Primary care practice characteristics associated with team functioning in primary care settings in Canada: A practice-based cross-sectional survey.

Team-based care is recognized as a foundational building block of high-performing primary care. The purpose of this study was to identify primary care practice characteristics associated with team functioning and examine whether there is relationship between team composition or size and team functioning. We sought to answer the following research questions: (1) are primary care practice characteristics associated with team functioning; and (2) does team composition or size influence team functioning. This cross-sectional correlational study was conducted in Fraser East, British Columbia, Eastern Ontario Health Unit, Ontario and Central Zone, Nova Scotia in Canada. Data were collected from primary care practices using an organization survey and the Team Climate Inventory (TCI) as a measure team functioning. The independent variables of interest were: physicians' payment model, internal clinic meetings to discuss clinical issues, care coordination through informal and ad hoc exchange, care coordination through electronic medical records and sharing clinic mission, values and objectives among health professionals. Potentially confounding variables were as follows: team size, composition, and practice panel size. A total of 63 practices were included in these analyses. The overall mean score of team climate was 73 (SD: 10.75) out of 100. Regression analyses showed that care coordination through human interaction and sharing the practice's mission, values, and objectives among health professionals were positively associated with higher functioning teams. Care coordination through electronic medical records and larger team size were negatively associated with team climate. This study provides baseline data on what practice characteristics are associated with highly functioning teams in Canada.

Patient clustering in primary care settings: Outcomes and quality of care.

OBJECTIVE: To determine whether neighbours who share the same family physicians have better cardiovascular and health care outcomes. DESIGN: Retrospective cohort study using administrative health databases. SETTING: Ontario. PARTICIPANTS: The study population included 2,690,482 adult patients cared for by 1710 family physicians. INTERVENTIONS: Adult residents of Ontario were linked to their family physicians and the geographic distance between patients in the same panel or list was calculated. Using distance between patients within a panel to stratify physicians into quintiles of panel proximity, physicians and patients from close-proximity practices were compared with those from more-distant-proximity practices. Age- and sex-standardized incidence rates and hazard ratios from cause-specific hazards regression models were determined. MAIN OUTCOME MEASURES: The occurrence of a major cardiovascular event during a 5-year follow-up period (2008 to 2012). RESULTS: Patients of panels in the closest-proximity quintile lived an average of 3.9 km from the 10 closest patients in their panel compared with 12.4 km for the 10 closest patients of panels in the distant-proximity quintile. After adjusting for various patient and physician characteristics, patients in the most-distant-proximity practices had a 24% higher rate of cardiovascular events (adjusted hazard ratio=1.24 [95% CI 1.20 to 1.28], P<.001) than patients in the closest-proximity practices. Age- and sex-standardized all-cause mortality and total per patient health care costs were also lowest in the closest-proximity quintile. In sensitivity analyses restricted to large urban communities and to White long-term residents, results were similar. CONCLUSION: The better cardiovascular outcomes observed in close-proximity panels may be related to a previously unrecognized mechanism of social connectedness that extends the effectiveness of primary care practitioners.

Response to language barriers with patients from refugee background in general practice in Australia: findings from the OPTIMISE study.

BACKGROUND: Language is a barrier to many patients from refugee backgrounds accessing and receiving quality primary health care. This paper examines the way general practices address these barriers and how this changed following a practice facilitation intervention. METHODS: The OPTIMISE study was a stepped wedge cluster randomised trial set within 31 general practices in three urban regions in Australia with high refugee settlement. It involved a practice facilitation intervention addressing interpreter engagement as one of four core intervention areas. This paper analysed quantitative and qualitative data from the practices and 55 general practitioners from these, collected at baseline and after 6 months during which only those assigned to the early group received the intervention. RESULTS: Many practices (71 %) had at least one GP who spoke a language spoken by recent humanitarian entrants. At baseline, 48 % of practices reported using the government funded Translating and Interpreting Service (TIS). The role of reception staff in assessing and recording the language and interpreter needs of patients was well defined. However, they lacked effective systems to share the information with clinicians. After the intervention, the number of practices using the TIS increased. However, family members and friends continued to be used to interpret with GPs reporting patients preferred this approach. The extra time required to arrange and use interpreting services remained a major barrier. CONCLUSIONS: In this study a whole of practice facilitation intervention resulted in improvements in procedures for and engagement of interpreters. However, there were barriers such as the extra time required, and family members continued to be used. Based on these findings, further effort is needed to reduce the administrative burden and GP's opportunity cost needed to engage interpreters, to provide training for all staff on when and how to work with interpreters and discuss and respond to patient concerns about interpreting services.

