1
|
Bammert P, Franke S, Flemming R, Iashchenko I, Brittner M, Gerlach R, Voß K, Sundmacher L. Comparing the quality of care in physician networks to usual care for elderly patients in three German regions: a quasi-experimental cohort study. Public Health 2024; 232:161-169. [PMID: 38788492 DOI: 10.1016/j.puhe.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 05/26/2024]
Abstract
OBJECTIVES Patients in Germany have free choice of physicians in the ambulatory care sector and can consult them as often as they wish without a referral. This can lead to inefficiencies in treatment pathways. In response, some physicians have formed networks to improve the coordination and quality of care. This study aims to investigate whether the care provided by these networks results in better health and process outcomes than usual care. STUDY DESIGN This was a quasi-experimental cohort study. METHODS We analysed claims data from 2017 to 2018 in Bavaria, Brandenburg, and Westphalia-Lippe. Our study population includes patients aged 65 years or older with heart failure (n = 267,256), back pain (n = 931,672), or depression (n = 483,068). We compared condition-specific and generic quality indicators between patients treated in physician networks and usual care. Ambulatory care-sensitive emergency department cases were used as a primary outcome measure. Imbalances between the groups were minimized using propensity score matching. RESULTS Rates of ambulatory care-sensitive emergency department cases yielded insignificant differences between networks and usual care in the depression and heart failure subgroups. For back pain patients, rates were 0.17 percentage points higher (P < 0.01) in network patients compared with usual care. Among network patients, generic indicators for prevention and coordination showed significantly better performance. For instance, the rate of completed vaccination against influenza is 3.03 percentage points higher (P < 0.01), and the rate of specialist visits after referral is 1.6 percentage points higher (P < 0.01) in heart failure patients, who are treated in physician networks. This is accompanied by higher rates of polypharmacy. Furthermore, the results for condition-specific indicators suggest that for most indicators, a greater proportion of the care provided by physician networks adhered to national treatment guidelines. CONCLUSIONS Our findings suggest that physician networks in Germany do not reduce rates of ambulatory care-sensitive emergency department cases but perform better than usual care in terms of care coordination and prevention. Further research is needed to confirm our findings and explore the implications of the potentially higher rates of polypharmacy seen in physician networks.
Collapse
Affiliation(s)
- P Bammert
- School of Medicine and Health, Technical University of Munich, Munich, Germany.
| | - S Franke
- School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - R Flemming
- School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - I Iashchenko
- School of Medicine and Health, Technical University of Munich, Munich, Germany
| | - M Brittner
- Association of Statutory Health Insurance Physicians Westphalia-Lippe, Dortmund, Germany
| | - R Gerlach
- Association of Statutory Health Insurance Physicians Bavaria, Munich, Germany
| | - K Voß
- Association of Statutory Health Insurance Physicians Brandenburg, Potsdam, Germany
| | - L Sundmacher
- School of Medicine and Health, Technical University of Munich, Munich, Germany
| |
Collapse
|
2
|
Premji K, Green ME, Glazier RH, Khan S, Schultz SE, Mathews M, Nastos S, Frymire E, Ryan BL. Characteristics of patients attached to near-retirement family physicians: a population-based serial cross-sectional study in Ontario, Canada. BMJ Open 2023; 13:e074120. [PMID: 38149429 PMCID: PMC10711930 DOI: 10.1136/bmjopen-2023-074120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 11/15/2023] [Indexed: 12/28/2023] Open
Abstract
OBJECTIVES Population ageing is a global phenomenon. Resultant healthcare workforce shortages are anticipated. To ensure access to comprehensive primary care, which correlates with improved health outcomes, equity and costs, data to inform workforce planning are urgently needed. We examined the medical and social characteristics of patients attached to near-retirement comprehensive primary care physicians over time and explored the early-career and mid-career workforce's capacity to absorb these patients. DESIGN A serial cross-sectional population-based analysis using health administrative data. SETTING Ontario, Canada, where most comprehensive primary care is delivered by family physicians (FPs) under universal insurance. PARTICIPANTS All insured Ontario residents at three time points: 2008 (12 936 360), 2013 (13 447 365) and 2019 (14 388 566) and all Ontario physicians who billed primary care services (2008: 11 566; 2013: 12 693; 2019: 15 054). OUTCOME MEASURES The number, proportion and health and social characteristics of patients attached to near-retirement age comprehensive FPs over time; the number, proportion and characteristics of near-retirement age comprehensive FPs over time. SECONDARY OUTCOME MEASURES The characteristics of patients and their early-career and mid-career comprehensive FPs. RESULTS Patient attachment to comprehensive FPs increased over time. The overall FP workforce grew, but the proportion practicing comprehensiveness declined (2008: 77.2%, 2019: 70.7%). Over time, an increasing proportion of the comprehensive FP workforce was near retirement age. Correspondingly, an increasing proportion of patients were attached to near-retirement physicians. By 2019, 13.9% of comprehensive FPs were 65 years or older, corresponding to 1 695 126 (14.8%) patients. Mean patient age increased, and all physicians served markedly increasing numbers of medically and socially complex patients. CONCLUSIONS The primary care sector faces capacity challenges as both patients and physicians age and fewer physicians practice comprehensiveness. Nearly 15% (1.7 million) of Ontarians may lose their comprehensive FP to retirement between 2019 and 2025. To serve a growing, increasingly complex population, innovative solutions are needed.
Collapse
Affiliation(s)
- Kamila Premji
- Department of Family Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Michael E Green
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
- Health Services and Policy Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Richard H Glazier
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, Ontario, Canada
| | - Shahriar Khan
- Health Services and Policy Research Institute, Queen's University, Kingston, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Kingston, Ontario, Canada
| | - Susan E Schultz
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Maria Mathews
- Department of Family Medicine, University of Western Ontario, London, Ontario, Canada
| | - Steve Nastos
- Economics, Policy & Research, Ontario Medical Association, Toronto, Ontario, Canada
| | - Eliot Frymire
- Health Services and Policy Research Institute, Queen's University, Kingston, Ontario, Canada
| | - Bridget L Ryan
- Department of Family Medicine, University of Western Ontario, London, Ontario, Canada
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| |
Collapse
|
3
|
AGGARWAL MONICA, HUTCHISON BRIAN, ABDELHALIM REHAM, BAKER GROSS. Building High-Performing Primary Care Systems: After a Decade of Policy Change, Is Canada "Walking the Talk?". Milbank Q 2023; 101:1139-1190. [PMID: 37743824 PMCID: PMC10726918 DOI: 10.1111/1468-0009.12674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 07/29/2023] [Accepted: 08/15/2023] [Indexed: 09/26/2023] Open
Abstract
Policy Points Considerable investments have been made to build high-performing primary care systems in Canada. However, little is known about the extent to which change has occurred over the last decade with implementing programs and policies across all 13 provincial and territorial jurisdictions. There is significant variation in the degree of implementation of structural features of high-performing primary care systems across Canada. This study provides evidence on the state of primary care reform in Canada and offers insights into the opportunities based on changes that governments elsewhere have made to advance primary care transformation. CONTEXT Despite significant investments to transform primary care, Canada lags behind its peers in providing timely access to regular doctors or places of care, timely access to care, developing interprofessional teams, and communication across health care settings. This study examines changes over the last decade (2012 to 2021) in policies across 13 provincial and territorial jurisdictions that address the structural features of high-performing primary care systems. METHODS A multiple comparative case study approach was used to explore changes in primary care delivery across 13 Canadian jurisdictions. Each case consisted of (1) qualitative interviews with academics, provincial health care leaders, and health care professionals and (2) a literature review of policies and innovations. Data for each case were thematically analyzed within and across cases, using 12 structural features of high-performing primary care systems to describe each case and assess changes over time. FINDINGS The most significant changes include adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. The rate of change was slowest for patient engagement, leadership development, performance measurement, research capacity, and systematic evaluation of innovation. CONCLUSIONS Progress toward building high-performing primary care systems in Canada has been slow and variable, with limited change in the organization and delivery of primary care. Canada's experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform, with progress less pronounced in the attributes that impact physician autonomy. To accelerate primary care transformation in Canada and abroad, a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous research.
