The Impact of Primary Care Clinic and Family Physician Continuity on Patient Health Outcomes: A Retrospective Analysis From Alberta, Canada.

PURPOSE: Continuity of care is broadly associated with better patient health outcomes. The relative contributions of continuity with an individual physician and with a practice, however, have not generally been distinguished. This retrospective observational study examined the impact of continuity of care for patients seen at their main clinic but by different family physicians. METHODS: We analyzed linked health administrative data from 2015-2018 from Alberta, Canada to explore the association of physician and clinic continuity with rates of emergency department (ED) visits and hospitalizations across varying levels of patient complexity. Physician continuity was calculated using the known provider of care index and clinic continuity with an analogous measure. We developed zero-inflated negative binomial models to assess the association of each with all-cause ED visits and hospitalizations. RESULTS: High physician continuity was associated with lower ED use across all levels of patient complexity and with fewer hospitalizations for highly complex patients. Broadly, no (0%) clinic continuity was associated with increased use and complete (100%) clinic continuity with decreased use, with the largest effect seen for the most complex patients. Levels of clinic continuity between 1% and 50% were generally associated with slightly higher use, and levels of 51% to 99% with slightly lower use. CONCLUSIONS: The best health care outcomes (measured by ED visits and hospitalizations) are associated with consistently seeing one's own primary family physician or seeing a clinic partner when that physician is unavailable. The effect of partial clinic continuity appears complex and requires additional research. These results provide some reassurance for part-time and shared practices, and guidance for primary care workforce policy makers.

Implementation of a Hearing Loss Screening Intervention in Primary Care.

PURPOSE: Hearing loss (HL) is underdiagnosed and often unaddressed. A recent study of screening for HL using an electronic prompt showed efficacy in increasing appropriate referrals for subsequent testing. We build on the results of this study using a qualitative lens to explore implementation processes through the perspectives of family medicine clinicians. METHODS: We collected clinic observations and semistructured interviews of family medicine clinicians and residents who interacted with the HL prompt. All data were analyzed using thematic, framework, and mixed methods integration strategies. RESULTS: We interviewed 27 clinicians and conducted 10 observations. Thematic analysis resulted in 6 themes: (1) the prompt was overwhelmingly viewed as easy, simple to use, accurate; (2) clinicians considered prompt as an effective way to increase awareness and conversations with patients about HL; (3) clinician and staff buy-in played a vital role in implementation; (4) clinicians prioritized prompt during annual visits; (5) medical assistant involvement in prompt workflow varied by health system, clinic, and clinician; (6) prompt resulted in more conversations about HL, but uncertain impact on patient outcomes. Themes are presented alongside constructs of normalization process theory and intervention outcomes. CONCLUSION: Integration of a HL screening prompt into clinical practice varied by clinician buy-in and beliefs about the impact on patient outcomes, involvement of medical assistants, and prioritization during clinical visits. Further research is needed to understand how to leverage clinician and staff buy-in and whether implementation of a new clinical prompt has sustained impact on HL screening and patient outcomes.

Effective Hearing Loss Screening in Primary Care: The Early Auditory Referral-Primary Care Study.

PURPOSE: Hearing loss, the second most common disability in the United States, is under-diagnosed and under-treated. Identifying it in early stages could prevent its known substantial adverse outcomes. METHODS: A multiple baseline design was implemented to assess a screening paradigm for identifying and referring patients aged ≥55 years with hearing loss at 10 family medicine clinics in 2 health systems. Patients completed a consent form and the Hearing Handicap Inventory for the Elderly (HHI). An electronic alert prompted clinicians to screen for hearing loss during visits. RESULTS: The 14,877 eligible patients during the study period had 36,701 encounters. Referral rates in the family medicine clinics increased from a baseline rate of 3.2% to 14.4% in 1 health system and from a baseline rate of 0.7% to 4.7% in the other. A general medicine comparison group showed referral rate increase from the 3.0% baseline rate to 3.3%. Of the 5,883 study patients who completed the HHI 25.2% (n=1,484) had HHI scores suggestive of hearing loss; those patients had higher referral rates, 28% vs 9.2% (P <.001). Of 1,660 patients referred for hearing testing, 717 had audiology data available for analysis: 669 (93.3%) were rated appropriately referred and 421 (58.7%) were considered hearing aid candidates. Overall, 71.5% of patients contacted felt their referral was appropriate. CONCLUSION: An electronic alert used to remind clinicians to ask patients aged ≥55 years about hearing loss significantly increased audiology referrals for at-risk patients. Audiologic and audiogram data support the effectiveness of the prompt. Clinicians should consider adopting this method to identify patients with hearing loss to reduce its known and adverse sequelae.

