Development of comparable algorithms to measure primary care indicators using administrative health data across three Canadian provinces

INTRODUCTION

Performance measurement has been recognized as key to transforming primary care (PC). Yet, performance reporting in PC lags behind even though high-performing PC is foundational to an effective and efficient health care system.

OBJECTIVES

We used administrative data from three Canadian provinces, British Columbia, Ontario and Nova Scotia, to: 1) identify and develop a core set of PC performance indicators using administrative data and 2) examine their ability to capture PC performance.

METHODS

Administrative data used included Physician Billings, Discharge Abstract Database, the National Ambulatory Care and Reporting System database, Census and Vital Statistics. Indicators were compiled based on a literature review of PC indicators previously developed with administrative data available in Canada (n=158). We engaged in iterative discussions to assess data conformity, completeness, and plausibility of results in all jurisdictions. Challenges to creating comparable algorithms were examined through content analysis and research team discussions, which included clinicians, analysts, and health services researchers familiar with PC.

RESULTS

Our final list included 21 PC performance indicators pertaining to 1) technical care (n=4), 2) continuity of care (n=6), and 3) health services utilization (n=11). Establishing comparable algorithms across provinces was possible though time intensive. A major challenge was inconsistent data elements. Ease of data access, and a deep understanding of the data and practice context, was essential for selecting the most appropriate data elements.

CONCLUSIONS

This project is unique in creating algorithms to measure PC performance across provinces. It was essential to balance internal validity of the indicators within a province and external validity across provinces. The intuitive desire of having the exact same coding across provinces was infeasible due to lack of standardized PC data. Rather, a context-tailored definition was developed for each jurisdiction. This work serves as an example for developing comparable PC performance indicators across different provincial/territorial jurisdictions.

Improving care for elderly patients living with polypharmacy: protocol for a pragmatic cluster randomized trial in community-based primary care practices in Canada

Background

Elders living with polypharmacy may be taking medications that do not benefit them. Polypharmacy can be associated with elevated risks of poor health, reduced quality of life, high care costs, and persistently complex care needs. While many medications could be problematic, this project targets medications that should be deprescribed for most elders and for which guidelines and evidence-based deprescribing tools are available. These are termed potentially inappropriate prescriptions (PIPs) and are as follows: proton pump inhibitors, benzodiazepines, antipsychotics, and sulfonylureas. Implementation strategies for deprescribing PIPs in complex older patient populations are needed.

Methods

This will be a pragmatic cluster randomized controlled trial in community-based primary care practices across Canada. Eligible practices provide comprehensive primary care and have at least one physician that consents to participate. Community-dwelling patients aged 65 years and older with ten or more unique medication prescriptions in the past year will be included. The objective is to assess whether the intervention reduces targeted PIPs for these patients compared with usual care. The intervention, Structured Process Informed by Data, Evidence and Research (SPIDER), is a collaboration between quality improvement (QI) and research programs. Primary care teams will form interprofessional Learning Collaboratives and work with QI coaches to review electronic medical record data provided by their regional Practice Based Research Networks (PBRNs), identify areas of improvement, and develop and implement changes. The study will be tested for feasibility in three PBRNs (Toronto, Montreal, and Edmonton) using prospective single-arm mixed methods. Findings will then guide a pragmatic cluster randomized controlled trial in five PBRNs (Calgary, Winnipeg, Ottawa, Montreal, and Halifax). Seven practices per PBRN will be recruited for each arm. The analysis will be by intention to treat. Ten percent of patients who have at least one PIP at baseline will be randomly selected to participate in the assessment of patient experience and self-reported outcomes. Qualitative methods will be used to explore patient and physician experience and evaluate SPIDER’s processes.

Conclusion

We are testing SPIDER in a primary care population with complex care needs. This could provide a widely applicable model for care improvement.

Trial registration

Clinicaltrials.gov NCT03689049; registered September 28, 2018

Electronic supplementary material

The online version of this article (10.1186/s13012-019-0904-4) contains supplementary material, which is available to authorized users.

Temporal association between home nursing and hospital costs at end of life in three provinces

BACKGROUND

Research has demonstrated that increases in palliative homecare nursing are associated with a reduction in the rate of subsequent hospitalizations. However, little evidence is available about the cost-savings potential of palliative nursing when accounting for both increased nursing costs and potentially reduced hospital costs.

METHODS

Our retrospective cohort study included cancer decedents from British Columbia, Ontario, and Nova Scotia who received any palliative nursing in the last 6 months of life. A Poisson regression analysis was used to determine the association of increased nursing costs (in 2-week blocks) on the relative average hospital costs in the subsequent 2-week block and on the overall total cost (hospital costs plus nursing costs in the preceding 2-week block).

