Analysis of the first 5 years of an interdisciplinary Rheumatology-Dermatology clinic.

BACKGROUND: Multispeciality clinics, such as combined psoriasis-psoriatic arthritis clinics, have shown improved outcomes in various diseases. At Massachusetts General Hospital, we are entering our ninth year of having an interdisciplinary Rheumatology-Dermatology (R-D) clinic. AIM: To evaluate the contribution of an R-D clinic by comparing care of patients pre- and post-evaluation in the combined clinic. As proxies of care, rates and comprehensiveness of evaluations (capillaroscopic examination, skin and joint examination) were compared between the combined clinic and standard Rheumatology or Dermatology clinic. METHODS: This was a retrospective chart review of patients at the R-D clinic in Massachusetts General Hospital during the period November 2012 to December 2017. RESULTS: Prior to the patients visiting the R-D only 5% of capillaroscopic examinations were documented, only 5% of rheumatologists specifically described a rash even when present, and pruritus was documented in only 6% of rheumatology notes. By contrast, in the R-D clinic, capillaroscopic, skin and joint examinations were documented in 100% of visits, and 19% of patients were given a different or a refined diagnosis. Although all our patients had cutaneous manifestations of their disease (hair loss, rash, itch, Raynaud phenomenon, ulcerations, calcinosis) only 34% had seen a dermatologist prior to the combined clinic and only 5% of those had had their concerns addressed by the rheumatologist. This suggests that 95% had a more complete evaluation and management of all aspects of their disease by attendance at the R-D clinic. CONCLUSION: Despite this study being limited by its retrospective nature, we found that it is an efficient model to achieve more comprehensive and potentially lower medication costs. Collaboration between dermatologists and rheumatologists in a combined clinic led to more complete skin and joint examinations, consistent tracking of capillaroscopic examination, better description of rash and improved management. Having this clinic helped in reaching a diagnosis and overall better disease control and outcome.

Distress and problem assessment among people living with cancer from Culturally and Linguistically Diverse backgrounds.

OBJECTIVE: To examine whether routine assessment of distress, recommended as part of comprehensive cancer care, is utilised equally with culturally and linguistically diverse (CALD) vs non-CALD people living with cancer. METHODS: A medical records review of all patients attending cancer-specific treatment units at a single tertiary hospital in Melbourne, Australia between 2015-2018. Recording of administration of the Distress Thermometer and Problem Checklist (DT and PC) was extracted for all patients. Details regarding how the DT and PC (used together) was administered were extracted for a random sub-sample of 294 CALD patients and 294 matched non-CALD patients. RESULTS: A total of 6977 patients were identified (12.0% CALD). Just over half of the CALD (54.7%) and non-CALD (58.2%) patients had a recorded DT and PC (P > 0.05). For the sub-sample analysis, CALD patients were less likely to complete the form themselves (14.8% vs 75.9% non-CALD) and were more likely to have a family member complete the form (55.1% vs 15.1% non-CALD). CALD patients reported a similar level of distress to non-CALD patients. Distress scores for CALD and non-CALD patients were higher when family members completed the form. Provision of discussion, written information, referral offers and rates of referral acceptance were similar between CALD and non-CALD patients. CONCLUSIONS: Assessment of distress and associated problems, and the process following assessment, were similar for CALD and non-CALD patients. However, differences in how the form was completed highlight the need for further improvements to ensure that CALD patients are actively involved in their care.

Levels of type 1 diabetes care in children and adolescents for countries at varying resource levels.