The Effect of Warfarin Administration Time on Anticoagulation Stability (INRange): A Pragmatic Randomized Controlled Trial.

PURPOSE: Without supporting evidence, clinicians commonly recommend that warfarin be taken in the evening. We conducted a randomized controlled trial to evaluate the effect of administration time (morning vs evening) on the stability of warfarin's anticoagulant effect. METHODS: A total of 236 primary care physicians serving 54 western Canadian communities mailed letters of invitation to all their warfarin-using patients. Eligible patients were community-dwelling warfarin users (any indication) with at least 3 months of evening warfarin use and no plans for discontinuation. Participants were randomized (by web-based allocation) to morning vs continued evening warfarin ingestion. We used the Rosendaal method to determine the proportion of time within therapeutic range (TTR) of the international normalized ratio (INR) blood test month 2 to 7 postrandomization vs the 6 months prerandomization. The primary outcome was the percent change in proportion of time outside target INR range (with an a priori minimum clinically important difference of ±20%). All analyses were intention to treat. RESULTS: Between March 8, 2015 and September 30, 2016, we randomized 109 participants to morning and 108 to evening warfarin use. TTR rose from 71.8% to 74.7% in the morning group, and from 72.6% to 75.6% in the evening group, for a change in TTR of 2.9% in the former vs 3.0% in the latter (difference, -0.1%; P = .97; 95% CI for the difference, -6.1% to 5.9%). The difference in percent change in proportion of time outside the therapeutic INR range (obtained via Hodges-Lehmann estimation of the difference in medians) was 4.4% (P = .62; 95% CI for the difference, -17.6% to 27.3%). CONCLUSIONS: Administration time has no statistically significant nor clinically important impact on the stability of warfarin's anticoagulant effect. Patients should take warfarin whenever regular compliance would be easiest.

The cirrhosis care Alberta (CCAB) protocol: implementing an evidence-based best practice order set for the management of liver cirrhosis - a hybrid type I effectiveness-implementation trial.

BACKGROUND: Liver cirrhosis is a leading cause of morbidity, premature mortality and acute care utilization in patients with digestive disease. In the province of Alberta, hospital readmission rates for patients with cirrhosis are estimated at 44% at 90 days. For hospitalized patients, multiple care gaps exist, the most notable stemming from i) the lack of a structured approach to best practice care for cirrhosis complications, ii) the lack of a structured approach to broader health needs and iii) suboptimal preparation for transition of care into the community. Cirrhosis Care Alberta (CCAB) is a 4-year multi-component pragmatic trial which aims to address these gaps. The proposed intervention is initiated at the time of hospitalization through implementation of a clinical information system embedded electronic order set for delivering evidence-based best practices under real-world conditions. The overarching objective of the CCAB trial is to demonstrate effectiveness and implementation feasibility for use of the order set in routine patient care within eight hospital sites in Alberta. METHODS: A mixed methods hybrid type I effectiveness-implementation design will be used to evaluate the effectiveness of the order set intervention. The primary outcome is a reduction in 90-day cumulative length of stay. Implementation outcomes such as reach, adoption, fidelity and maintenance will also be evaluated alongside other patient and service outcomes such as readmission rates, quality of care and cost-effectiveness. This theory-based trial will be guided by Normalization Process Theory, Consolidated Framework on Implementation Research (CFIR) and the Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM) Framework. DISCUSSION: The CCAB project is unique in its breadth, both in the comprehensiveness of the multi-component order set and also for the breadth of its roll-out. Lessons learned will ultimately inform the feasibility and effectiveness of this approach in "real-world" conditions as well as adoption and adaptation of these best practices within the rest of Alberta, other provinces in Canada, and beyond. TRIAL REGISTRATION: ClinicalTrials.gov: NCT04149223, November 4, 2019.