Collapse
Affiliation(s)
| | - BRIAN HUTCHISON
- Centre for Health Economics and Policy AnalysisMcMaster University
| | - REHAM ABDELHALIM
- Institute of Health PolicyManagement and EvaluationUniversity of Toronto
| | - G. ROSS BAKER
- Dalla Lana School of Public HealthUniversity of Toronto
- Institute of Health PolicyManagement and EvaluationUniversity of Toronto
| |
Collapse
|
4
|
Rudoler D, Austin N, Allin S, Bjerre LM, Dolovich L, Glazier RH, Grudniewicz A, Laporte A, Martin E, Schultz S, Sirois C, Strumpf E. The impact of team-based primary care on medication-related outcomes in older adults: A comparative analysis of two Canadian provinces. Prev Med Rep 2023; 36:102512. [PMID: 38116285 PMCID: PMC10728440 DOI: 10.1016/j.pmedr.2023.102512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 09/29/2023] [Accepted: 11/08/2023] [Indexed: 12/21/2023] Open
Abstract
Objective To evaluate if access to team-based primary care is related to medication management outcomes for older adults. Methods We completed two retrospective cohort studies using administrative health data for older adults (66+) in Ontario (n = 428,852) and Québec (n = 310,198) who were rostered with a family physician (FP) between the 2001/02 and 2017/18 fiscal years. We generated matched comparison groups of older adults rostered to an FP practicing in a team-based model, and older adults rostered to an FP in a non-team model. We compared the following outcomes between these groups: any adverse drug reactions (ADRs), any potentially inappropriate prescription (PIP), and polypharmacy. Average treatment effects of access to team-based care were estimated using a difference-in-differences estimator. Results The risk of an ADR was 22 % higher (RR = 1.22, 95 % CI = 1.18, 1.26) for older adults rostered to a team-based FP in Québec and 6 % lower (RR = 0.943, 95 % CI = 0.907, 0.978) in Ontario. However, absolute risk differences were less than 0.5 %. Differences in the risk of polypharmacy were small in Québec (RR = 1.005, 95 % CI = 1.001, 1.009) and Ontario (RR = 1.004, 95 % CI = 1.001, 1.007) and had absolute risk differences of less than 1 % in both provinces. Effects on PIP were not statistically or clinically significant in adjusted models. Interpretation We did not find evidence that access to team-based primary care in Ontario or Québec meaningfully improved medication management outcomes for older adults.
Collapse
Affiliation(s)
- David Rudoler
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Nichole Austin
- School of Health Administration, Dalhousie University, Halifax, Canada
| | - Sara Allin
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Lise M. Bjerre
- Department of Family Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Lisa Dolovich
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada
| | - Richard H. Glazier
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Family and Community Medicine, St. Michael's Hospital and University of Toronto, Toronto, Ontario, Canada
| | - Agnes Grudniewicz
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
| | - Audrey Laporte
- ICES, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Canadian Centre for Health Economics, University of Toronto, Toronto, Ontario, Canada
| | - Elisabeth Martin
- Faculty of Nursing Sciences, Université Laval, Québec City, Québec, Canada
| | | | - Caroline Sirois
- Faculty of Pharmacy, Université Laval, Québec, Québec, Canada
| | - Erin Strumpf
- Canadian Centre for Health Economics, University of Toronto, Toronto, Ontario, Canada
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Québec, Canada
- Department of Economics, McGill University, Montréal, Québec, Canada
| |
Collapse
|
5
|
Lavergne MR, Bodner A, Allin S, Christian E, Hajizadeh M, Hedden L, Katz A, Kephart G, Leslie M, Rudoler D, Spencer S. Disparities in access to primary care are growing wider in Canada. Healthc Manage Forum 2023; 36:272-279. [PMID: 37340726 PMCID: PMC10447912 DOI: 10.1177/08404704231183599] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
Canadian provinces and territories have undertaken varied reforms to how primary care is funded, organized, and delivered, but equity impacts of reforms are unclear. We explore disparities in access to primary care by income, educational attainment, dwelling ownership, immigration, racialization, place of residence (metropolitan/non-metropolitan), and sex/gender, and how these have changed over time, using data from the Canadian Community Health Survey (2007/08 and 2015/16 or 2017/18). We observe disparities by income, educational attainment, dwelling ownership, recent immigration, immigration (regular place of care), racialization (regular place of care), and sex/gender. Disparities are persistent over time or increasing in the case of income and racialization (regular medical provider and consulted with a medical professional). Primary care policy decisions that do not explicitly consider existing inequities may continue to entrench them. Careful study of equity impacts of ongoing policy reforms is needed.
Collapse
Affiliation(s)
| | | | - Sara Allin
- University of Toronto, Toronto, Ontario, Canada
| | | | | | - Lindsay Hedden
- Simon Fraser University, Burnaby, British Columbia, Canada
| | - Alan Katz
- University of Manitoba, Winnipeg, Manitoba, Canada
| | | | | | | | - Sarah Spencer
- Simon Fraser University, Burnaby, British Columbia, Canada
| |
Collapse
|
6
|
McAlister FA, Nabipoor M, Wang T, Bakal JA. Emergency Visits or Hospitalizations for Cardiovascular Diagnoses in the Post-Acute Phase of COVID-19. JACC. ADVANCES 2023; 2:100391. [PMID: 38939433 PMCID: PMC11198398 DOI: 10.1016/j.jacadv.2023.100391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 03/07/2023] [Accepted: 04/03/2023] [Indexed: 06/29/2024]
Abstract
Background Prior studies of COVID-19 cardiovascular sequelae include diagnoses made within 4 weeks, but the World Health Organization definition for "postacute phase" is >3 months. Objectives The purpose of this study was to determine which cardiovascular diagnoses in the postacute phase of COVID-19 are associated with SARS-CoV-2 infection. Methods Retrospective cohort study of all adults in Alberta who had a positive SARS-CoV-2 reverse transcription polymerase chain reaction test between March 1, 2020 and June 30, 2021, matched (by age, sex, Charlson Comorbidity score, and test date) with controls who had a negative reverse transcription polymerase chain reaction test. Results The 177,892 patients with laboratory confirmed SARS-CoV-2 infection (mean age 42.7 years, 49.7% female) were more likely to visit an emergency department (5.7% vs 3.3%), be hospitalized (3.4% vs 2.1%), or die (1.3% vs 0.4%) within 1 month than matched test-negative controls. After 3 months, cases were significantly more likely than controls to have an emergency department visit or hospitalization for diabetes mellitus (1.5% vs 0.7%), hypertension (0.6% vs 0.4%), heart failure (0.2% vs 0.1%), or kidney injury (0.3% vs 0.2%). In the 6,030 patients who had survived a hospitalization for COVID-19, postacute phase risks were substantially greater for diabetes mellitus (9.5% vs 3.0%, adjusted odds ratio [aOR]: 3.16 [95% CI: 2.43-4.12]), hypertension (3.5% vs 1.4%, aOR: 2.89 [95% CI: 1.97-4.23]), heart failure (2.1% vs 0.7%, aOR: 3.16 [95% CI: 1.88-5.29]), kidney injury (3.1% vs 0.8%, aOR: 2.70 [95% CI: 1.71-4.28]), bleeding (1.5% vs 0.5%, aOR: 3.40 [95% CI: 1.83-6.32]), and venous thromboembolism (0.8% vs 0.3%, aOR: 3.60 [95% CI: 1.59-8.13]). Conclusions Clinicians should screen COVID-19 survivors for diabetes mellitus, hypertension, heart failure, and kidney dysfunction in the postacute phase.