Optimal care for children and adolescents with type 1 diabetes is well described in guidelines, such as those of the International Society for Pediatric and Adolescent Diabetes. High-income countries can usually provide this, but the cost of this care is generally prohibitive for lower-income countries. Indeed, in most of these countries, very little care is provided by government health systems, resulting in high mortality, and high complications rates in those who do survive. As lower-income countries work toward establishing guidelines-based care, it is helpful to describe the levels of care that are potentially affordable, cost-effective, and result in substantially improved clinical outcomes. We have developed a levels of care concept with three tiers: "minimal care," "intermediate care," and "comprehensive (guidelines-based) care." Each tier contains levels, which describe insulin and blood glucose monitoring regimens, requirements for hemoglobin A1c (HbA1c) testing, complications screening, diabetes education, and multidisciplinary care. The literature provides various examples at each tier, including from countries where the life for a child and the changing diabetes in children programs have assisted local diabetes centres to introduce intermediate care. Intra-clinic mean HbA1c levels range from 12.0% to 14.0% (108-130 mmol/mol) for the most basic level of minimal care, 8.0% to 9.5% (64-80 mmol/mol) for intermediate care, and 6.9% to 8.5% (52-69 mmol/mol) for comprehensive care. Countries with sufficient resources should provide comprehensive care, working to ensure that it is accessible by all in need, and that resulting HbA1c levels correspond with international recommendations. All other countries should provide Intermediate care, while working toward the provision of comprehensive care.

The Impact of Comprehensive Care for Joint Replacement Bundled Payment Program on Care Delivery.

BACKGROUND: Comprehensive Care for Joint Replacement (CJR) is a Medicare initiative to test the impact of holding a hospital accountable for services provided during an episode of care for a lower extremity joint arthroplasty on costs and quality. This study examines whether hospital participation in CJR is associated with having programs focused on improving posthospitalization care or reducing costs using a survey of orthopedic surgeons. METHODS: Seventy-three (of 104) orthopedic surgeon members of the Hip Society, a national professional organization of hip surgeons, completed the survey. RESULTS: Surgeons practicing in CJR hospitals were more likely to report that their hospital had implemented programs focused on improving posthospitalization care or reducing costs. Surgeons in CJR hospitals were significantly more likely to report that the hospital had a narrow network of skilled nursing facilities to enhance care and limit length of stay in skilled nursing facilities (83% vs 47%, P < .01). Surgeons in CJR hospitals were also more likely to report the hospital provides incentives or some type of gainsharing. There were no statistically significant differences in implementation of having programs to reduce costs or improve care during hospitalization. CONCLUSION: Participation in CJR is associated with higher utilization of hospital practices aimed at improving postdischarge care and higher utilization of linking surgeon compensation to cost and quality.

Comprehensive preventive care assessments for adults with intellectual and developmental disabilities: Part 2: 2003 to 2014.

OBJECTIVE: To determine if there has been an increase in preventive care among adults with intellectual and developmental disabilities (IDD) as a result of the publication of the Canadian consensus guidelines on the care of adults with IDD in 2006 and 2011. DESIGN: Ecological study. SETTING: Ontario. PARTICIPANTS: The study group consisted of community-dwelling adults with IDD between the ages of 40 and 64 living in Ontario identified in 2009-2010 through administrative health and social services data. The comparison group consisted of a propensity-score-matched sample of the remaining Ontario population. MAIN OUTCOME MEASURES: A combined measure of a health examination or a Primary Care Quality Composite Score (PCQS) of 0.6 or greater, or both. Both measures were identified using administrative health data. RESULTS: Adults with IDD were 2.04% more likely to have had a health examination or a PCQS of 0.6 or greater before 2011-2012 and 1.70% less likely after 2011-2012. Adults without IDD were 1.03% more likely before 2011-2012 and 13.74% less likely after 2011-2012 to have had a health examination or a PCQS of 0.6 or greater. Male patients with IDD were 15.60% more likely and male patients without IDD were 7.39% less likely to have had a health examination or PCQS of 0.6 or greater compared with female patients. CONCLUSION: Despite the publication of the guidelines there has not been a corresponding increase in the uptake of the annual health examination or in the quality of preventive care among adults with IDD. More is required to reduce this documented inequity in care.

Evaluation of a hepatitis C clinical care coordination programme's effect on treatment initiation and cure: A surveillance-based propensity score matching approach.