An implementation history of primary health care transformation: Alberta's primary care networks and the people, time and culture of change.

BACKGROUND: Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province's healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment. METHODS: Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders' perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses. RESULTS: Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another's cultures to achieve the transformation towards PHC has been central to the PCNs' survival and success. CONCLUSIONS: Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another's cultures; and how best to support the transformation of a system while delivering care locally.

Differences in Team Mental Models Associated With Medical Home Transformation Success.

PURPOSE: Primary care transformation is widely seen as essential to improving patient outcomes and health care costs. The medical home model can achieve these ends, but dissemination and scale-up of practice transformation is challenging. We sought to understand how to move past successful pilot efforts by early adopters to widespread adoption by applying cognitive task analysis using the diffusion of innovations framework. METHODS: We undertook a qualitative cross-sectional comparison of 3 early adopter practices and 15 early majority practices in Alberta, Canada. Practices completed a total of 42 cognitive task analysis interviews. We conducted a framework-guided qualitative analysis, with allowance for emergent themes, using the macrocognition framework on which cognitive task analysis is based. Independent codings of interview transcripts for key macrocognitive functions were reviewed in group analysis meetings to describe macrocognitive functions and team mental models, and identify emergent themes. Two external focus groups provided support for these findings. RESULTS: Three prominent findings emerged. The first was a spectrum of mental models from "doctor with helpers," through degrees of delegation, to fully team based care. The second was differences in how teams distributed macrocognitive functions among members, with early adopters distributing these functions more widely across the team than early majority practices. Finally, we saw emergence of several themes also common in the diffusion of innovations literature, such as the importance of trying new practices in small, reversible steps. CONCLUSIONS: Our findings provide guidance to practice teams, health systems, and policymakers seeking to move beyond early adopters, to improve team functioning and advance the medical home transformation at scale.

The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions.

BACKGROUND: Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care. METHODS: We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months. RESULTS: Adults receiving care within a primary care network (n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care (n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96-0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93-0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03-1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07-1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years. INTERPRETATION: Care within a primary care network was associated with fewer emergency department visits and fewer hospital days.

Designing a framework for primary health care research in Canada: a scoping literature review.

BACKGROUND: Despite significant investments to improve primary health care (PHC) delivery in Canada, provincial health care systems remain fragmented and uncoordinated. Canada's commitment to strengthening PHC should be driven by robust research and evaluation that reflects our health policy priorities and responds to the needs of the population. One challenge facing health services researchers is developing and sustaining meaningful research priorities and agendas in an overburdened, complex health care system with limited capacity for PHC research and support for clinician researchers. METHODS: A scoping review of the literature was conducted to examine PHC research priorities in Canada. We compared national research priorities for PHC to research priorities being considered in the province of Alberta. Our scoping review was guided by the following questions: (1) What are the research priorities for PHC in Canada?; and (2) What process is used to identity PHC research priorities? RESULTS: Six key theme areas for consideration in setting a PHC research agenda were identified: research in practice, research on practice, research about practice, methods of priority setting, infrastructure, and the intersection of PHC and population/public health. These thematic areas provide a new framework for guiding PHC research in Canada. It was developed to generate best practices and new knowledge (i.e., innovation), transform PHC clinical practice or support quality improvement (i.e., spread), and lead to large-scale health care system transformation (i.e., scale). CONCLUSIONS: Priority-driven research aims to answer questions of key importance that are likely to have a significant impact on knowledge or practice in the short to medium term. Setting PHC research priorities ensures funded research has the greatest potential population health benefit, that research funding and outputs are aligned with the needs of practitioners and decision makers, and that there is efficient and equitable use of limited resources with less duplication of research effort. Our findings also suggest that a common research priority framework for PHC research in Canada would ensure that research priority-setting exercises are grounded in an evidence-based process.

Alberta Family Physician Electronic Endoscopy study: Quality of 1769 colonoscopies performed by rural Canadian family physicians.

