Health economic analysis of polygenic risk score use in primary prevention of coronary artery disease - A system dynamics model.

Background: Primary prevention programs utilising traditional risk scores fail to identify all individuals who suffer acute cardiovascular events. We aimed to model the impact and cost effectiveness of incorporating a Polygenic risk scores (PRS) into the cardiovascular disease CVD primary prevention program in Australia, using a whole-of-system model. Methods: System dynamics models, encompassing acute and chronic CVD care in the Australian healthcare setting, assessing the cost-effectiveness of incorporating a CAD-PRS in the primary prevention setting. The time horizon was 10-years. Results: Pragmatically incorporating a CAD-PRS in the Australian primary prevention setting in middle-aged individuals already attending a Heart Health Check (HHC) who are determined to be at low or moderate risk based on the 5-year Framingham risk score (FRS), with conservative assumptions regarding uptake of PRS, could have prevented 2, 052 deaths over 10-years, and resulted in 24, 085 QALYs gained at a cost of $19, 945 per QALY with a net benefit of $724 million. If all Australians overs the age of 35 years old had their FRS and PRS performed, and acted upon, 12, 374 deaths and 60, 284 acute coronary events would be prevented, with 183, 682 QALYs gained at a cost of $18, 531 per QALY, with a net benefit of $5, 780 million. Conclusions: Incorporating a CAD-PRS in a contemporary primary prevention setting in Australia would result in substantial health and societal benefits and is cost-effective. The broader the uptake of CAD-PRS in the primary prevention setting in middle-aged Australians, the greater the impact and the more cost-effective the strategy.

Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability.

BACKGROUND: This study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals' capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers' ability to cope with unexpected scenarios is key to managing change. METHODS: We used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes. RESULTS: CMO statements were refined for four initial program theories: Making it Relevant- where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement- where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss- where the effects of staff turnover were mitigated; and Community-Wide Priority- where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care. CONCLUSIONS: A key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

Improving access to primary health care: a cross-case comparison based on an a priori program theory.

BACKGROUND: Inequitable access to primary health care (PHC) remains a problem for most western countries. Failure to scale up effective interventions has been due, in part, to a failure to share the logic and essential elements of successful programs. The aim of this paper is to describe what we learned about improving access to PHC for vulnerable groups across multiple sites through use of a common theory-based program logic model and a common evaluation approach. This was the IMPACT initiative. METHODS: IMPACT's evaluation used a mixed methods design with longitudinal (pre and post) analysis of six interventions. The analysis for this paper included four of the six sites that met study criteria. These sites were located in Canada (Alberta, Quebec and Ontario) and Australia (New South Wales). Using the overarching logic model, unexpected findings were reviewed, and alternative explanations were considered to understand how the mechanisms of each intervention may have contributed to results. RESULTS: Each site addressed their local access problem with different strategies and from different starting points. All sites observed changes in patient abilities to access PHC and provider access capabilities. The combination of intended and observed consequences for consumers and providers was different at each site, but all sites achieved change in both consumer ability and provider capability, even in interventions where there was no activity targeting provider behaviors. DISCUSSION: The model helped to identify, explore and synthesize intended and unintended consequences of four interventions that appeared to have more differences than similarities. Similar outcomes for different interventions and multiple impacts of each intervention on abilities were observed, implying complex causal pathways. CONCLUSIONS: All the interventions were a low-cost incremental attempt to address unmet health care needs of vulnerable populations. Change is possible; sustaining change may be more challenging. Access to PHC requires attention to both patient abilities and provider characteristics. The logic model proved to be a valuable heuristic tool for defining the objectives of the interventions, evaluating their impacts, and learning from the comparison of 'cases'.

Assessing primary care organization and performance: Literature synthesis and proposition of a consolidated framework.