Hepatitis C (HCV) is a viral infection that if left untreated can severely damage the liver. Project INSPIRE was a 3 year HCV care coordination programme in New York City (NYC) that aimed to address barriers to treatment initiation and cure by providing patients with supportive services and health promotion. We examined whether enrolment in Project INSPIRE was associated with differences in HCV treatment and cure compared with a demographically similar group not enrolled in the programme. INSPIRE participants in 2015 were matched with a cohort of HCV-infected persons identified in the NYC surveillance registry, using full optimal matching on propensity scores and stratified by INSPIRE enrolment status. Conditional logistic regression was used to assess group differences in the two treatment outcomes. Two follow-up sensitivity analyses using individual pair-matched sets and the full unadjusted cohort were also conducted. Treatment was initiated by 72% (790/1130) of INSPIRE participants and 36% (11 960/32 819) of study-eligible controls. Among initiators, 65% (514/790) of INSPIRE participants compared with 47% (5641/11 960) of controls achieved cure. In the matched analysis, enrolment in INSPIRE increased the odds of treatment initiation (OR: 5.25, 95% CI: 4.47-6.17) and cure (OR: 2.52, 95% CI: 2.00-3.16). Results from the sensitivity analyses showed agreement with the results from the full optimal match. Participation in the HCV care coordination programme significantly increased the probability of treatment initiation and cure, demonstrating that care coordination for HCV-infected individuals improves treatment outcomes.

Comprehensive practice: Normative definition across 3 generations of alumni from a single family practice program, 1985 to 2012.

OBJECTIVE: To determine the range of services and procedures offered by family physicians who define themselves as comprehensive practitioners and compare responses across 3 generations of alumni of a single family practice program. DESIGN: Cross-sectional survey. SETTING: Western University in London, Ont. PARTICIPANTS: All graduates of the family medicine program between 1985 and 2012. MAIN OUTCOME MEASURES: Self-reported provision of the following types of care: in-office care, in-hospital care, intrapartum obstetrics, housecalls, palliative care, after-hours care, nursing home care, minor surgery, emergency department care, sport medicine, and walk-in care. Sex, training site (urban or rural), size of community of practice, practice model, and satisfaction with practice were also reported. RESULTS: Participants practised in 7 provinces and 1 territory across Canada, but principally in Ontario. A small number were located in the United States. There was a decline in the number of services provided across 3 generations of graduates, with newer graduates providing fewer services than the older graduates. Significant decreases across the 3 groups were observed in provision of housecalls (P = .004), palliative care (P = .028), and nursing home care (P < .001). Non-significant changes were seen in provision of intrapartum obstetrics across the 3 alumni groups, with an initial decline and then increase in reported activity. Most respondents were in a family health organization or family health network practice model and those in such models reported offering significantly more services than those in family health group or salary models (P < .001). CONCLUSION: The normative definition of comprehensive care varies across 3 generations of graduates of this family medicine program, with newer physicians reporting fewer overall services and procedures than older graduates. Greater understanding of the forces (institutional, regulatory, economic, and personal) that determine the meaning of comprehensive primary care is necessary if this foundational element of family medicine is to be preserved.

[Access barriers to comprehensive care for people affected by tuberculosis and human immunodeficiency virus coinfection in Peru, 2010-2015]. / Barreras para el acceso a la atención integral de las personas afectadas por la coinfección por tuberculosis y virus de inmunodeficiencia humana en Perú, 2010­2015.

OBJECTIVE: Identify the programmatic barriers that hinder access to comprehensive care of patients with tuberculosis and human immunodeficiency virus (TB/HIV) coinfection. METHODS: This is a mixed-method study. Qualitative research was conducted via in-depth interviews with key actors and the quantitative component involved cross-sectional descriptive analysis of programmatic data from 2010-2015 on tuberculosis and HIV programs at health facilities in the cities of Lima and Iquitos. RESULTS: Twenty-two key actors in seven establishments were interviewed. The identified barriers were: little or no coordination between tuberculosis and HIV teams, separate management of tuberculosis and HIV cases at different levels of care, insufficient financing, limited or poorly trained human resources, and lack of an integrated information system. It was found that HIV screening in TB patients increased (from 18.8% in 2011 to 95.2% in 2015), isoniazid coverage of HIV patients declined (from 62% to 9%), and the proportion of deaths among TB/HIV coinfection cases averaged 20%. CONCLUSIONS: There is poor coordination between HIV and TB health strategies. Management of TB/HIV coinfection is fragmented into different levels of care, which has an impact on comprehensive patient care. As a result of this research, a technical document was prepared to establish joint procedures that should be implemented to improve comprehensive care of TB/HIV coinfection.