OBJECTIVE: To determine whether rural FP colonoscopists in Alberta are achieving benchmarks in colonoscopy quality. DESIGN: Prospective, multicentre observational study. SETTING: Alberta. PARTICIPANTS: Nine FP colonoscopists. MAIN OUTCOME MEASURES: Proportion of successful cecal intubations; proportion of patients aged 50 and older with pathologically confirmed adenomas; mean number of adenomas per colonoscopy; and serious adverse events related to colonoscopy. RESULTS: In this 6-month study, 9 rural FPs in Alberta performed 1769 colonoscopies. Overall, all key colonoscopy quality benchmarks were met or exceeded. The proportion of successful cecal intubations was 97.9% (95% CI 97.2% to 98.6%). The proportion of male and female patients aged 50 and older whose first-time colonoscopy results revealed an adenoma was 67.4% (95% CI 62.4% to 72.7%) and 51.1% (95% CI 45.5% to 56.7%), respectively. There were 120 adenomas, 36 advanced adenomas, and 1 colon cancer case per 100 colonoscopies. There were 2 postpolypectomy bleeds and no other serious complications. CONCLUSION: Alberta rural FP colonoscopists are meeting benchmarks in colonoscopy quality. Ongoing electronic collection of endoscopy quality markers should be encouraged. Supporting and training rural FPs who perform endoscopy might help alleviate current wait times and improve access for rural Canadian patients.

A Comparison of Health Plan- and Provider-Delivered Chronic Care Management Models on Patient Clinical Outcomes.

BACKGROUND: The real world implementation of chronic care management model varies greatly. One aspect of this variation is the delivery mode. Two contrasting strategies include provider-delivered care management (PDCM) and health plan-delivered care management (HPDCM). OBJECTIVE: We aimed to compare the effectiveness of PDCM vs. HPDCM on improving clinical outcomes for patients with chronic diseases. DESIGN: We used a quasi-experimental two-group pre-post design using the difference-in-differences method. PATIENTS: Commercially insured patients, with any of the five chronic diseases-congestive heart failure, chronic obstructive pulmonary disease, coronary heart disease, diabetes, or asthma, who were outreached to and engaged in either PDCM or HPDCM were included in the study. MAIN MEASURES: Outreached patients were those who received an attempted or actual contact for enrollment in care management; and engaged patients were those who had one or more care management sessions/encounters with a care manager. Effectiveness measures included blood pressure, low density lipoprotein (LDL), weight loss, and hemoglobin A1c (for diabetic patients only). Primary endpoints were evaluated in the first year of follow-up. KEY RESULTS: A total of 4,000 patients were clustered in 165 practices (31 in PDCM and 134 in HPDCM). The PDCM approach demonstrated a statistically significant improvement in the proportion of outreached patients whose LDL was under control: the proportion of patients with LDL < 100 mg/dL increased by 3 % for the PDCM group (95 % CI: 1 % to 6 %) and 1 % for the HPDCM group (95 % CI: -2 % to 5 %). However, the 2 % difference in these improvements was not statistically significant (95 % CI: -2 % to 6 %). The HPDCM approach showed 3 % [95 % CI: 2 % to 6 %] improvement in overall diabetes care among outreached patients and significant reduction in obesity rates compared to PDCM (4 %, 95 % CI: 0.3 % to 8 %). CONCLUSIONS: Both care management delivery modes may be viable options for improving care for patients with chronic diseases. In this commercially insured population, neither PDCM nor HPDCM resulted in substantial improvement in patients' clinical indicators in the first year. Different care management strategies within the provider-delivered programs need further investigation.

Effect of care management program structure on implementation: a normalization process theory analysis.