BACKGROUND AND OBJECTIVES: Many frameworks describing primary care (PC) organization exist. This study proposes a consolidated framework based on the synthesis of published frameworks for the assessment of primary care organization and performance. APPROACH: We conducted a review of the literature to identify relevant existing frameworks that aimed to describe PC organization or/and monitor its activities. First, we extracted all domains from the frameworks and then hierarchically organized them into domains, dimensions and elements. Second, we mapped key domains. Third, we grouped together domains covering the same field to build a consolidated framework. Finally, the consolidated framework was assessed by 10 international experts in PC evaluation using a survey. RESULTS: We retained seven frameworks. The consolidated framework comprises four domains: 1) population needs; 2) organization and structure of PC practices; 3) delivery of PC services and 4) patient and population health outcomes. We added five connecting constructs to the framework in order to link the domains: accessibility, appropriateness, productivity, efficiency, effectiveness, equity and integration. None of the previously published frameworks encompassed all domains, dimensions and elements of the new consolidated framework. CONCLUSION: We propose a consolidated framework of PC organization based on the synthesis of seven published frameworks. This unitary framework may provide a foundation for comparative assessment across various contexts to support researchers and policy makers.

Does healthcare inequity reflect variations in peoples' abilities to access healthcare? Results from a multi-jurisdictional interventional study in two high-income countries.

BACKGROUND: Primary healthcare services must respond to the healthcare-seeking needs of persons with a wide range of personal and social characteristics. In this study, examined whether socially vulnerable persons exhibit lower abilities to access healthcare. First, we examined how personal and social characteristics are associated with the abilities to access healthcare described in the patient-centered accessibility framework and with the likelihood of reporting problematic access. We then examined whether higher abilities to access healthcare are protective against problematic access. Finally, we explored whether social vulnerabilities predict problematic access after accounting for abilities to access healthcare. METHODS: This is an exploratory analysis of pooled data collected in the Innovative Models Promoting Access-To-Care Transformation (IMPACT) study, a Canadian-Australian research program that aimed to improve access to primary healthcare for vulnerable populations. This specific analysis is based on 284 participants in four study regions who completed a baseline access survey. Hierarchical linear regression models were used to explore the effects of personal or social characteristics on the abilities to access care; logistic regression models, to determine the increased or decreased likelihood of problematic access. RESULTS: The likelihood of problematic access varies by personal and social characteristics. Those reporting at least two social vulnerabilities are more likely to experience all indicators of problematic access except hospitalizations. Perceived financial status and accumulated vulnerabilities were also associated with lower abilities to access care. Higher scores on abilities to access healthcare are protective against most indicators of problematic access except hospitalizations. Logistic regression models showed that ability to access is more predictive of problematic access than social vulnerability. CONCLUSIONS: We showed that those at higher risk of social vulnerability are more likely to report problematic access and also have low scores on ability to seek, reach, pay, and engage with healthcare. Equity-oriented healthcare interventions should pay particular attention to enhancing people's abilities to access care in addition to modifying organizational processes and structures that reinforce social systems of discrimination or exclusion.

Combining patient, clinical and system perspectives in assessing performance in healthcare: an integrated measurement framework.

BACKGROUND: The science of measuring and reporting on the performance of healthcare systems is rapidly evolving. In the past decade, across many jurisdictions, organisations tasked with monitoring progress towards reform targets have broadened their purview to take a more system-functioning approach. Their aim is to bring clarity to performance assessment, using relevant and robust concepts - and avoiding reductionist measures - to build a whole-of-system view of performance. Existing performance frameworks are not fully aligned with these developments. METHODS: An eight stage process to develop a conceptual framework incorporated literature review, mapping, categorisation, integration, synthesis and validation of performance constructs that have been used by organisations and researchers in order to assess, reflect and report on healthcare performance. RESULTS: A total of 19 performance frameworks were identified and included in the review. Existing frameworks mostly adopted either a logic model (inputs, outputs and outcomes), a functional, or a goal-achievement approach. The mapping process identified 110 performance terms and concepts. These were integrated, synthesised and resynthesised to produce a framework that features 12 derived constructs reflecting combinations of patients' needs and expectations; healthcare resources and structures; receipt and experience of healthcare services; healthcare processes, functions and context; and healthcare outcomes. The 12 constructs gauge performance in terms of coverage, accessibility, appropriateness, effectiveness, safety, productivity, efficiency, impact, sustainability, resilience, adaptability and equity. They reflect four performance perspectives (patient, population, delivery organisation and system). CONCLUSIONS: Internationally, healthcare systems and researchers have used a variety of terms to categorise indicators of healthcare performance, however few frameworks are based on a theoretically-based conceptual underpinning. The proposed framework incorporates a manageable number of performance domains that together provide a comprehensive assessment, as well as conceptual and operational clarity and coherence that support multifaceted measurement systems for healthcare.