Collapse
Affiliation(s)
- Finlay A. McAlister
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- The Alberta Strategy for Patient Oriented Research Support Unit, Edmonton, Alberta, Canada
| | - Majid Nabipoor
- The Alberta Strategy for Patient Oriented Research Support Unit, Edmonton, Alberta, Canada
| | - Ting Wang
- The Alberta Strategy for Patient Oriented Research Support Unit, Edmonton, Alberta, Canada
| | - Jeffrey A. Bakal
- Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- The Alberta Strategy for Patient Oriented Research Support Unit, Edmonton, Alberta, Canada
| |
Collapse
|
7
|
Aggarwal M, Hutchison B, Kokorelias KM, Mehta K, Greenberg L, Moran K, Barber D, Samson K. Impact of remuneration, extrinsic and intrinsic incentives on interprofessional primary care teams: protocol for a rapid scoping review. BMJ Open 2023; 13:e072076. [PMID: 37336539 DOI: 10.1136/bmjopen-2023-072076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
INTRODUCTION Interprofessional teams and funding and payment provider arrangements are key attributes of high-performing primary care. Several Canadian jurisdictions have introduced team-based models with different payment models. Despite these investments, the evidence of impact is mixed. This has raised questions about whether team-based primary care models are being implemented to facilitate team collaboration and effectiveness. Thus, we present a protocol for a rapid scoping review to systematically map, synthesise and summarise the existing literature on the impact of provider remuneration mechanisms and extrinsic and intrinsic incentives in team-based primary care. This review will answer three research questions: (1) What is the impact of provider remuneration models on team, patient, provider and system outcomes in primary care?; (2) What extrinsic and intrinsic incentives have been used in interprofessional primary care teams?; and (3) What is the impact of extrinsic and intrinsic team-based incentives on team, patient, provider and system outcomes? METHODS AND ANALYSIS We will conduct a rapid scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. We will search electronic databases (Medline, Embase, CINAHL, PsycINFO, EconLit) and grey literature sources (Google Scholar, Google). This review will consider all empirical studies and full-text English-language articles published between 2000 and 2022. Reviewers will independently perform the literature search, data extraction and synthesis of included studies. The Mixed Methods Appraisal Tool will be used to appraise the quality of evidence. The literature will be synthesised, summarised and mapped to themes that answer the research question of this review. ETHICS AND DISSEMINATION Ethics approval is not required. Findings from this study will be written for publication in an open-access peer-review journal and presented at national and international conferences. Knowledge users are part of the research team and will assist with disseminating findings to the public, clinicians, funders and professional associations.
Collapse
Affiliation(s)
- Monica Aggarwal
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Brian Hutchison
- Department of Family Medicine, Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Kristina Marie Kokorelias
- Department of Geriatric Medicine, Sinai Health and University Health Network, Toronto, Ontario, Canada
- Rehabiliation Sciences Institute and Department of Occupational Therapy and Occupational Sciences, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Kavita Mehta
- Association of Family Health Teams of Ontario, Toronto, Ontario, Canada
| | | | - Kimberly Moran
- Ontario College of Family Physicians, Toronto, Ontario, Canada
| | - David Barber
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kevin Samson
- East Wellington Family Health Team, Erin/Rockwood, Ontario, Canada
| |
Collapse
|
8
|
Jopling S, Wodchis WP, Rayner J, Rudoler D. Who gets access to an interprofessional team-based primary care programme for patients with complex health and social needs? A cross-sectional analysis. BMJ Open 2022; 12:e065362. [PMID: 36517102 PMCID: PMC9756166 DOI: 10.1136/bmjopen-2022-065362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES To determine whether a voluntary referral-based interprofessional team-based primary care programme reached its target population and to assess the representativeness of referring primary care physicians. DESIGN Cross-sectional analysis of administrative health data. SETTING Ontario, Canada. INTERVENTION TeamCare provides access to Community Health Centre services for patients of non-team physicians with complex health and social needs. PARTICIPANTS All adult patients who participated in TeamCare between 1 April 2015 and 31 March 2017 (n=1148), and as comparators, all non-referred adult patients of the primary care providers who shared patients in TeamCare (n=546 989), and a 1% random sample of the adult Ontario population (n=117 753). RESULTS TeamCare patients were more likely to live in lower income neighbourhoods with a higher degree of marginalisation relative to comparison groups. TeamCare patients had a higher mean number of diagnoses, higher prevalence of all chronic conditions and had more frequent encounters with the healthcare system in the year prior to participation. CONCLUSIONS TeamCare reached a target population and fills an important gap in the Ontario primary care landscape, serving a population of patients with complex needs that did not previously have access to interprofessional team-based care. STRENGTHS AND LIMITATIONS This study used population-level administrative health data. Data constraints limited the ability to identify patients referred to the programme but did not receive services, and data could not capture all relevant patient characteristics.
Collapse
Affiliation(s)
- Sydney Jopling
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Walter P Wodchis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Rayner
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Alliance for Healthier Communities, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - David Rudoler
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- Ontario Shores Centre for Mental Health Sciences, Whitby, Ontario, Canada
| |
Collapse
|
9
|
Lau T, Maltby A, Ali S, Moran V, Wilk P. Does the definition of preventable emergency department visit matter? An empirical analysis using 20 million visits in Ontario and Alberta. Acad Emerg Med 2022; 29:1329-1337. [PMID: 36043233 DOI: 10.1111/acem.14587] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 08/11/2022] [Accepted: 08/28/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES This study had two objectives: (1) to estimate the prevalence of preventable emergency department (ED) visits during the 2016-2020 time period among those living in 19 large urban centers in Alberta and Ontario, Canada, and (2) to assess if the definition of preventable ED visits matters in estimating the prevalence. METHODS A retrospective, population-based study of ED visits that were reported to the National Ambulatory Care Reporting System from April 1, 2016, to March 31, 2020, was conducted. Preventable ED visits were operationalized based on the following approaches: (1) Canadian Triage and Acuity Scale (CTAS), (2) ambulatory care-sensitive conditions (ACSC), (3) family practice-sensitive conditions (FPSC), and (4) sentinel nonurgent conditions (SNC). The overall proportion of ED visits that were preventable was estimated. We also estimated the adjusted relative risks of preventable ED visits by patients' sex and age, fiscal year, province of residence, and census metropolitan area (CMA) of residence. RESULTS There were 20,171,319 ED visits made by 8,919,618 patients ages 1 to 74 who resided in one of the 19 CMAs in Alberta or Ontario. On average, there were 2.26 visits per patient over the period of 4 fiscal years; most patients made one (44.22%) or two ED visits (20.72%). The overall unadjusted prevalence of preventable ED visits varied by definition; 35.33% of ED visits were defined as preventable based on CTAS, 12.88% based on FPSC, 3.41% based on SNC, and 2.33% based on ACSC. CONCLUSIONS There is a substantial level of variation in prevalence estimates across definitions of preventable ED visits, and care should be taken when interpreting these estimates as each has a different meaning and may lead to different conclusions. The conceptualization and measurement of preventable ED visits is complex and multifaceted and may not be adequately captured by a single definition.