RESULTS

The cohort included 58,022 cancer decedents. Results of the analysis for the last month of life showed an association between increased nursing costs and decreased relative hospital costs in comparisons with a reference group (>0 to 1 hour nursing in the block): the maximum decrease was 55% for Ontario, 31% for British Columbia, and 38% for Nova Scotia. Also, increased nursing costs in the last month were almost always associated with lower total costs in comparison with the reference. For example, cost savings per person-block ranged from $376 (>10 nursing hours) to $1,124 (>4 to 6 nursing hours) in British Columbia.

CONCLUSIONS

In the last month of life, increased palliative nursing costs (compared with costs for >0 to 1 hour of nursing in the block) were associated with lower relative hospital costs and a lower total cost in a subsequent block. Our research suggests a cost-savings potential associated with increased community-based palliative nursing.

Quality of end-of-life cancer care in Canada: a retrospective four-province study using administrative health care data

BACKGROUND

The quality of data comparing care at the end of life (eol) in cancer patients across Canada is poor. This project used identical cohorts and definitions to evaluate quality indicators for eol care in British Columbia, Alberta, Ontario, and Nova Scotia.

METHODS

This retrospective cohort study of cancer decedents during fiscal years 2004-2009 used administrative health care data to examine health service quality indicators commonly used and previously identified as important to quality eol care: emergency department use, hospitalizations, intensive care unit admissions, chemotherapy, physician house calls, and home care visits near the eol, as well as death in hospital. Crude and standardized rates were calculated. In each province, two separate multivariable logistic regression models examined factors associated with receiving aggressive or supportive care.

RESULTS

Overall, among the identified 200,285 cancer patients who died of their disease, 54% died in a hospital, with British Columbia having the lowest standardized rate of such deaths (50.2%). Emergency department use at eol ranged from 30.7% in Nova Scotia to 47.9% in Ontario. Of all patients, 8.7% received aggressive care (similar across all provinces), and 46.3% received supportive care (range: 41.2% in Nova Scotia to 61.8% in British Columbia). Lower neighbourhood income was consistently associated with a decreased likelihood of supportive care receipt.

INTERPRETATION

We successfully used administrative health care data from four Canadian provinces to create identical cohorts with commonly defined indicators. This work is an important step toward maturing the field of eol care in Canada. Future work in this arena would be facilitated by national-level data-sharing arrangements.

Intravesical Botulinum Toxin for Overactive Bladder Syndrome without Detrusor Overactivity

Objective:

To report our experience of intravesical botulinum toxin for idiopathic overactive bladder syndrome (OAB) without detrusor overactivity (DOA) on urodynamic assessment.

Patients and methods:

Data regarding presentation, diagnosis, urodynamic findings, date and dose of treatment, and outcomes were recorded prospectively for 94 patients undergoing intravesical botulinum toxin injection for idiopathic overactive bladder syndrome at our institution. The cohort included 19 patients without DOA on urodynamics. A positive response to treatment was defined as patient-reported improvement without the need for further treatment. ICIQ-OAB and UI scores, and bladder diary parameters were also recorded. Rates of urinary retention requiring intermittent or indwelling catheterisation were noted.

Results:

The overall response rate to treatment was 82% ( n = 94). Patients without DOA ( n = 19) had a response rate of 89%, which compared favourably with a response rate of 81% in patients with DOA ( n = 75). Overall, 29% of patients who were voiding normally prior to treatment required intermittent self-catheterisation after the procedure. The requirement for self-catheterisation did not appear to be influenced by urodynamic findings.

Conclusion:

These preliminary, non-randomised data suggest that intravesical botulinum toxin injection may be efficacious in patients with OAB symptoms without DOA. Further evaluation by means of a randomised, controlled trial is suggested.

Quality indicators for end-of-life breast cancer care: Testing the use of administrative databases