Improving access to primary healthcare for vulnerable populations in Australia and Canada: protocol for a mixed-method evaluation of six complex interventions.

INTRODUCTION: Access to primary healthcare (PHC) has a fundamental influence on health outcomes, particularly for members of vulnerable populations. Innovative Models Promoting Access-to-Care Transformation (IMPACT) is a 5-year research programme built on community-academic partnerships. IMPACT aims to design, implement and evaluate organisational innovations to improve access to appropriate PHC for vulnerable populations. Six Local Innovation Partnerships (LIPs) in three Australian states (New South Wales, Victoria and South Australia) and three Canadian provinces (Ontario, Quebec and Alberta) used a common approach to implement six different interventions. This paper describes the protocol to evaluate the processes, outcomes and scalability of these organisational innovations. METHODS AND ANALYSIS: The evaluation will use a convergent mixed-methods design involving longitudinal (pre and post) analysis of the six interventions. Study participants include vulnerable populations, PHC practices, their clinicians and administrative staff, service providers in other health or social service organisations, intervention staff and members of the LIP teams. Data were collected prior to and 3-6 months after the interventions and included interviews with members of the LIPs, organisational process data, document analysis and tools collecting the cost of components of the intervention. Assessment of impacts on individuals and organisations will rely on surveys and semistructured interviews (and, in some settings, direct observation) of participating patients, providers and PHC practices. ETHICS AND DISSEMINATION: The IMPACT research programme received initial ethics approval from St Mary's Hospital (Montreal) SMHC #13-30. The interventions received a range of other ethics approvals across the six jurisdictions. Dissemination of the findings should generate a deeper understanding of the ways in which system-level organisational innovations can improve access to PHC for vulnerable populations and new knowledge concerning improvements in PHC delivery in health service utilisation.

The Quebec emergency department guide: A cross-sectional study to evaluate its use, perceived usefulness, and implementation in rural emergency departments.

OBJECTIVES: The Quebec Emergency Department Management Guide (QEDMG) is a unique document with 78 recommendations designed to improve the organization of emergency departments (EDs) in the province of Quebec. However, no study has examined how this guide is perceived or used by rural health care management. METHODS: We invited all directors of professional services (DPS), directors of nursing services (DNS), head nurses (HN), and emergency department directors (EDD) working in Quebec's rural hospitals to complete an online survey (144 questions). Simple frequency analyses (percentage [%] and 95% confidence interval) were conducted to establish general familiarity and use of the QEDMG, as well as perceived usefulness and implementation of its recommendations. RESULTS: Seventy-three percent (19/26) of Quebec's rural EDs participated in the study. A total of 82% (62/76) of the targeted stakeholders participated. Sixty-one percent of respondents reported being "moderately or a lot" familiar with the QEDMG, whereas 77% reported "almost never or sometimes" refer to this guide. Physician management (DPS, EDD) were more likely than nursing management (DNS and especially HN) to report "not at all" or "little" familiarity on use of the guide. Finally, 98% of the QEDMG recommendations were considered useful. CONCLUSIONS: Although the QEDMG is considered a useful guide for rural EDs, it is not optimally known or used in rural EDs, especially by physician management. Stakeholders should consider these findings before implementing the revised versions of the QEDMG.

Patterns of patient experience with primary care access in Australia, Canada, New Zealand and Switzerland: a comparative study.

OBJECTIVE: Access to primary care (PC) is vital, but complex to define and compare between settings. We aimed to generate a typology of patients' access patterns across countries using a novel inductive approach. DESIGN: Cross-sectional surveys. SETTING: Australia, Canada, New Zealand and Switzerland between 2012 and 2014 as part of the QUALICO-PC project. PARTICIPANTS: Data were collected from 1306 general practices and 10 000+ patients, with nine patients per practice. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Typology of access. RESULTS: Three axes were retained, explaining 23% of the total variance: (i) 'temporal and geographical access'; (ii) 'frequency of access and unmet healthcare needs'; and (iii) 'affordability and frequency of access'.Based on the three axes, we identified four clusters of patients: (i) patients reporting overall good access to PC; (ii) frequent users with unmet healthcare needs; (iii) under-users with financial barriers; and (iv) users with poor time/geographical access.Better access to PC was experienced in Switzerland and New Zealand, while worst access was reported in Canada, where most of the time and geographical barriers were reported. Most financial barriers were observed in Australia and New Zealand. Frequent users with some level of unmet healthcare needs are prevalent in all four countries. CONCLUSIONS: Four main groups of patients with different patterns of access were identified: (i) good access; (ii) geographical and time barriers; (iii) financial barriers; and (iv) frequent users with unmet healthcare needs. Differences in access between the four countries are substantial.