Primary Care Physician Panel Size and Quality of Care: A Population-Based Study in Ontario, Canada.

PURPOSE: The purpose of this study was to determine the relationship between the number of patients under a primary care physician's care (panel size) and primary care quality indicators. METHODS: We conducted a cross-sectional, population-based study of fee-for-service and capitated interprofessional and non-interprofessional primary health care practices in Ontario, Canada between April 2008 and March 2010, encompassing 4,195 physicians with panel sizes ≥1,200 serving 8.3 million patients. Data was extracted from multiple linked, health-related administrative databases and covered 16 quality indicators spanning 5 dimensions of care: access, continuity, comprehensiveness, and evidence-based indicators of cancer screening and chronic disease management. RESULTS: The likelihood of being up-to-date on cervical, colorectal, and breast cancer screening showed relative decreases of 7.9% (P <.001), 5.9% (P = .01), and 4.6% (P <.001), respectively, with increasing panel size (from 1,200 to 3,900). Eight chronic care indicators (4 medication-based and 4 screening-based) showed no significant association with panel size. The likelihood of individuals with a new diagnosis of congestive heart failure having an echocardiogram, however, increased by a relative 8.1% (P <.001) with higher panel size. Increasing panel size was also associated with a 10.8% relative increase in hospitalization rates for ambulatory-care-sensitive conditions (P = .04) and a 10.8% decrease in non-urgent emergency department visits (P = .004). Continuity was highest with medium panel sizes (P <.001), and comprehensiveness had a small decrease (P = .03) with increasing panel size. CONCLUSIONS: Increasing panel size was associated with small decreases in cancer screening, continuity, and comprehensiveness, but showed no consistent relationships with chronic disease management or access indicators. We found no panel size threshold above which quality of care suffered.

Having a usual source of care and its associated factors in Korean adults: a cross-sectional study of the 2012 Korea Health Panel Survey.

BACKGROUND: Usual source of care (USC) is one of the hallmarks of primary care. We aimed to examine the status of having a USC and its patient-related sociodemographic factors among Korean adults. METHODS: Data were obtained from the 2012 Korea Health Panel survey. Panel participants were selected for the study who were aged 18 years or older and who replied to questionnaire items on having a USC (n = 11,935). RESULTS: Of the participants, 21.5% had a usual place and 13.9% had a usual physician. Reasons for not having a USC were seldom being ill (66.1%), the preference to visit multiple medical institutions (27.9%), and others. The private community clinic was the most common type of usual place (57.0%). In patient-reported attributes of care provided by a usual physician, the percentages of positive responses for comprehensiveness and coordination were 67.2% and 34.5%, respectively. By institution type, primary care clinics showed the lowest percentage (32.8%) of positive responses for coordination. Adjusted odds ratios of having a usual physician were 3.77 (95% confidence interval, CI: 3.75-3.79) for those aged 65 years or older (vs. aged 18-34 years), 1.31 (CI: 1.30-1.31) for females (vs. males), 0.72 (CI: 0.72-0.73) for unmarried people (vs. married), 1.16 (CI: 1.16-1.16) for college graduates or higher (vs. elementary school graduate or less), 0.64 for the fifth quintile (vs. the first quintile) by household income, 1.53 (CI: 1.52-1.54) for Medical Aid (vs. employee health insurance) for type of health insurance, and 4.09 (CI: 4.08-4.10) for presence (vs. absence) of a chronic diseases. CONCLUSIONS: The proportion of Korean adults who have a USC is extremely low, the most influential factor of having a USC is having a chronic disease or not, and Korean patients experience much poorer health care coordination than do patients in other industrialized countries. The findings of this study will give insight to researchers and policy makers regarding the potential facilitators of and barriers to promoting having a USC in the general Korean public.

Women's care during home visits for the "First Comprehensive Healthcare Week". / Cuidados prestados à mulher na visita domiciliar da "Primeira Semana de Saúde Integral".