Collapse
Affiliation(s)
- Tammy Lau
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Alana Maltby
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Shehzad Ali
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Bruyère Research Institute, Ottawa, Ontario, Canada
| | - Valérie Moran
- Department of Precision Health, Luxembourg Institute of Health, Strassen, Luxembourg.,Luxembourg Institute of Socio-Economic Research, Living Conditions, Esch-sur-Alzette, Luxembourg
| | - Piotr Wilk
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada.,Department of Paediatrics, Western University, London, Ontario, Canada.,Child Health Research Institute, London, Ontario, Canada.,Lawson Health Research Institute, London, Ontario, Canada.,ICES, London, Ontario, Canada.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| |
Collapse
|
10
|
Smithman MA, Haggerty J, Gaboury I, Breton M. Improved access to and continuity of primary care after attachment to a family physician: longitudinal cohort study on centralized waiting lists for unattached patients in Quebec, Canada. BMC PRIMARY CARE 2022; 23:238. [PMID: 36114464 PMCID: PMC9482231 DOI: 10.1186/s12875-022-01850-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 09/08/2022] [Indexed: 11/10/2022]
Abstract
Abstract
Background
Having a regular family physician is associated with many benefits. Formal attachment – an administrative patient-family physician agreement – is a popular feature in primary care, intended to improve access to and continuity of care with a family physician. However, little evidence exists about its effectiveness. In Quebec, Canada, where over 20% of the population is unattached, centralized waiting lists help attach patients. This provides a unique opportunity to observe the influence of attachment in previously unattached patients. The aim was to evaluate changes in access to and continuity of primary care associated with attachment to a family physician through Quebec’s centralized waiting lists for unattached patients.
Methods
We conducted an observational longitudinal population cohort study, using medical services billing data from public health insurance in the province of Québec, Canada. We included patients attached through centralized waiting lists for unattached patients between 2012 and 2014 (n = 410,140). Our study was informed by Aday and Andersen’s framework for the study of access to health services. We compared outcomes during four 12-month periods: two periods before and two periods after attachment, with T0–2 years as the reference period. Outcome measures were number of primary care visits and Bice-Boxerman Concentration of Care Index at the physician and practice level (for patients with ≥2 visits in a given period). We included age, sex, region remoteness, medical vulnerability, and Charlson Comorbidity Index as covariates in regression models fitted with generalized estimating equations.
Results
The number of primary care visits increased by 103% in the first post attachment year and 29% in the second year (p < 0.001). The odds of having all primary care visits concentrated with a single physician increased by 53% in the first year and 22% (p < 0.001) in the second year after attachment. At the practice level, the odds of perfect concentration of care increased by 19% (p < 0.001) and 15% (p < 0.001) respectively, in first and second year after attachment.
Conclusion
Our results show an increase in patients’ number of primary care visits and concentration of care at the family physician and practice level after attachment to a family physician. This suggests that attachment may help improve access to and continuity of primary care.
Collapse
|
11
|
Kiran T, Moineddin R, Kopp A, Glazier RH. Impact of Team-Based Care on Emergency Department Use. Ann Fam Med 2022; 20:24-31. [PMID: 35074764 PMCID: PMC8786428 DOI: 10.1370/afm.2728] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 05/17/2021] [Accepted: 05/26/2021] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We sought to assess the impact of team-based care on emergency department (ED) use in the context of physicians transitioning from fee-for-service payment to capitation payment in Ontario, Canada. METHODS We conducted an interrupted time series analysis to assess annual ED visit rates before and after transition from an enhanced fee-for-service model to either a team capitation model or a nonteam capitation model. We included Ontario residents aged 19 years and older who had at least 3 years of outcome data both pretransition and post-transition (N = 2,524,124). We adjusted for age, sex, income quintile, immigration status, comorbidity, and morbidity, and we stratified by rurality. A sensitivity analysis compared outcomes for team vs nonteam patients matched on year of transition, age, sex, rurality, and health region. RESULTS We compared 387,607 team and 1,399,103 nonteam patients in big cities, 213,394 team and 380,009 nonteam patients in small towns, and 65,289 team and 78,722 nonteam patients in rural areas. In big cities, after adjustment, the ED visit rate increased by 2.4% (95% CI, 2.2% to 2.6%) per year for team patients and 5.2% (95% CI, 5.1% to 5.3%) per year for nonteam patients in the years after transition (P <.001). Similarly, there was a slower increase in ED visits for team relative to nonteam patients in small towns (0.9% [95% CI, 0.7% to 1.1%] vs 2.9% [95% CI, 2.8% to 3.1%], P <.001) and rural areas (‒0.5% [95% CI, -0.8% to 0.2%] vs 1.3% [95% CI, 1.0% to 1.6%], P <.001). Results were much the same in the matched analysis. CONCLUSIONS Adoption of team-based primary care may reduce ED use. Further research is needed to understand optimal team composition and roles.
Collapse
Affiliation(s)
- Tara Kiran
- Department of Family and Community Medicine and the MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada
| | | | - Richard H Glazier
- Department of Family and Community Medicine and the MAP Centre for Urban Health Solutions, St Michael's Hospital, Toronto, Ontario, Canada.,Department of Family and Community Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.,ICES, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
12
|
Lee SK, Mahl SK, Rowe BH. The Induced Productivity Decline Hypothesis: More Physicians, Higher Compensation and Fewer Services. Healthc Policy 2021; 17:90-104. [PMID: 34895412 PMCID: PMC8665726 DOI: 10.12927/hcpol.2021.26655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Public outrage regarding physician shortages during the past two decades have led to policies aimed at significantly increasing physician supply, yet access remains elusive. In this paper, we examine this puzzling trend and the causes underlying it by analyzing physician supply, compensation and productivity and the reasons behind productivity decline. We hypothesize that excess physician compensation beyond a target income induces productivity decline. In contrast to a wage–productivity gap for the average Canadian worker (where productivity has increased but compensation has not kept pace), physicians are experiencing a “reverse wage–productivity gap” whereby compensation is increasing but productivity is decreasing, resulting in more physicians, higher compensation and fewer services. We conclude by discussing potential policy options to address how best to provide timely access to medical care for Canadians while keeping physician healthcare expenditures at sustainable levels.