Moving regional health services planning and management to a population-based approach: implementation of the Regional Operating Model (ROM) in Victoria, Australia.

Various jurisdictions are moving towards population-based approaches to plan and manage healthcare services. The evidence on the implementation of these models remains limited. The aim of this study is to evaluate the effect of a regional operating model (ROM) on internal functioning and stakeholder engagement of a regional office. Semi-structured interviews and focus groups with staff members and stakeholders of the North West Metropolitan Regional office in Victoria, Australia, were conducted. Overall, the ROM was perceived as relevant to staff and stakeholders. However, creating shared objectives and priorities across a range of organisations remained a challenge. Area-based planning and management is seen as simplifying management of contracts; however, reservations were expressed about moving from specialist to more generalist approaches. A clearer articulation of the knowledge, skills and competencies required by staff would further support the implementation of the model. The ROM provides a platform for public services and stakeholders to discuss, negotiate and deliver on shared outcomes at the regional level. It provides an integrated managerial platform to improve service delivery and avoid narrow programmatic approaches.

The influence of patient-clinician ethnocultural and language concordance on continuity and quality of care: a cross-sectional analysis.

BACKGROUND: Concordance refers to shared characteristics between a clinician and patient, such as ethnicity or language. The purpose of this study was to examine whether patient-clinician concordance is associated with patient-reported continuity of care (relational, informational and management) and patient-reported impacts of care (quality and empowerment). METHODS: This is a secondary analysis of cross-sectional patient surveys that were administered across British Columbia, Manitoba and Quebec using random digit dialling. Participants were adults who spoke English, French, Mandarin, Cantonese or Punjabi and who had visited a primary care clinician in the previous 12 months (n = 3156). Patients self-identified as being of European, Chinese, South Asian and Indigenous descent. Outcome measures included patients' perceptions of continuity, quality and empowerment. Adjusted logistic regression models and odds ratio were generated. RESULTS: More than 64% of non-Indigenous respondents reported ethnocultural concordance. Ethnocultural concordance was associated with higher odds of relational and management continuity. This same pattern held when there was both ethnocultural and language concordance. No association was found between language concordance and any outcome measure. Chinese participants reported lower quality (odds ratio [OR] 0.24, 95% confidence interval [CI] 0.12-0.48), as did South Asian participants (OR 0.17, 95% CI 0.09-0.31) than did participants of European descent. INTERPRETATION: Higher relational and management continuity is more likely with the presence of patient-clinician ethnocultural and language concordance. Lower continuity and quality reported by Chinese and South Asian particpants could indicate important health care disparities.

The Influence of Individuals' Vulnerabilities and Their Interactions on the Assessment of a Primary Care Experience.

This study examines the relationship between the vulnerabilities of individuals and their assessments of their primary care experiences in the setting of a universal care system. It focuses on 2 specific objectives: (1) evaluating the influence of each of the 5 vulnerabilities on the assessment of the care experience; (2) evaluating the influence of the interactions between the different types of vulnerabilities on the assessment of the care experience. The study identifies the primary care experience of 9,206 people. The health-related, biological, material, relational, and cultural vulnerabilities are also evaluated. Generally, individuals' vulnerabilities are associated with a positive assessment of the primary care experience except for the cultural vulnerability. Material vulnerability is most frequently associated with a positive assessment of the primary care experience. The interactions between the multiple vulnerabilities present for one individual often modify the effect of vulnerability on the assessment of the experience of care. The positive effect of a vulnerability on the assessment of the care experience often increases in the presence of a second vulnerability, especially the health-related vulnerability. The simultaneous presence of health-related vulnerability cancels the negative influence of cultural vulnerability on the assessment of the primary care experience.

Do Gender-Predominant Primary Health Care Organizations Have an Impact on Patient Experience of Care, Use of Services, and Unmet Needs?