OBJECTIVE: To evaluate women's care during home visits for the "First Comprehensive Care Week". METHOD: A cross-sectional study was carried out in a specialized service in Recife, Pernambuco, Brazil. A total of 190 women who had recently given birth enrolled at the Family Health Strategy answered the questionnaire between September and December 2013 to verify the association between home visits and the investigated variables. This association was verified using the chi-square test with a confidence level of 95%. RESULTS: Most of the women were 29 years old or under (68.5%), with high gestational risk (59.5%), and primiparous (46.9%). On the first week after hospital discharge, 42.1% received a home visit. An association was detected between local pre-natal care and a home visit on the first week (p = 0.049). The participation of the nurses during the visits was associated with better performance for breast and abdomen examinations (p = 0.000) and investigations on emotional conditions (p = 0.029). CONCLUSIONS: These findings stress the need to establish a routine home visit plan to solve the issues of women with high-risk pregnancies after labour.

Improvements in HIV care engagement and viral load suppression following enrollment in a comprehensive HIV care coordination program.

BACKGROUND: Substantial evidence gaps remain regarding human immunodeficiency virus (HIV) intervention strategies that improve engagement in care (EiC) and viral load suppression (VLS). We assessed EiC and VLS before and after enrollment in a comprehensive intervention for persons at risk of poor HIV care outcomes. METHODS: New York City's Ryan White Part A HIV Care Coordination Program (CCP), launched at 28 agencies in 2009, applies multiple strategies to promote optimal utilization of medical and social services. Using laboratory test records from an HIV surveillance registry, we examined pre-post outcomes among 3641 CCP clients enrolled before April 2011. For the year before and after enrollment, we assessed EiC (defined as ≥2 tests, ≥90 days apart, with ≥1 in each half-year) and VLS (defined as viral load [VL] ≤200 copies/mL on latest VL test in the second half of the year). We estimated relative risks (RRs), comparing pre- and postenrollment proportions achieving EiC and VLS. RESULTS: Among newly diagnosed clients, 90.5% (95% confidence interval [CI], 87.9%-93.2%) and 66.2% (95% CI, 61.9%-70.6%) achieved EiC and VLS, respectively. Among previously diagnosed clients, EiC increased from 73.7% to 91.3% (RR = 1.24; 95% CI, 1.21-1.27) and VLS increased from 32.3% to 50.9% (RR = 1.58; 95% CI, 1.50-1.66). Clients without evidence of HIV care during the 6 months preenrollment contributed most to overall improvements. Pre-post improvements were robust, retaining statistical significance within most sociodemographic and clinical subgroups, and in 89% (EiC) and 75% (VLS) of CCP agencies. CONCLUSIONS: Clients in comprehensive HIV care coordination for persons with evident barriers to care showed substantial and consistent improvement in short-term outcomes.

Impact evaluation of a health promotion-focused organisational development strategy on a health service's capacity to deliver comprehensive primary health care.

A comprehensive primary health care approach is required to address complex health issues and reduce inequities. However, there has been limited uptake of this approach by health services nationally or internationally. Reorienting health services towards becoming more health promoting provides a mechanism to support the delivery of comprehensive primary health care. The aim of this study was to determine the impact of a health promotion-focused organisational development strategy on the capacity of a primary health care service to deliver comprehensive primary health care. A questionnaire and semistructured individual interviews were used to collect quantitative and qualitative impact evaluation data, respectively, from 13 health service staff across three time points with regard to 37 indicators of organisational capacity. There were significant increases in mean scores for 31 indicators, with effect sizes ranging from moderate to nearly perfect. A range of key enablers and barriers to support the delivery of comprehensive primary health care was identified. In conclusion, an organisational development strategy to reorient health services towards becoming more health promoting may increase the capacity to deliver comprehensive primary health care.

Predictors of psychological well-being and stress among Jordanian menopausal women.

