Team-based innovations in primary care delivery in Quebec and timely physician follow-up after hospital discharge: a population-based cohort study

Avoidable Hospitalizations in Persons with Dementia: a Population-Wide Descriptive Study (2000-2015)

Background

Whether avoidable hospitalizations in community-dwelling persons with dementia have decreased during primary care reforms is unknown.

Methods

We described the prevalence and trends in avoidable hospitalizations in population-based repeated yearly cohorts of 192,144 community-dwelling persons with incident dementia (Quebec, 2000-2015) in the context of a province-wide primary care reform, using the provincial health administrative database.

Results

Trends in both types of Ambulatory Care Sensitive Condition (ACSC) hospitalization (general and older population) and 30-day readmission rates remained constant with average rates per 100 person-years: 20.5 (19.9-21.1), 31.7 (31.0-32.4), 20.6 (20.1-21.2), respectively. Rates of delayed hospital discharge (i.e., alternate level of care (ALC) hospitalizations) decreased from 23.8 (21.1-26.9) to 17.9 (16.1-20.1) (relative change -24.6%).

Conclusions

These figures shed light on the importance of the phenomenon, its lack of improvement for most outcomes over the years, and the need to develop evidence-based policies to prevent avoidable hospitalizations in this vulnerable population.

Eliciting Preferences of Providers in Primary Care Settings for Post Hospital Discharge Patient Follow-Up

Background: Post-hospital discharge follow-up has been a principal intervention in addressing gaps in care pathways. However, evidence about the willingness of primary care providers to deliver post-discharge follow-up care is lacking. This study aims to assess primary care providers’ preferences for delivering post-discharge follow-up care for patients with chronic diseases. Methods: An online questionnaire survey of 623 primary care providers who work in a hospital group of southeast China. Face-to-face interviews with 16 of the participants. A discrete choice experiment was developed to elicit preferences of primary care providers for post-hospital discharge patient follow-up based on six attributes: team composition, workload, visit pattern, adherence of patients, incentive mechanism, and payment. A conditional logit model was used to estimate preferences, willingness-to-pay was modelled, a covariate-adjusted analysis was conducted to identify characteristics related to preferences, 16 interviews were conducted to explore reasons for participants’ choices. Results: 623 participants completed the discrete choice experiment (response rate 86.4%, aged 33 years on average, 69.5% female). Composition of the follow-up team and adherence of patients were the attributes of greatest relative importance with workload and incentives being less important. Participants were indifferent to follow-up provided by home visit or as an outpatient visit. Conclusion: Primary care providers placed the most importance on the multidisciplinary composition of the follow-up team. The preference heterogeneity observed among primary care providers suggests personalized management is important in the multidisciplinary teams, especially for those providers with relatively low educational attainment and less work experience. Future research and policies should work towards innovations to improve patients’ engagement in primary care settings.

The Impact of Team-Based Primary Care on Guideline-Recommended Disease Screening

INTRODUCTION

Family Medicine Groups, implemented in Quebec in 2002, are interprofessional primary care teams designed to improve timely access to high-quality primary care. This study investigates whether Family Medicine Groups increased rates of guideline-recommended screenings for 3 chronic diseases: colorectal cancer (colonoscopy/sigmoidoscopy), breast cancer (mammography), and osteoporosis (bone mineral density testing).

METHODS

Using population-based administrative health data from the provincial insurer (2000-2010), the authors examined elderly and chronically ill patients who registered with a general practitioner in the first 15 months of the Family Medicine Group policy. Propensity score weighting and a difference-in-differences model estimated differential change in biennial screening rates among Family Medicine Group and non-Family Medicine Group patients over 5 years of follow-up (analysis, 2016-2018).

RESULTS

Rates of mammography, colonoscopy/sigmoidoscopy, and bone mineral density testing increased after patient registration with a general practitioner, similarly for both Family Medicine Group and non-Family Medicine Group patients. Colonoscopy/sigmoidoscopy rates increased by 9.7% and 10.4% for Family Medicine Group and non-Family Medicine Group patients, mammography rates by 5.3% and 3.4%, and bone mineral density testing by 4.2% and 7.1%. Difference-in-differences estimates showed no detectable effect of Family Medicine Groups on disease screening rates: -0.06 percentage points (95% CI= -0.32, 0.20) for colonoscopy/sigmoidoscopy, 1.01 percentage points (95% CI= -0.25, 2.27) for mammography, and -0.32 (95% CI= -0.71, -0.07) for bone mineral density testing.

CONCLUSIONS

This study found no evidence that Family Medicine Groups affected screening rates for these 3 chronic diseases. Limitations in the implementation of the Family Medicine Group policy in its early years may have contributed to this lack of impact. Interprofessional primary care teams may need to include elements other than organizational changes to increase disease prevention efforts.

Team-based versus traditional primary care models and short-term outcomes after hospital discharge

BACKGROUND

Strategies to reduce hospital readmission have been studied mainly at the local level. We assessed associations between population-wide policies supporting team-based primary care delivery models and short-term outcomes after hospital discharge.

METHODS

We extracted claims data on hospital admissions for any cause from 2002 to 2009 in the province of Quebec. We included older or chronically ill patients enrolled in team-based or traditional primary care practices. Outcomes were rates of readmission, emergency department visits and mortality in the 90 days following hospital discharge. We used inverse probability weighting to balance exposure groups on covariates and used marginal structural survival models to estimate rate differences and hazard ratios.

RESULTS

We included 620 656 index admissions involving 312 377 patients. Readmission rates at any point in the 90-day post-discharge period were similar between primary care models. Patients enrolled in team-based primary care practices had lower 30-day rates of emergency department visits not associated with readmission (adjusted difference 7.5 per 1000 discharges, 95% confidence interval [CI] 4.2 to 10.8) and lower 30-day mortality (adjusted difference 3.8 deaths per 1000 discharges, 95% CI 1.7 to 5.9). The 30-day difference for mortality differed according to morbidity level (moderate morbidity: 1.0 fewer deaths per 1000 discharges in team-based practices, 95% CI 0.3 more to 2.3 fewer deaths; very high morbidity: 4.2 fewer deaths per 1000 discharges, 95% CI 3.0 to 5.3; p < 0.001).

INTERPRETATION

Our study showed that enrolment in the newer team-based primary care practices was associated with lower rates of postdischarge emergency department visits and death. We did not observe differences in readmission rates, which suggests that more targeted or intensive efforts may be needed to affect this outcome.