Collapse
Affiliation(s)
- Shoo K Lee
- Professor of Paediatrics, Obstetrics & Gynecology, and Public Health, University of Toronto; Director, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON
| | - Sukhy K Mahl
- Assistant Director, Maternal-Infant Care Research Centre, Mount Sinai Hospital, Toronto, ON
| | - Brian H Rowe
- Professor, Department of Emergency Medicine and School of Public Health, University of Alberta, Edmonton, AB
| |
Collapse
|
13
|
Perrault-Sequeira L, Torti J, Appleton A, Mathews M, Goldszmidt M. Discharging the complex patient - changing our focus to patients' networks of care providers. BMC Health Serv Res 2021; 21:950. [PMID: 34507571 PMCID: PMC8431846 DOI: 10.1186/s12913-021-06841-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 07/30/2021] [Indexed: 11/18/2022] Open
Abstract
Background A disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning. Methods This was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical. Results We identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network’s scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial. Conclusions Our results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06841-2.
Collapse
Affiliation(s)
| | - Jacqueline Torti
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Centre for Education Research & Innovation - Western University, London, ON, Canada
| | - Andrew Appleton
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Maria Mathews
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada
| | - Mark Goldszmidt
- Schulich School of Medicine & Dentistry, Western University, London, ON, Canada.,Centre for Education Research & Innovation - Western University, London, ON, Canada
| |
Collapse
|
14
|
Multiple Sclerosis Clinic Utilization is Associated with Fewer Emergency Department Visits. Can J Neurol Sci 2021; 49:393-397. [PMID: 34027837 DOI: 10.1017/cjn.2021.118] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Alberta is a Canadian province with a high prevalence of multiple sclerosis (MS). In this ecological study, we examined group differences in health care utilization among persons with MS (pwMS) living within different regions of the province. METHODS pwMS were identified from provincial administrative databases spanning 2002-2011. Utilization of health care services was determined for a 2-year period (April 2010-March 2012). Residential postal codes placed patients into their provincial health care zones. As data were provided to the investigators in an aggregated form, tests of statistical significance and confounding were not performed. RESULTS In total, 11,721 pwMS were identified. During the 2-year observation period, 96.2% of pwMS accessed a family physician and 57.1% accessed a neurologist. Nearly all (99.0%) pwMS who received neurologist care in Calgary visited an MS clinic, in contrast to Edmonton where a larger proportion (34.8%) received solely community neurologist care. More pwMS living in Edmonton accessed the ED (41.1%) compared to Calgary (35.7%), and the rate of visits per pwMS was higher in Edmonton (1.07/pwMS) than in Calgary (0.81/pwMS). The frequency of inpatient admissions was similar. CONCLUSIONS Over 2 years, most pwMS accessed primary care and over half saw a neurologist. Despite a similar frequency of inpatient admissions, the frequency of ED visits by pwMS was higher in Edmonton compared to Calgary, where more patients received MS clinic care. Although this exploratory study is subject to several limitations, our findings suggest that specialized MS clinics may reduce costly ED visits.
Collapse
|
15
|
Foo CD, Surendran S, Tam CH, Ho E, Matchar DB, Car J, Koh GCH. Perceived facilitators and barriers to chronic disease management in primary care networks of Singapore: a qualitative study. BMJ Open 2021; 11:e046010. [PMID: 33947737 PMCID: PMC8098912 DOI: 10.1136/bmjopen-2020-046010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE The increasing chronic disease burden has placed tremendous strain on tertiary healthcare resources in most countries, necessitating a shift in chronic disease management from tertiary to primary care providers. The Primary Care Network (PCN) policy was promulgated as a model of care to organise private general practitioners (GPs) into groups to provide GPs with resources to anchor patients with chronic conditions with them in the community. As PCN is still in its embryonic stages, there is a void in research regarding its ability to empower GPs to manage patients with chronic conditions effectively. This qualitative study aims to explore the facilitators and barriers for the management of patients with chronic conditions by GPs enrolled in PCN. DESIGN We conducted 30 semistructured interviews with GPs enrolled in a PCN followed by a thematic analysis of audio transcripts until data saturation was achieved. SETTING Singapore. RESULTS Our results suggest that PCNs facilitated GPs to more effectively manage patients through (1) provision of ancillary services such as diabetic foot screening, diabetic retinal photography and nurse counselling to permit a 'one-stop-shop', (2) systematic monitoring of process and clinical outcome indicators through a chronic disease registry (CDR) to promote accountability for patients' health outcomes and (3) funding streams for PCNs to hire additional manpower to oversee operations and to reimburse GPs for extended consultations. Barriers include high administrative load in maintaining the CDR due to the lack of a smart electronic clinic management system and financial gradient faced by patients seeking services from private GPs which incur higher out-of-pocket expenses than public primary healthcare institutions. CONCLUSION PCNs demonstrate great promise in empowering enrolled GPs to manage patients with chronic conditions. However, barriers will need to be addressed to ensure the viability of PCNs in managing more patients in the face of an ageing population.
Collapse
Affiliation(s)
- Chuan De Foo
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Shilpa Surendran
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Chen Hee Tam
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - Elaine Ho
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| | - David Bruce Matchar
- Internal Medicine, Duke University, Durham, North Carolina, USA
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - Josip Car
- Centre for Population Health Sciences, Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gerald Choon Huat Koh
- Health Systems and Behavioural Sciences Domain, Saw Swee Hock School of Public Health, National University Singapore, Singapore
| |
Collapse
|
16
|
Damiani G, Pascucci D, Sindoni A, Mete R, Ricciardi W, Villari P, De Vito C. The bigger, the better? A systematic review on the impact of mergers on primary care organizations. Eur J Public Health 2021; 31:244-252. [PMID: 33624788 PMCID: PMC8071597 DOI: 10.1093/eurpub/ckaa248] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Primary care services are the first point of contact in a healthcare system; in the last years, many mergers and reconfigurations have taken place in this setting. The aim of this study is to summarize the literature evidence on the relationship between the increase in the size of these organizations and their performance. METHODS A systematic review of the literature was carried out querying EMBASE, MEDLINE and Web of Science databases, from their inception to January 2020. Articles which quantitatively assessed outcomes and process indicators of merger/structural reorganization of primary care organizations and qualitative articles that assessed staff perception and satisfaction were included in the review. RESULTS A total of 3626 articles was identified and another study was retrieved through snowball search; 11 studies were included in the systematic review. Studies about lipid profile evaluation and emergency admissions for chronic conditions showed moderate evidence in supporting the merging of primary care organizations; conversely, clinical outcome studies did not reach a sufficient level of evidence to support merging actions. A moderate evidence of a negative effect on patient's perspective was found. CONCLUSION Actually, there is no strong evidence in favour or against merging of primary care organizations without equivocation. This review supports the possibility to identify indicators for evaluating a merging process of primary care organizations and for adopting eventual remedies during this process. Further efforts should be made to identify additional indicators to assess merge actions among primary care organizations.
Collapse
Affiliation(s)
- Gianfranco Damiani
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico Pascucci
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Sindoni
- Dipartimento di Sanità Pubblica e Malattie Infettive, Sapienza Università di Roma, Rome, Italy
| | | | - Walter Ricciardi
- Dipartimento di Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Rome, Italy
- Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Paolo Villari
- Dipartimento di Sanità Pubblica e Malattie Infettive, Sapienza Università di Roma, Rome, Italy
| | - Corrado De Vito
- Dipartimento di Sanità Pubblica e Malattie Infettive, Sapienza Università di Roma, Rome, Italy
| |
Collapse
|
17
|
Berthelot S, Breton M, Guertin JR, Archambault PM, Berger Pelletier E, Blouin D, Borgundvaag B, Duhoux A, Harvey Labbé L, Laberge M, Lachapelle P, Lapointe-Shaw L, Layani G, Lefebvre G, Mallet M, Matthews D, McBrien K, McLeod S, Mercier E, Messier A, Moore L, Morris J, Morris K, Ovens H, Pageau P, Paquette JS, Perry J, Schull M, Simon M, Simonyan D, Stelfox HT, Talbot D, Vaillancourt S. A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study. JMIR Res Protoc 2021; 10:e25619. [PMID: 33616548 PMCID: PMC7939947 DOI: 10.2196/25619] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/15/2020] [Accepted: 12/18/2020] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. OBJECTIVE The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. METHODS A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. RESULTS Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. CONCLUSIONS The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/25619.