6066

Background: Defining, measuring and monitoring quality of care is a facet of health services research that is growing in importance. Breast cancer offers a disease model to examine quality end-of-life (EOL) care provided to women. Administrative data have the unique potential to provide population-based measures of quality of care. The objective of this study was to assess the feasibility of using routinely-collected administrative data to measure quality EOL care for breast cancer patients. Methods: A cohort of all women in Nova Scotia who died of breast cancer between 01/01/1998 and 31/12/2002 was assembled from the Cancer Registry and Vital Statistics data. The EOL study period was defined as the last 6 months of life. A total of 864 women met the eligibility criteria. After a literature review, an expert panel identified 19 indicators that were potentially measurable through administrative data. Physician billings, hospital discharge abstracts and seniors pharmacare data, supplemented by clinical datasets, were utilized to calculate the statistics with which to represent the indicators. Results: Benchmark measures of care across the cohort show 63.4% died in a hospital, a mean continuity of care index of 0.786, and the mean number of inpatient days in the last 30 was 9.9. Indicators of aggressive care include 9.3% had chemotherapy in the last 14 days, 5.6% had more than 1 emergency room visit in the last 30 days, and 29.1% had more than 14 inpatient days in the last 30 days. Conclusions: Weaknesses of using these data include: 1) fixed variables with an administrative rather than a clinical objective; 2) lack of comprehensiveness of various datasets; and 3) the use of billings data where increasingly physicians are paid through methods other than fee-for-service. Strengths of this approach are: 1) population-based cohort; 2) comprehensiveness of cohort selection through the provincial Vital Statistics file; and 3) accessibility of data.

No significant financial relationships to disclose.

Physician characteristics in relation to cardiovascular drugs commonly prescribed for hypertension in Nova Scotia

BACKGROUND

Cardiovascular drugs are the most frequently prescribed class of drugs in Canada. Among them, drugs used to treat hypertension are the single largest component. Variability in how these drugs are prescribed should be based on the specific characteristics of patients. However, some evidence shows that physician characteristics can also play a substantial role in prescribing trends. Such variation is also associated with varying beneficial and adverse patient outcomes.

PURPOSE

To determine whether prescribing patterns of drugs used to treat hypertension in elderly patients in Nova Scotia varied by physician characteristics.

METHODS

A retrospective, population-based descriptive study was done using the Nova Scotia Pharmacare program data for the fiscal year 1995/96. The unit of analysis was the individual physician. All drugs indicated in the management of hypertension were included for the analysis.

RESULTS

Of 1466 physicians included in the analysis, 1004 were family physicians (FPs) and/or general practitioners (GPs), 155 were internal medicine specialists and 307 were other specialists. Fifty-eight per cent of 103,193 eligible senior citizens received at least one of the study medications. FPs and/or GPs prescribed 95.9% of all the study drugs. Internists prescribed proportionately fewer angiotensin-converting enzyme inhibitors, thiazides and other diuretics compared with the FPs and/or GPs but more beta-blockers and calcium channel blockers. A large proportion of the FPs and/or GPs (55.3%) prescribed less than 10% of the total day's supply of drugs, whereas a small proportion of FPs and/or GPs (16.3%) prescribed 52.6% of all the study drugs. There was no variation in the distribution of the types of antihypertensives prescribed based on physician age, sex or volume of prescribing. A slight variation in prescribing was seen with location of practice.

CONCLUSIONS

Patterns of prescribing cardiovascular drugs used to treat hypertension were remarkably unaffected by physician characteristics. This finding counters other evidence in the literature that has raised concerns over prescribing patterns of certain types of physicians. Prescribing patterns may vary for other drug classes, but for this group of antihypertensives, little variability was found.

Palliative care by family physicians in the 1990s. Resilience amid reform

OBJECTIVE

To explore issues family physicians face in providing community-based palliative care to their patients in the context of a changing health care system.

DESIGN

Focus groups.

SETTING

Small (< 10,000 population), medium-sized (10,000 to 50,000), and large (> 50,000) communities in Nova Scotia.

PARTICIPANTS

Twenty-five men and women physicians with varying years of practice experience in both solo and group practices.

METHOD

A semistructured approach was used, asking physicians to reflect on recent palliative care experiences in order to explore issues of care.

MAIN FINDINGS

Five themes emerged from the discussions: resources needed, availability of family support, time and money supporting physicians' activities, symptom control for patients, and physicians' emotional reactions to caring for dying patients.

CONCLUSION

With downsizing of hospitals and greater emphasis on community-based care, the issues identified in this study will need attention, particularly in designing an integrated service delivery model for palliative care.

Asthma in primary care: making guidelines work

OBJECTIVE

To determine the views of family physicians regarding selected asthma recommendations from a Canadian practice guideline and the supporting evidence, and to identify issues needing further development if family physicians are to find guideline recommendations to be truly useful clinical tools.

SETTING

Four urban communities in Nova Scotia, Prince Edward Island and New Brunswick.

PARTICIPANTS

Twenty community family physicians representing different practice settings, and varying according to age and sex, were recruited to participate.

DATA COLLECTION

Four focus groups were held, each lasting 2 h, at which recommendations from a published asthma guideline were presented for discussion on the applicability to their practices. The data were analyzed using a grounded theory method.