PURPOSE: The aim of this study was to investigate purpose in life, self-acceptance, perceived stress levels, and menopausal symptoms among Jordanian women. METHODS: A descriptive, correlational design with a convenience sample of 193 women aged 40-55 years was employed. RESULTS: The average age at menopause for the current sample was 47.4 years, and menopausal status did not significantly affect purpose in life, self-acceptance, or perceived stress levels. Negative correlations were found between purpose in life and perceived stress, and between self-acceptance and perceived stress (r = -0.49; p = 0.01 and r = -0.58; p = 0.01, respectively). Menopausal symptoms were found to be a strong negative predictor of purpose in life, self-acceptance, and perceived stress levels. In addition, higher health rating was significantly associated with higher psychological well-being and lower perceived stress levels. Perimenopause was found to be a vulnerable stage for severe menopausal symptoms particularly psychological complaints. However, vasomotor symptoms and loss of sexual interest became more intense among postmenopausal women. Although women in the current study had low psychological well-being and high perceived stress, these were not affected by their menopausal status. CONCLUSION: The study showed the importance of including both physical and psychological symptoms during encounters with health professionals, besides considering women's expectations about menopause to help ease their menopausal transition and improve their well-being.

Prevalence of psychoses in Stockholm County--a population-based study using comprehensive healthcare registers.

BACKGROUND: Major variations in the prevalence of schizophrenia and other psychoses have been reported in different geographical areas, partly explained by the methodology used as well as characteristics of the area. AIMS: The purpose of this study was to estimate the 1-year prevalence of schizophrenia (ICD-10 F20) and non-affective psychoses (ICD-10 F20-F29) in Stockholm County using population-based health records from inpatient and outpatient care. METHODS: Psychiatric outpatient and inpatient healthcare data during the period 1997 to 2006 in Stockholm County was collected from mental health facilities in a defined geographical area covering almost one million adult inhabitants. Data included 13,561 individuals with ICD-10 diagnoses of non-affective psychoses, their contacts with healthcare and demographic variables constituting the Stockholm Non-Affective Psychoses-registry. RESULTS: The 1-year prevalence was 6.7/1000 for non-affective psychoses and 3.7/1000 for schizophrenia. The estimates were markedly stable during the study period, years 2000-2005. However, a substantial variation in the 1-year prevalence between areas in Stockholm County was noted (range 3.5/1000-13.2/1000). The 1-year prevalence was correlated to the proportion of immigrants as well as the proportion of individuals receiving social welfare benefits, in the area. An increase in the proportion of individuals only visiting outpatient care was seen. CONCLUSION: The 1-year prevalence of schizophrenia was 3.7/1000 and approximately twice as high for non-affective psychoses. The estimates were stable over time but varied substantially between local areas, corresponding to social and demographic factors.

Receipt of National Comprehensive Cancer Network guideline-concordant prostate cancer care among African American and Caucasian American men in North Carolina.

BACKGROUND: African Americans have a higher incidence of prostate cancer and experience poorer outcomes compared with Caucasian Americans. Racial differences in care are well documented; however, few studies have characterized patients based on their prostate cancer risk category, which is required to differentiate appropriate from inappropriate guideline application. METHODS: The medical records of a population-based sample of 777 North Carolina men with newly diagnosed prostate cancer were studied to assess the association among patient race, clinical factors, and National Comprehensive Cancer Network (NCCN) guideline-concordant prostate cancer care. RESULTS: African Americans presented with significantly higher Gleason scores (P = .025) and prostate-specific antigen levels (P = .008) than did Caucasian Americans. However, when clinical T stage was considered as well, difference in overall risk category only approached statistical significance (P = .055). Across risk categories, African Americans were less likely to have surgery (58.1% versus 68.0%, P = .004) and more likely to have radiation (39.0% versus 27.4%, P = .001) compared with Caucasian Americans. However, 83.5% of men received guideline-concordant care within 1 year of diagnosis, which did not differ by race in multivariable analysis (odds ratio = 0.83; 95% confidence interval = 0.54-1.25). Greater patient-perceived access to care was associated with greater odds of receiving guideline-concordant care (odds ratio = 1.06; 95% confidence interval = 1.01-1.12). CONCLUSIONS: After controlling for NCCN risk category, there were no racial differences in receipt of guideline-concordant care. Efforts to improve prostate cancer treatment outcomes should focus on improving access to the health care system.

Medicare beneficiaries with more comprehensive primary care physicians report better primary care.