Collapse
Affiliation(s)
- Simon Berthelot
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
| | - Mylaine Breton
- Department of Community Health sciences, Université de Sherbrooke, Campus de Longueuil, Longueuil, QC, Canada
- Centre de recherche Charles-Le Moyne - Saguenay-Lac-Saint-Jean sur les innovations en santé, Longueuil, QC, Canada
| | - Jason Robert Guertin
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Patrick Michel Archambault
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Centre de recherche du Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Lévis, QC, Canada
| | - Elyse Berger Pelletier
- Ministère de la santé et des services sociaux, Gouvernement du Québec, Québec, QC, Canada
| | - Danielle Blouin
- Department of Emergency Medicine, Queen's University, Kingston, ON, Canada
| | - Bjug Borgundvaag
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
| | - Arnaud Duhoux
- Faculty of Nursing, Université de Montréal, Montréal, QC, Canada
| | - Laurie Harvey Labbé
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Maude Laberge
- Operations and Decision Systems Department, Faculty of Administrative Sciences, Université Laval, Québec, QC, Canada
| | - Philippe Lachapelle
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | | | - Géraldine Layani
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Gabrielle Lefebvre
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Myriam Mallet
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Deborah Matthews
- Ministry of Health and Long Term Care, Government of Ontario, Toronto, ON, Canada
| | - Kerry McBrien
- Departments of Family Medicine and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Shelley McLeod
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
- Division of Emergency Medicine, Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Eric Mercier
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
| | - Alexandre Messier
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
| | - Lynne Moore
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Judy Morris
- Department of Family and Emergency Medicine, Université de Montréal, Montréal, QC, Canada
- Hôpital du Sacré-Coeur-de-Montréal, Centre intégré universitaire de santé et de services sociaux du Nord-de-l'Île-de Montréal, Montréal, QC, Canada
| | - Kathleen Morris
- Canadian Institute for Health Information, Ottawa, ON, Canada
| | - Howard Ovens
- Schwartz/Reisman Emergency Medicine Institute, Sinai Health System, Toronto, ON, Canada
| | - Paul Pageau
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Jean-Sébastien Paquette
- Department of Family and Emergency Medicine, Université Laval, Québec, QC, Canada
- VITAM - Centre de recherche en santé durable, Québec, QC, Canada
- Laboratoire ARIMED, GMF-U de Saint-Charles-Borromée, Québec, QC, Canada
| | - Jeffrey Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Michael Schull
- Department of Emergency Medicine, Sunnybrook Research Institute, University of Toronto, Toronto, ON, Canada
| | - Mathieu Simon
- Institut universitaire de cardiologie et de pneumologie de Québec, Québec, QC, Canada
| | - David Simonyan
- Axe Santé des populations et Pratiques optimales en santé, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Henry Thomas Stelfox
- Department of Critical Care Medicine, Medicine and Community Health Sciences, O'Brien Institute for Public Health, University of Calgary, Calgary, AB, Canada
| | - Denis Talbot
- Department of Social and Preventive Medicine, Université Laval, Québec, QC, Canada
| | - Samuel Vaillancourt
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Department of Emergency Medicine, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| |
Collapse
|
18
|
Jan CFJ, Chang CJJ, Hwang SJ, Chen TJ, Yang HY, Chen YC, Huang CK, Chiu TY. Impact of team-based community healthcare on preventable hospitalisation: a population-based cohort study in Taiwan. BMJ Open 2021; 11:e039986. [PMID: 33593765 PMCID: PMC7888366 DOI: 10.1136/bmjopen-2020-039986] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVES The objective of this study was to explore the impact of Taiwan's Family Practice Integrated Care Project (FPICP) on hospitalisation. DESIGN A population-based cohort study compared the hospitalisation rates for ambulatory care sensitive conditions (ACSCs) among FPICP participating and non-participating patients during 2011-2015. SETTING The study accessed the FPICP reimbursement database of Taiwan's National Health Insurance (NHI) administration containing all NHI administration-selected patients for FPICP enrolment. PARTICIPANTS The NHI administration-selected candidates from 2011 to 2015 became FPICP participants if their primary care physicians joined the project, otherwise they became non-participants. INTERVENTIONS The intervention of interest was enrolment in the FPICP or not. The follow-up time interval for calculating the rate of hospitalisation was the year in which the patient was selected for FPICP enrolment or not. PRIMARY OUTCOME MEASURES The study's primary outcome measures were hospitalisation rates for ACSC, including asthma/chronic obstructive pulmonary disease (COPD), diabetes or its complications and heart failure. Logistic regression was used to calculate the ORs concerning the influence of FPICP participation on the rate of hospitalisation for ACSC. RESULTS The enrolled population for data analysis was between 3.94 and 5.34 million from 2011 to 2015. Compared to non-participants, FPICP participants had lower hospitalisation for COPD/asthma (28.6‰-35.9‰ vs 37.9‰-42.3‰) and for diabetes or its complications (10.8‰-14.9‰ vs 12.7‰-18.1‰) but not for congestive heart failure. After adjusting for age, sex and level of comorbidities by logistic regression, participation in the FPICP was associated with lower hospitalisation for COPD/asthma (OR 0.91, 95% CI 0.87 to 0.94 in 2015) and for diabetes or its complications (OR 0.87, 95% CI 0.83 to 0.92 in 2015). CONCLUSION Participation in the FPICP is an independent protective factor for preventable ACSC hospitalisation. Team-based community healthcare programs such as the FPICP can strengthen primary healthcare capacity.