RESULTS

Physicians rely on clinical judgment in lieu of objective measures in diagnosing asthma and resist treating every exacerbation with steroids. They thought that the recommendations on smoking and patient education should have been stronger or more prominent. Patient noncompliance limits the usefulness of home peak flow measures. Topics such as allergy assessment and most pharmacological therapies triggered little discussion.

DISCUSSION

Asthma guideline developers and those interested in enhancing compliance with recommendations will need to attend to factors such as physician attitudes and beliefs on a variety of issues, including the use of objective measures and the availability of adequate resources to conduct the tests. Similarly, negative patient attitudes toward an increased use of corticosteroids suggest that a public education program would be most helpful regarding that group of recommendations.

Family Medicine residents' knowledge and attitudes about end-of-life care

The medical management of end-of-life symptoms, and the psychosocial care of the dying and their families have not been a specific part of the curriculum for undergraduate medical students or residency training programs. The purpose of our research was to assess family medicine residents' knowledge of and attitudes toward care of the dying. All entering (PGY1) and exiting (PGY2) residents of the Dalhousie University Family Medicine Residency Program were given a 50-item survey on end-of-life care. They survey contains two 25-item subscales concerning attitudes/opinions toward end-of-life care, and knowledge about care. Thirty-one of the 33 entering PGY1s 94%) and 26 of the 30 exiting PGY2s (86%) completed the surveys. Overall attitude scores were felt to be high among both groups, with little difference between them. Areas of concern regarding the adequacy of knowledge were found in relation to managing opioid drugs and the symptom of dyspnea. Interventions are now in development to address these issues in the residency program. In an era of subspecialties, the challenge of integrating these areas into the curriculum without creating rotations in specialist palliative care is an issue faced by most family medicine residency programs.

Pod people. Response of family physicians and family practice nurses to Kosovar refugees in Greenwood, NS

OBJECTIVE

To explore roles of family physicians and family practice nurses who provided care to Kosovar refugees at Greenwood, NS.

DESIGN

Qualitative study based on individual interviews with family physicians and family practice nurses.

SETTING

Family practices in Halifax, NS.

PARTICIPANTS

Six family practice nurses, four physician faculty members, four community-based family physicians, and two family medicine residents were interviewed. Participants were purposefully chosen from the roster of service providers.

METHOD

All interviews were conducted by one of the researchers and were semistructured. Interviews lasted approximately 30 minutes and were immediately transcribed. Key words and phrases were identified and compared with subsequent interviews until saturation was achieved.

MAIN FINDINGS

Data yielded four analytical categories: the clinical encounter, expectation and experience, role and team functioning, and response. Participants reported how providing care in the context of a refugee camp was both similar to and different from their daily activities in family practice, as were their working relationships with other health care professionals.

CONCLUSION

Primary care for refugees during complex health emergencies is often underreported in the literature. Yet family practice physicians and nurses recounted that they had the requisite skills to provide care in such a context.

The family's perspective on issues of hydration in terminal care

We identified issues that are important to family caregivers when deciding whether or not artificial hydration should be provided to patients with advanced cancer. A qualitative study using semi-structured interviews was carried out in the home support and inpatient divisions of a palliative care program in Halifax, Nova Scotia. Participants included children and spouses of terminally ill patients who had dealt with or would soon deal with issues of hydration. Factors influencing caregivers included issues of symptom distress, ethical and emotional considerations, information exchange between health professionals and family, and culture. The perceived benefits of artificial hydration by the caregivers were central to the ethical, emotional, and cultural considerations involved in their decision making. Discussions with caregivers should attempt to (a) discover the patient's wishes and attitudes concerning the procedure; (b) provide as accurate information as is available about advantages and disadvantages; and (c) recognize and explore caregivers' concerns that may or may not have been expressed.

Pharmacy services in family medicine residencies. Survey of clinics associated with Canadian residency programs

Surveys were mailed to 82 family medicine clinics associated with residency programs in Canada to ascertain the extent, if any, of pharmacy involvement in the programs. Eight of the 58 (13.8%) usable returns had pharmacists directly involved. They provided pharmacy-based services, offered clinical services, and participated in research.

Continuous intravenous infusion of opioid analgesics for severe pain

Severe continuous pain is frequently a complication of terminal malignancy and other disease or trauma states. Effective pain relief will be an important factor in the physical and psychological outcome for the patient. At times, the continuous intravenous infusion of opioid analgesics will be indicated. Indications and guidelines for this therapy are described, with an illustrative case study.