OBJECTIVE: To examine whether primary care physician (PCP) comprehensiveness is associated with Medicare beneficiaries' overall rating of care from their PCP and staff. DATA SOURCES: We linked Medicare claims with survey data from Medicare beneficiaries attributed to Comprehensive Primary Care Plus (CPC+) physicians and practices. STUDY DESIGN: We performed regression analyses of the associations between two claims-based measures of PCP comprehensiveness in 2017 and beneficiaries' rating of care from their PCP and practice staff in 2018. DATA COLLECTION/EXTRACTION METHODS: The analytic sample included 6228 beneficiaries cared for by 3898 PCPs. Regressions controlled for beneficiary, physician, practice, and market characteristics. PRINCIPAL FINDINGS: Beneficiaries with more comprehensive PCPs rated care from their PCP and practice staff higher than did those with less comprehensive PCPs. For each comprehensiveness measure, beneficiaries whose PCP was in the 75th percentile were more likely than beneficiaries whose PCP was in the 25th percentile to rate their care highly (2 percentage point difference, p = 0.02). CONCLUSIONS: Medicare beneficiaries with more comprehensive PCPs rate overall care from their PCPs and staff higher than those with less comprehensive PCPs.

Tracking family medicine graduates. Where do they go, what services do they provide and whom do they see?

BACKGROUND: There are continued concerns over an adequate supply of family physicians (FPs) practicing in Canada. While most resource planning has focused on intake into postgraduate education, less information is available on what postgraduate medical training yields. We therefore undertook a study of Family Medicine (FM) graduates from the University of Toronto (U of T) to determine the type of information for physician resource planning that may come from tracking FM graduates using health administrative data. This study compared three cohorts of FM graduates over a 10 year period of time and it also compared FM graduates to all Ontario practicing FPs in 2005/06. The objectives for tracking the three cohorts of FM graduates were to: 1) describe where FM graduates practice in the province 2) examine the impact of a policy introduced to influence the distribution of new FM graduates in the province 3) describe the services provided by FM graduates and 4) compare workload measures. The objectives for the comparison of FM graduates to all practicing FPs in 2005/06 were to: 1) describe the patient population served by FM graduates, 2) compare workload of FM graduates to all practicing FPs. METHODS: The study cohort consisted of all U of T FM postgraduate trainees who started and completed their training between 1993 and 2003. This study was a descriptive record linkage study whereby postgraduate information for FM graduates was linked to provincial health administrative data. Comprehensiveness of care indicators and workload measures based on administrative data where determined for the study cohort. RESULTS: From 1993 to 2003 there were 857 University of Toronto FM graduates. While the majority of U of T FM graduates practice in Toronto or the surrounding Greater Toronto Area, there are FM graduates from U of T practicing in every region in Ontario, Canada. The proportion of FM graduates undertaking further emergency training had doubled from 3.6% to 7.8%. From 1993 to 2003, a higher proportion of the most recent FM graduates did hospital visits, emergency room care and a lower proportion undertook home visits. Male FM graduates appear to have had higher workloads compared with female FM graduates, though the difference between them was decreasing over time. A 1997 policy initiative to discount fees paid to new FPs practicing in areas deemed over supplied did result in a decrease in the proportion of FM graduates practicing in metropolitan areas. CONCLUSIONS: We were able to profile the practices of FM graduates using existing and routinely collected population-based health administrative data. Further work tracking FM graduates could be helpful for physician resource forecasting and in examining the impact of policies on family medicine practice.

Assessing the level of public health partner spending using the funding formula analysis tool.

Public health services are delivered through a variety of organizations. Traditional accounting of public health expenditures typically captures only spending by government agencies. New Hampshire collected information from public health partners, such as community centers that host smoking cessation classes or health education done by Girls, Inc. This study compares the new data to spending by government agencies, focusing on breakdowns by fund source and service categories. Expanded funds secured by these partners account for a 42% of all local public health spending, and they spent 4 times more than government agencies on promoting healthy behavior. The funding formula analysis tool revealed that these partners spent in ways that would be politically difficult to achieve. In an era of declining budgets, an understanding of public health's partners is increasingly vital.