Physicians' gender can have an impact on many aspects of patient experience of care. Organization processes through which the influence of gender is exerted have not been fully explored. The aim of this article is to compare primary health care (PHC) organizations in which female or male doctors are predominant regarding organization and patient characteristics, and to assess their influence on experience of care, preventive care delivery, use of services, and unmet needs. In 2010, we conducted surveys of a population stratified sample (N = 9180) and of all PHC organizations (N = 606) in 2 regions of the province of Québec, Canada. Patient and organization variables were entered sequentially into multilevel regression analyses to measure the impact of gender predominance. Female-predominant organizations had younger doctors and nurses with more expanded role; they collaborated more with other PHC practices, used more tools for prevention, and allotted more time to patient visits. However, doctors spent fewer hours a week at the practice in female-predominant organizations. Patients of these organizations reported lower accessibility. Conversely, they reported better comprehensiveness, responsiveness, counseling, and screening, but these effects were mainly attributable to doctors' younger age. Their reporting unmet needs and emergency department attendance tended to decrease when controlling for patient and organization variables other than doctors' age. Except for accessibility, female-predominant PHC organizations are comparable with their male counterparts. Mean age of doctors was an important confounding variable that mitigated differences, whereas other organization variables enhanced them. These findings deserve consideration to better understand and assess the impacts of the growing number of female-predominant PHC organizations on the health care system.

Out-of-pocket healthcare expenditure and chronic disease - do Australians forgo care because of the cost?

Although we do know that out-of-pocket healthcare expenditure is relatively high in Australia, little is known about what health conditions are associated with the highest out-of-pocket expenditure, and whether the cost of healthcare acts as a barrier to care for people with different chronic conditions. Cross-sectional analysis using linear and logistic regression models applied to the Commonwealth Fund international health policy survey of adults aged 18 years and over was conducted in 2013. Adults with asthma, emphysema and chronic obstructive pulmonary disease (COPD) had 109% higher household out-of-pocket healthcare expenditure than did those with no health condition (95% CI: 50-193%); and adults with depression, anxiety and other mental health conditions had 95% higher household out-of-pocket expenditure (95% CI: 33-187%). People with a chronic condition were also more likely to forego care because of cost. People with depression, anxiety and other mental health conditions had 7.65 times higher odds of skipping healthcare (95% CI: 4.13-14.20), and people with asthma, emphysema and chronic obstructive pulmonary disease had 6.16 times higher odds of skipping healthcare (95% CI: 3.30-11.50) than did people with no health condition. People with chronic health conditions in Canada, the United Kingdom, Germany, France, Norway, Sweden and Switzerland were all significantly less likely to skip healthcare because of cost than were people with a condition in Australia. The out-of-pocket cost of healthcare in Australia acts as a barrier to accessing treatment for people with chronic health conditions, with people with mental health conditions being likely to skip care. Attention should be given to the accessibility and affordability of mental health services in Australia.

Barriers to accessing primary health care: comparing Australian experiences internationally.

Most highly developed economies have embarked on a process of primary health care (PHC) transformation. To provide evidence on how nations vary in terms of accessing PHC, the aim of this study is to describe the extent to which barriers to access were experienced by adults in Australia compared with other countries. Communities participating in an international research project on PHC access interventions were engaged to prioritise questions from the 2013 Commonwealth Fund International Health Policy Survey within a framework that conceptualises access across dimensions of approachability, acceptability, availability, affordability and appropriateness. Logistic regression models, with barriers to access as outcomes, found measures of availability to be a problematic dimension in Australia; 27% of adults experienced difficulties with out-of-hours access, which was higher than 5 of 10 comparator countries. Although less prevalent, affordability was also perceived as a substantial barrier; 16% of Australians said they had forgone health care due to cost in the previous year. After adjusting for age and health status, this barrier was more common in Australia than 7 of 10 countries. Findings of this integrated assessment of barriers to access offer insights for policymakers and researchers on Australia's international performance in this crucial PHC domain.

Measuring the effect of Family Medicine Group enrolment on avoidable visits to emergency departments by patients with diabetes in Quebec, Canada.