Collapse
Affiliation(s)
- Chyi-Feng Jeff Jan
- Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Family Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | | | - Shinn-Jang Hwang
- Family Medicine, National Yang-Ming Medical College, Taipei, Taiwan
- Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Taiwan Association of Family Medicine, Taipei, Taiwan
| | - Tzeng-Ji Chen
- Family Medicine, National Yang-Ming Medical College, Taipei, Taiwan
- Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Hsiao-Yu Yang
- Department of Public Health and Institute of Occupational Medicine and Industrial Hygiene, National Taiwan University College of Public Health, Taipei, Taiwan
| | - Yu-Chun Chen
- Family Medicine, National Yang-Ming Medical College, Taipei, Taiwan
- Family Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Cheng-Kuo Huang
- Taiwan Association of Family Medicine, Taipei, Taiwan
- Taiwan Medical Association, Taipei, Taiwan
| | - Tai-Yuan Chiu
- Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Family Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
- Taiwan Medical Association, Taipei, Taiwan
| |
Collapse
|
19
|
Schraeder K, Allemang B, Scott C, McBrien K, Dimitropoulos G, Felske A, Samuel S. Primary care during the transition to adult care for adolescents involved with pediatric specialty services: a scoping review protocol. Syst Rev 2021; 10:46. [PMID: 33531077 PMCID: PMC7856752 DOI: 10.1186/s13643-021-01593-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 01/18/2021] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Of the 15-20% of youth in North America affected by a chronic health condition (e.g., type 1 diabetes, cystic fibrosis) and/or mental health or neurodevelopmental disorder (e.g., depression, eating disorder, Attention Deficit-Hyperactivity Disorder), many often require lifelong specialist healthcare services. Ongoing primary care during childhood and into young adulthood is recommended by best practice guidelines. To date, it is largely unknown if, how, and when primary care physicians (PCPs; such as family physicians) collaborate with specialists as AYAs leave pediatric-oriented services. The proposed scoping review will synthesize the available literature on the roles of PCPs for AYAs with chronic conditions leaving pediatric specialty care and identify potential benefits and challenges of maintaining PCP involvement during transition. METHODS Arksey and O'Malley's original scoping review framework will be utilized with guidance from Levac and colleagues and the Joanna Briggs Institute. A search of databases including MEDLINE (OVID), EMBASE, PsycINFO, and CINAHL will be conducted following the development of a strategic search strategy. Eligible studies will (i) be published in English from January 2004 onwards, (ii) focus on AYAs (ages 12-25) with a chronic condition(s) who have received specialist services during childhood, and (iii) include relevant findings about the roles of PCPs during transition to adult services. A data extraction tool will be developed and piloted on a subset of studies. Both quantitative and qualitative data will be synthesized. DISCUSSION Key themes about the roles of PCPs for AYAs involved with specialist services will be identified through this review. Findings will inform the development and evaluation of a primary-care based intervention to improve transition care for AYAs with chronic conditions.
Collapse
Affiliation(s)
- Kyleigh Schraeder
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Brooke Allemang
- Faculty of Social Work, University of Calgary, Calgary, Alberta, Canada
| | - Cathie Scott
- PolicyWise for Children & Families, Calgary, Alberta, Canada.,Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kerry McBrien
- Department of Family Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | | | - Ashley Felske
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susan Samuel
- Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
20
|
Keddy AC, Packer TL, Audulv Å, Sutherland L, Sampalli T, Edwards L, Kephart G. The Team Assessment of Self-Management Support (TASMS): A new approach to uncovering how teams support people with chronic conditions. Healthc Manage Forum 2021; 34:43-48. [PMID: 32729329 DOI: 10.1177/0840470420942262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Canadian and other healthcare systems are adopting primary care models founded on multidisciplinary, team-based care. This paper describes the development and use of a new tool, the Team Assessment of Self-Management Support (TASMS), designed to understand and improve the self-management support teams provide to patients with chronic conditions. Team Assessment of Self-Management Support captures the time providers spend supporting seven different types of self-management support (process strategies, resources strategies, disease controlling strategies, activities strategies, internal strategies, social interactions strategies, and healthy behaviours strategies), their referral patterns and perceived gaps in care. Four unique features make TASMS user-friendly: it is patient-centred, it uses provider-level data to create a team profile, it has the ability to be tailored to needs (diagnosis and visit type), and visual presentation of results are quickly and intuitively understood by both providers and planners. Currently being used by providers and planners in Nova Scotia, scaling up will allow more widespread use.
Collapse
Affiliation(s)
| | | | | | | | - Tara Sampalli
- 432234Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Lynn Edwards
- 432234Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | | |
Collapse
|
21
|
Fletcher MJ, Tsiligianni I, Kocks JWH, Cave A, Chunhua C, Sousa JCD, Román-Rodríguez M, Thomas M, Kardos P, Stonham C, Khoo EM, Leather D, van der Molen T. Improving primary care management of asthma: do we know what really works? NPJ Prim Care Respir Med 2020; 30:29. [PMID: 32555169 PMCID: PMC7300034 DOI: 10.1038/s41533-020-0184-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 05/13/2020] [Indexed: 12/14/2022] Open
Abstract
Asthma imposes a substantial burden on individuals and societies. Patients with asthma need high-quality primary care management; however, evidence suggests the quality of this care can be highly variable. Here we identify and report factors contributing to high-quality management. Twelve primary care global asthma experts, representing nine countries, identified key factors. A literature review (past 10 years) was performed to validate or refute the expert viewpoint. Key driving factors identified were: policy, clinical guidelines, rewards for performance, practice organisation and workforce. Further analysis established the relevant factor components. Review evidence supported the validity of each driver; however, impact on patient outcomes was uncertain. Single interventions (e.g. healthcare practitioner education) showed little effect; interventions driven by national policy (e.g. incentive schemes and teamworking) were more effective. The panel's opinion, supported by literature review, concluded that multiple primary care interventions offer greater benefit than any single intervention in asthma management.
Collapse
Affiliation(s)
- Monica J Fletcher
- Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Old Medical School, Teviot Place, Edinburgh, EH8 9AG, UK.
| | - Ioanna Tsiligianni
- Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Janwillem W H Kocks
- General Practitioners Research Institute, 59713 GH, Groningen, The Netherlands
- University of Groningen, University Medical Center Groningen, GRIAC Research Institute, Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Andrew Cave
- Department of Family Medicine, 6-10 University Terrace, University of Alberta, Edmonton, AB, T6G 2T4, Canada
| | - Chi Chunhua
- Peking University First Hospital, Beijing, China
| | - Jaime Correia de Sousa
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal
- 33ICVS/3B's, PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Miguel Román-Rodríguez
- Primary Care Respiratory Research Unit, Instituto de Investigación Sanitaria de las Islas Baleares (IdISBa), Palma, Spain
| | - Mike Thomas
- Department of Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, SO16 5ST, UK
| | - Peter Kardos
- Respiratory, Allergy and Sleep Unit at Red Cross Maingau Hospital, Friedberger Anlage 31-32, 60316, Frankfurt, Germany
| | - Carol Stonham
- NHS Gloucestershire Clinical Commissioning Group, Brockworth, UK
| | - Ee Ming Khoo
- Department of Primary Care Medicine, Faculty of Medicine, University of Malaya, 50603, Kuala Lumpur, Malaysia
| | - David Leather
- Global Respiratory Franchise, GlaxoSmithKline plc., GSK House, 980 Great West Rd, Brentford, Middlesex, TW8 9GS, UK
| | - Thys van der Molen
- Department of General Practice, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| |
Collapse
|
22
|
Leclerc J, Blais C, Rochette L, Hamel D, Guénette L, Beaudoin C, Poirier P. Public Health Outcomes May Differ After Switching from Brand-Name to Generic Angiotensin II Receptor Blockers. Drugs R D 2020; 20:135-145. [PMID: 32342284 PMCID: PMC7221012 DOI: 10.1007/s40268-020-00307-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background It is unclear whether generics are as safe as brand-name drugs in cardiology. For public health surveillance purposes, we evaluated if switching from the brand-name losartan, valsartan, or candesartan impacted the occurrence of the following outcomes: emergency room (ER) consultations, hospitalizations, or death. Study Design This was a retrospective cohort study. Methods This study was conducted in the Quebec Integrated Chronic Disease Surveillance System, including healthcare administrative data of the population of Quebec, Canada. We included brand-name users of losartan, valsartan, or candesartan aged ≥ 66 years who had undergone ≥ 30 days of stable treatment on the brand-name drug prior to cohort entry (substitution time-distribution matching was used to prevent immortal time bias). Outcomes up to 1 year were compared between groups using multivariable Cox proportional hazards regression models (validity assumptions were verified). Results In our cohorts (losartan, n =15,783; valsartan, n =16,907; candesartan, n =26,178), mean age was 76–78 years, 59–66% were female, 90–92% had hypertension, and 13–15% had heart failure. Validity assumptions were violated for losartan only. For patients switched to generic valsartan, the hazard ratio (95% confidence interval) was 1.07 (0.99–1.14) for ER consultation, 1.26 (1.14–1.39) for hospitalization, and 1.01 (0.61–1.67) for death. The corresponding rates for candesartan were 1.00 (0.95–1.05), 0.96 (0.89–1.03), and 0.57 (0.37–0.88), respectively. Conclusions We observed an increased risk of hospitalizations for patients switched to generic valsartan, and a decreased risk of death for patients switched to generic candesartan, compared with those who continued taking the brand-name drug. The differences between generic and brand-name drugs may lead to some differences in public health outcomes, but this safety signal must be further studied using other cohorts and settings. Electronic supplementary material The online version of this article (10.1007/s40268-020-00307-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Jacinthe Leclerc
- Institut national de santé publique du Québec, Bureau d'information et d'études en santé des populations, Quebec, QC, Canada. .,Département des Sciences infirmières, Université du Québec à Trois-Rivières, 3351, boul. des Forges, C.P. 500, Local 4849, Santé, Trois-Rivières, QC, G9A 5H7, Canada. .,Faculty of Medicine, McGill University, Montreal, QC, Canada.
