the capacity of an organization to implement an innovation. Both a political and a structural model of analysis were empirically probed. We found strong support for the political model and moderate support for the structural model. This article contributes to the understanding of the relative contribution of structural and political determinants in the implementation of changes in organizations.

Factors influencing the practice of vaginal birth after cesarean section.

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.

The Reform of the Quebec Health Care System: Potential for Innovation?

The study is concerned with the practice of physicians in a prepaid group practice setting. Specifically, it is concerned 1) with investigating the extent of variation in physician behavior concerning use of clinical resources, that is, office visits and telephone calls, and technical resources, that is, x-rays and laboratory procedures, and 2) with determining the factors that account for such variation. The universe of this study consists of all internists practicing in 1970 in the prepaid group setting of Kaiser Permanente at Portland, Oregon, a total of 34. The overall framework for the study is based on the belief that medical training and the setting in which physicians work are significant determinants of their use of clinical and technical resources in different disease situations. Specifically, the framework posits that different sets of organizational variables are important in determining use of resources for acute and undiagnosed conditions. The findings reported in the study suggest that while the teaching environment in which a physician is trained is important in shaping his clinical personality, the setting in which he actually works contains its own source of influence over his professional activity. These results also provide supportive evidence for the widely held notion that prepaid group practice, through changing the nature of the incentives to physicians and introducing professional regulation, leads to a more efficient way of providing medical care by reducing the use of costly resources.

Quality of life assessment and HIV infection: a review.

OBJECTIVES Vaginal birth after cesarean has been recommended for most women with previous cesarean sections for the past 10 years. This practice, however, has not yet been generalized because high variations can still be observed among countries, hospitals, and physicians. METHODS A case-control study involving 635 case patients and 2593 control patients was carried out to determine which characteristics of the physician, the patient, or the hospital were important in the adoption of this practice. RESULTS The results of the multiple stepwise logistic regression analysis indicate a higher likelihood that women will experience vaginal birth after cesarean if their physicians had cesarean rates under 20%, had less than 5% of their patients considered at risk, and were younger than 54 years old. Vaginal birth after cesarean was also favored by hospitals characterized by a high degree of neonatal and obstetrical specialization, and a patient population with a low level of education. CONCLUSIONS This policy is still in the developmental stage, as evidenced by the great variability between hospitals and physicians in rates of vaginal birth after cesarean. Further efforts are required for this policy to become the norm.