BACKGROUND: Care management in primary care can be effective in helping patients with chronic disease improve their health status, however, primary care practices are often challenged with implementation. Further, there are different ways to structure care management that may make implementation more or less successful. Normalization process theory (NPT) provides a means of understanding how a new complex intervention can become routine (normalized) in practice. In this study, we used NPT to understand how care management structure affected how well care management became routine in practice. METHODS: Data collection involved semi-structured interviews and observations conducted at 25 practices in five physician organizations in Michigan, USA. Practices were selected to reflect variation in physician organizations, type of care management program, and degree of normalization. Data were transcribed, qualitatively coded and analyzed, initially using an editing approach and then a template approach with NPT as a guiding framework. RESULTS: Seventy interviews and 25 observations were completed. Two key structures for care management organization emerged: practice-based care management where the care managers were embedded in the practice as part of the practice team; and centralized care management where the care managers worked independently of the practice work flow and was located outside the practice. There were differences in normalization of care management across practices. Practice-based care management was generally better normalized as compared to centralized care management. Differences in normalization were well explained by the NPT, and in particular the collective action construct. When care managers had multiple and flexible opportunities for communication (interactional workability), had the requisite knowledge, skills, and personal characteristics (skill set workability), and the organizational support and resources (contextual integration), a trusting professional relationship (relational integration) developed between practice providers and staff and the care manager. When any of these elements were missing, care management implementation appeared to be affected negatively. CONCLUSIONS: Although care management can introduce many new changes into delivery of clinical practice, implementing it successfully as a new complex intervention is possible. NPT can be helpful in explaining differences in implementing a new care management program with a view to addressing them during implementation planning.

A Systems Approach to Improving Tdap Immunization Within 5 Community-Based Family Practice Settings: Working Differently (and Better) by Transforming the Structure and Process of Care.

OBJECTIVES: We examined how family medicine clinic physicians and staff worked in collaborative teams to implement an automated clinical reminder to improve tetanus, diphtheria, and acellular pertussis (Tdap) booster vaccine administration and documentation. METHODS: A clinical reminder was developed at 5 University of Michigan family medicine clinics to identify patients 11 to 64 years old who were in need of the Tdap booster vaccine. Quality improvement cycles were used to improve clinic care processes. Immunization rates from 2008 to 2011 were compared with rates at 4 primary care control clinics. RESULTS: Vaccination rates among eligible patients increased from 15.5% to 47.3% within the family medicine clinics and from 14.1% to 30.2% within the control clinics. After adjustment for covariates, family medicine patients had a higher probability of vaccination than control patients during each measurement period (0.17 vs 0.15 at baseline, 0.53 vs 0.22 during year 1, and 0.50 vs 0.30 during year 2). CONCLUSIONS: Automated clinical reminders, when designed and implemented via a consensus-based framework that addresses the process of care, can dramatically improve provision of preventive health care.

Sustaining "meaningful use" of health information technology in low-resource practices.

PURPOSE: The implementation of electronic health records (EHRs) has been extensively studied, but their maintenance once implemented has not. The Regional Extension Center (REC) program provides implementation assistance to priority practices-those with limited financial, technical, and organizational resources-but the assistance is time limited. Our objective was to identify potential barriers to maintenance of meaningful use of EHRs in priority primary care practices using a qualitative observational study for federally qualified health centers (FQHCs) and priority practices in Michigan. METHODS: We conducted cognitive task analysis (CTA) interviews and direct observations of health information technology implementation in FQHCs. In addition, we conducted semistructured interviews with implementation specialists serving priority practices to detect emergent themes relevant to maintenance. RESULTS: Maintaining EHR technology will require ongoing expert technical support indefinitely beyond implementation to address upgrades and security needs. Maintaining meaningful use for quality improvement will require ongoing support for leadership and change management. Priority practices not associated with larger systems lack access to the necessary technical expertise, financial resources, and leverage with vendors to continue alone. Rural priority practices are particularly challenged, because expertise is often not available locally. CONCLUSIONS: Priority practices, especially in rural areas, are at high risk for falling on the wrong side of a "digital divide" as payers and regulators enact increasing expectations for EHR use and information management. For those without affiliation to maintain the necessary expert staff, ongoing support will be needed for those practices to remain viable.

Cardiovascular risk and statin use in the United States.