| | - Claudia Blais
- Institut national de santé publique du Québec, Bureau d'information et d'études en santé des populations, Quebec, QC, Canada.,Faculté de Pharmacie, Université Laval, Quebec City, QC, Canada
| | - Louis Rochette
- Institut national de santé publique du Québec, Bureau d'information et d'études en santé des populations, Quebec, QC, Canada
| | - Denis Hamel
- Institut national de santé publique du Québec, Bureau d'information et d'études en santé des populations, Quebec, QC, Canada
| | - Line Guénette
- Faculté de Pharmacie, Université Laval, Quebec City, QC, Canada.,Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Quebec City, QC, Canada
| | - Claudia Beaudoin
- Institut national de santé publique du Québec, Bureau d'information et d'études en santé des populations, Quebec, QC, Canada.,Axe santé des populations et pratiques optimales en santé, Centre de recherche du CHU de Québec, Quebec City, QC, Canada.,Faculté de médecine, Université Laval, Quebec City, QC, Canada
| | - Paul Poirier
- Faculté de Pharmacie, Université Laval, Quebec City, QC, Canada.,Centre de recherche de l'Institut universitaire de cardiologie et de pneumologie de Québec, Quebec City, QC, Canada
| |
Collapse
|
23
|
McAlister FA, Tonelli M, Wiebe N, Lin M, Svenson LW, Dean S. The ecology of medical care for adults in Alberta, 2002/03 to 2016/17: a retrospective cohort study. CMAJ Open 2020; 8:E169-E177. [PMID: 32184280 PMCID: PMC7082108 DOI: 10.9778/cmajo.20190188] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND If we are to improve the patient experience, knowing where and with whom people receive professional health advice and treatment (the ecology of medical care) is the first step. We designed this study to define the ecology of medical care in Alberta and to examine whether province-wide implementation of 5 policy changes between 2003 and 2012 changed patterns of care among adults in the province. METHODS This was a retrospective cohort study of adults (age ≥ 18 yr) in Alberta using routinely collected data from 6 linked administrative health databases, the 2016 Canadian Community Health Survey and the Alberta Health Link teletriage system. We collected data on all encounters with pharmacists, primary care physicians, specialists, emergency departments and hospitals in 2002/03, 2009/10 and 2016/17. RESULTS Between 2002/03 and 2016/17, the community-dwelling adult population of Alberta increased from 2.66 million to 3.84 million; the median age increased from 41 to 43 years, and the proportion with at least 1 ambulatory-care-sensitive condition increased from 20.6% to 27.8%. The proportion who saw a primary care physician decreased significantly (from 70.8% to 68.2%, p < 0.001), as did the proportion who visited an emergency department (from 20.6% to 19.2%, p < 0.001); the declines were seen in all subgroups examined. The proportion who saw a specialist as an outpatient increased from 31.9% to 33.2% (p < 0.001), and the proportion who received at least 1 medication dispensation increased from 54.9% to 60.2% (p < 0.001). The proportion admitted to an acute care hospital (5.6%-6.5%) or academic hospital (1.2%) was relatively stable over time. INTERPRETATION Despite implementation of 5 system-wide changes designed to affect the delivery of primary and specialty medical care as well as the use of pharmacist and nursing services in Alberta, patterns of health care delivery changed little between 2002/03 and 2016/17. Rather than searching for a policy "magic bullet," health care planners may be better served by focusing on upscaling and implementing interventions proven to be efficacious.
Collapse
Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta.
| | - Marcello Tonelli
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Natasha Wiebe
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Meng Lin
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Lawrence W Svenson
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| | - Stafford Dean
- Division of General Internal Medicine (McAlister), Alberta SPOR Support Unit Data Platform (McAlister, Lin) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Lin), University of Alberta, Edmonton, Alta.; Departments of Medicine (Tonelli, Svenson) and Community Health Sciences (Tonelli, Svenson), Cumming School of Medicine, University of Calgary, Calgary, Alta.; Division of Nephrology (Wiebe), Department of Medicine, University of Alberta; Alberta Health (Svenson); Division of Preventive Medicine (Svenson) and School of Public Health (Svenson), University of Alberta, Edmonton, Alta.; Data Integration Measurement and Reporting (Dean), Alberta Health Services, Calgary, Alta
| |
Collapse
|
24
|
Affiliation(s)
- Richard H Glazier
- Family physician and health services researcher, Institute for Clinical Evaluative Sciences, Toronto, Ont
| |
Collapse
|
25
|
Szafran O, Kennett SL, Bell NR, Green L. Patients’ perceptions of team-based care in family practice: access, benefits and team roles. J Prim Health Care 2018; 10:248-257. [DOI: 10.1071/hc18018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
ABSTRACT INTRODUCTION The increasing complexity of health care and escalating prevalence of multiple chronic conditions have driven interprofessional team-based care in family practice. Most published studies examine team-based care from the perspective of health professionals. The purpose of this study was to examine patients’ perceptions of team-based care in family practice. METHODS This was a waiting room survey conducted in five family medicine academic teaching clinics in Edmonton, Alberta, Canada. Patients aged ≥18 years were invited to participate in a survey addressing patient access to team-based care, perceived benefits, preferred health professional and team member roles. RESULTS Of the 44.3% (565/1274) of respondents, 41.8% (231/552) reported receiving care from a team of health professionals, primarily for chronic disease management or pharmacy consultations. While there was a consistent pattern of patient perception that many aspects of care did not worsen with team-based care, improvements in knowledge of their medical condition (67.4%); the care received (65.0%); access to care (51.1%); ability to self-care (48.9%) and maintain their independence (43.7%); and overall health (51.1%) were reported. Some patients felt that team-based care reduced emergency visits (34.6%) and hospitalisations (29.9%), and 44.1% of patients felt that they had an active role on the team and made decisions about their care together with health professionals. CONCLUSION Patients perceive that team-based care in family practice has improved their knowledge and access to care, overall health and avoided some emergency department visits and hospital admissions. The findings support the continued development of team-based care in family practice.
Collapse
|