The Family Medicine Group (FMG) model of primary care in Quebec, Canada, was driven by the voluntary implementation of family physicians. Our main objective was to measure the effect of FMG enrolment on avoidable use of the emergency department (ED) by diabetic patients. We also sought to determine if effects differed according to whether patients were infrequent or frequent users of the ED and according to high- versus low-regional levels of enrolment. We used data from provincial health administrative databases to identify the diabetic patient population over the age of 20 years for each fiscal year between 2003-2004 and 2011-2012. We used fixed effects and marginal structural models to estimate the effect of enrolment in FMGs on avoidable use of the ED. Our results indicated that for every 10-percentage point increase in the population enrolled with an FMG in the year prior to an event, there was a 3% reduction in avoidable visits to the ED made by an individual (RR = 0.97; 95% CI = 0.95, 0.99). We found a significant reduction among diabetic patients who had at most 1 visit to the ED per year (RR = 0.97; 95% CI = 0.95, 0.99) and nonsignificant effects among more frequent users. Within low-enrolment regions, a 10-percentage point increase in enrolment in FMG practices at t - 1 led to an 18% decrease in the number of avoidable ED visits (RR = 0.82; 95% CI = 0.78, 0.87). The effect disappeared when the analyses were restricted to the high-enrolment regions (RR = 1.00; 95% CI = 0.92, 1.09). The design and implementation of the incentive to promote team-based practice may not have borne much influence on early adopters who may have been overrepresented by physicians from high-performing practices before the introduction of the reform.

Scoping of models to support population-based regional health planning and management: comparison with the regional operating model in Victoria, Australia.

Objective The aim of the present study was to try to understand the breadth and comprehensiveness of a regional operating model (ROM) developed within the Victorian Department of Health's North West Metropolitan Region office in Melbourne, Australia. Methods A published literature search was conducted, with additional website scanning, snowballing technique and expert consultation, to identify existing operating models. An analytical grid was developed covering 16 components to evaluate the models and assess the exhaustiveness of the ROM. Results From the 34 documents scoped, 10 models were identified to act as a direct comparator to the ROM. These concerned models from Australia (n=5) and other comparable countries (Canada, UK). The ROM was among the most exhaustive models, covering 13 of 16 components. It was one of the few models that included intersectoral actions and levers of influence. However, some models identified more precisely the planning tools, prioritisation criteria and steps, and the allocation mechanisms. Conclusions The review finds that the ROM appears to provide a wide coverage of aspects of planning and integrates into a single model some of the distinctive elements of the other models scoped. What is known about the topic? Various jurisdictions are moving towards a population-based approach to manage public services with regard to the provision of individual medical and social care. Various models have been proposed to guide the planning of services from a population health perspective. What does this paper add? This paper assesses the coverage of attributes of operating models supporting a population health planning approach to the management of services at the regional or local level. It provides a scoping of current models proposed to organise activities to ensure an integrated approach to the provision of services and compares the scoped models to a model recently implemented in Victoria, Australia. What are the implications for practitioners? This paper highlights the relative paucity of operating models describing in concrete terms how to manage medical and social services from a population perspective and encourages organisations that are accountable for securing population health to clearly articulate their own operating model. It outlines strengths and potential gaps in current models.

Validation of a new measure of availability and accommodation of health care that is valid for rural and urban contexts.

CONTEXT: Patients are the most valid source for evaluating the accessibility of services, but a previous study observed differential psychometric performance of instruments in rural and urban respondents. OBJECTIVE: To validate a measure of organizational accessibility free of differential rural-urban performance that predicts consequences of difficult access for patient-initiated care. DESIGN: Sequential qualitative-quantitative study. Qualitative findings used to adapt or develop evaluative and reporting items. Quantitative validation study. SETTING: Primary data by telephone from 750 urban, rural and remote respondents in Quebec, Canada; follow-up mailed questionnaire to a subset of 316. MAIN MEASURES AND ANALYSES: Items were developed for barriers along the care trajectory. We used common factor and confirmatory factor analysis to identify constructs and compare models. We used item response theory analysis to test for differential rural-urban performance; examine individual item performance; adjust response options; and exclude redundant or non-discriminatory items. We used logistic regression to examine predictive validity of the subscale on access difficulty (outcome). RESULTS: Initial factor resolution suggested geographic and organizational dimensions, plus consequences of access difficulty. After second administration, organizational accommodation and geographic indicators were integrated into a 6-item subscale of Effective Availability and Accommodation, which demonstrates good variability and internal consistency (α = 0.84) and no differential functioning by geographic area. Each unit increase predicts decreased likelihood of consequences of access difficulties (unmet need and problem aggravation). CONCLUSION: The new subscale is a practical, valid and reliable measure for patients to evaluate first-contact health services accessibility, yielding valid comparisons between urban and rural contexts.