PURPOSE: Statins reduce the risk of mortality and coronary artery disease in individuals at high cardiovascular risk. Using nationally representative data, we examined the relationships between statin use and cardiovascular risk, diagnosis of hyperlipidemia, and other risk factors. METHODS: We analyzed data from the 2010 Medical Expenditure Panel Survey, a nationally representative survey of the U.S. civilian noninstitutionalized population. The study sample had a total of 16,712 individuals aged 30 to 79 years. Those who reported filling at least 2 statin prescriptions were classified as statin users. We created multiple logistic regression models for statin use as the dependent variable, with cardiovascular risk factors and sociodemographic factors as independent variables. RESULTS: Overall, 58.2% (95% CI, 54.6%-61.7%) of individuals with coronary artery disease and 52.0% (95% CI, 49.4%-54.6%) of individuals with diabetes aged older than 40 years were statin users. After adjusting for cardiovascular risk factors and sociodemographic factors, the probability of being on a statin was significantly higher among individuals with both hyperlipidemia and coronary artery disease, at 0.44 (95% CI, 0.40-0.48), or hyperlipidemia only, at 0.32 (95% CI, 0.30-0.33), than among those with coronary artery disease only, at 0.11 (95% CI, 0.07-0.15). A similar pattern was seen in people with diabetes. CONCLUSIONS: In this nationally representative sample, many people at high risk for cardiovascular events, including those with coronary artery disease, diabetes, or both, were not receiving statins despite evidence that these agents reduce adverse events. This undertreatment appears to be related to placing too much emphasis on hyperlipidemia and not enough on cardiovascular risk. Recently released guidelines from the American College of Cardiology and the American Heart Association offer an opportunity to improve statin use by focusing on cardiovascular risk instead of lipid levels.

The policy context of patient centered medical homes: perspectives of primary care providers.

BACKGROUND: Interest in the patient centered medical home (PCMH) model has increased significantly in recent years. Despite this attention, information is limited regarding the influence of policy context on implementation of the PCMH model. Using comparative, qualitative data, we identify several key policy impediments to PCMH implementation, and propose practical guidelines for addressing these issues. RESEARCH DESIGN: Qualitative, semi-structured in-person interviews with representatives of physician organizations and primary care practices pursuing PCMH. PARTICIPANTS: Practitioners and staff at 16 physician practices in Michigan, as well as key leaders of physician organizations. KEY RESULTS: We identified five primary policy issues cited by physicians and physician organization leaders as most impactful on their efforts to adopt PCMH: misalignment of current reimbursement schemes, administrative burden, conflicting criteria for PCMH designation, workforce policy issues, and uncertainty of health care reform. These policies were largely seen as barriers to their ability to implement PCMH. CONCLUSIONS: Providers' motivation to embrace PCMH, and their level of confidence regarding the results of such change, are greatly influenced by their perception of the external environment and the control they believe they have over this environment. Having policies in place that shape the path to PCMH in a manner that makes it as easy as possible for providers to accomplish the desired changes could well make the difference in whether successful transformation is achieved.

Assessment and measurement of patient-centered medical home implementation: the BCBSM experience.

PURPOSE: Our goal was to describe an approach to patient-centered medical home (PCMH) measurement based on delineating the desired properties of the measurement relative to assumptions about the PCMH and the uses of the measure by Blue Cross Blue Shield of Michigan (BCBSM) and health services researchers. METHODS: We developed and validated an approach to assess 13 functional domains of PCMHs and 128 capabilities within those domains. A measure of PCMH implementation was constructed using data from the validated self-assessment and then tested on a large sample of primary care practices in Michigan. RESULTS: Our results suggest that the measure adequately addresses the specific requirements and assumptions underlying the BCBSM PCMH program-ability to assess change in level of implementation; ability to compare across practices regardless of size, affiliation, or payer mix; and ability to assess implementation of the PCMH through different sequencing of capabilities and domains. CONCLUSIONS: Our experience illustrates that approaches to measuring PCMH should be driven by the measures' intended use(s) and users, and that a one-size-fits-all approach may not be appropriate. Rather than promoting the BCBSM PCMH measure as the gold standard, our study highlights the challenges, strengths, and limitations of developing a standardized approach to PCMH measurement.

Exploring provider roles, continuity, and mental models in cirrhosis care: A qualitative study.

BACKGROUND: Advanced cirrhosis results in frequent emergency department visits, hospital admissions and readmissions, and a high risk of premature death. We previously identified and compared differences in the mental models of cirrhosis care held by primary and specialty care physicians and nurse practitioners that may be addressed to improve coordination and transitions in care. The aim of this paper is to further explore how challenges to continuity and coordination of care influence how health care providers adapt in their approaches to and development of mental models of cirrhosis care. METHODS: Cross-sectional formal elicitation of mental models using Cognitive Task Analysis. Purposive and chain-referral sampling took place over 6 months across Alberta for a total of 19 participants, made up of family physicians (n = 8), specialists (n = 9), and cirrhosis nurse practitioners (n = 2). RESULTS: Lack of continuity in cirrhosis care, particularly informational and management continuity, not only hinders health care providers' ability to develop rich mental models of cirrhosis care but may also determine whether they form a patient-centred or task-based mental model, and whether they develop shared mental models with other providers. CONCLUSIONS: The system barriers and gaps that prevent the level of continuity needed to coordinate care for people with cirrhosis lead providers to create and work under mental models that perpetuate those barriers, in a vicious cycle. Understanding how providers approach cirrhosis care, adapt to the challenges facing them, and develop mental models offers insights into how to break that cycle and improve continuity and coordination.

Using care pathways for cancer diagnosis in primary care: a qualitative study to understand family physicians' mental models.

BACKGROUND: Care pathways are tools that can help family physicians navigate the complexities of the cancer diagnostic process. Our objective was to examine the mental models associated with using care pathways for cancer diagnosis of a group of family physicians in Alberta. METHODS: We conducted a qualitative study using cognitive task analysis, with interviews in the primary care setting between February and March 2021. Family physicians whose practices were not heavily oriented toward patients with cancer and who did not work closely with specialized cancer clinics were recruited with the support of the Alberta Medical Association and leveraging our familiarity with Alberta's Primary Care Networks. We conducted simulation exercise interviews with 3 pathway examples over Zoom, and we analyzed data using both macrocognition theory and thematic analysis. RESULTS: Eight family physicians participated. Macrocognitive functions (and subthemes) related to mental models were sense-making and learning (confirmation and validation, guidance and support, and sense-giving to patients), care coordination and diagnostic decision-making (shared understanding). Themes related to the use of the pathways were limited use in diagnosis decisions, use in guiding and supporting referral, only relevant and easy-to-process information, and easily accessible. INTERPRETATION: Our findings suggest the importance of designing pathways intentionally for streamlined integration into family physicians' practices, highlighting the need for co-design approaches. Pathways were identified as a tool that, used in combination with other tools, may help gather information and support cancer diagnosis decisions, with the goals of improving patient outcomes and care experience.

Family physician count and service provision in Ontario and Alberta between 2005/06 and 2017/18: a cross-sectional study.

BACKGROUND: Five million Canadians lack a family doctor or primary care team. Our goal was to examine trends over time in family physician workforce and service provision in Ontario and Alberta, with a view to informing policy discussions on primary care supply and delivery of services. METHODS: We used cross-sectional analyses in Ontario and Alberta for 2005/06, 2012/13 and 2017/18 to examine family physician provision of service days by provider demographic characteristics and geographic location. A service day was defined as 10 or more clinic visits worth $20 or more on the same calendar day. We included all active family physicians who had evidence of billing in each fiscal year analyzed. RESULTS: From 2005/06 to 2017/18, the number of family physicians increased by 35.3% in Ontario and 48.7% in Alberta; however, annual average service days per physician declined by 10.6% in Ontario and 5.9% in Alberta. The average daily patient volume remained stable in Ontario and declined in Alberta, and services per population kept pace modestly with population growth in both provinces. Rural areas had the smallest increases in physician counts and largest declines in average annual service days per physician. Physicians in both provinces who had graduated from medical school at least 30 years earlier accounted for more than one-third of the workforce in 2017/18. INTERPRETATION: Ontario and Alberta experienced rapid growth in the number of family physicians, with the largest increases among those in late career and the lowest increases in rural areas. The decline in service provision among physicians overall and in subgroups in both provinces highlights the importance of measuring activity to inform workforce planning.