Differences in Mode Preferences, Response Rates, and Mode Effect Between Automated Email and Phone Survey Systems for Patients of Primary Care Practices: Cross-Sectional Study.

BACKGROUND: A growing number of health care practices are adopting software systems that link with their existing electronic medical records to generate outgoing phone calls, emails, or text notifications to patients for appointment reminders or practice updates. While practices are adopting this software technology for service notifications to patients, its use for collection of patient-reported measures is still nascent. OBJECTIVE: This study assessed the mode preferences, response rates, and mode effect for a practice-based automated patient survey using phone and email modalities to patients of primary care practices. METHODS: This cross-sectional study analyzed responses and respondent demographics for a short, fully automated, telephone or email patient survey sent to individuals within 72 hours of a visit to their regular primary care practice. Each survey consisted of 5 questions drawn from a larger study's patient survey that all respondents completed in the waiting room at the time of their visit. Automated patient survey responses were linked to self-reported sociodemographic information provided on the waiting room survey including age, sex, reported income, and health status. RESULTS: A total of 871 patients from 87 primary care practices in British Columbia, Ontario, and Nova Scotia, Canada, agreed to the automated patient survey and 470 patients (45.2%) completed all 5 questions on the automated survey. Email administration of the follow-up survey was preferred over phone-based administration, except among patients aged 75 years and older (P<.001). Overall, response rates for those who selected an emailed survey (369/606, 60.9%) were higher (P<.001) than those who selected the phone survey (101/265, 38.1%). This held true irrespective of age, sex, or chronic disease status of individuals. Response rates were also higher for email (range 57.4% [58/101] to 66.3% [108/163]) compared with phone surveys (range 36% [23/64] to 43% [10/23]) for all income groups except the lowest income quintile, which had similar response rates (email: 29/63, 46%; phone: 23/50, 46%) for phone and email modes. We observed moderate (range 64.6% [62/96] to 78.8% [282/358]) agreement between waiting room survey responses and those obtained in the follow-up automated survey. However, overall agreement in responses was poor (range 45.3% [43/95] to 46.2% [43/93]) for 2 questions relating to care coordination. CONCLUSIONS: An automated practice-based patient experience survey achieved significantly different response rates between phone and email and increased response rates for email as income group rose. Potential mode effects for the different survey modalities may limit multimodal survey approaches. An automated minimal burden patient survey could facilitate the integration of patient-reported outcomes into care planning and service organization, supporting the move of our primary care practices toward a more responsive, patient-centered, continual learning system. However, practices must be attentive to furthering inequities in health care by underrepresenting the experience of certain groups in decision making based on the reach of different survey modes.

Priority measures for publicly reporting primary care performance: Results of public engagement through deliberative dialogues in 3 Canadian provinces.

OBJECTIVE: While public reporting of hospital-based performance measurement is commonplace, it has lagged in the primary care sector, especially in Canada. Despite the increasing recognition of patients as active partners in the health-care system, little is known about what information about primary care performance is relevant to the Canadian public. We explored patient perspectives and priorities for the public reporting of primary care performance measures. METHODS: We conducted six deliberative dialogue sessions across three Canadian provinces (British Columbia, Ontario, Nova Scotia). Participants were asked to rank and discuss the importance of collecting and reporting on specific dimensions and indicators of primary care performance. We conducted a thematic analysis of the data. RESULTS: Fifty-six patients participated in the dialogue sessions. Measures of access to primary care providers, communication with providers and continuity of information across all providers involved in a patient's care were identified as the highest priority indicators of primary care performance from a patient perspective. Several common measures of quality of care, such as rates of cancer screening, were viewed as too patient dependent to be used to evaluate the health system or primary care provider's performance. CONCLUSIONS: Our findings suggest that public reporting aimed at patient audiences should focus on a nuanced measure of access, incorporation of context reported alongside measurement that is for public audiences, clear reporting on provider communication and a measure of information continuity. Participants highlighted the importance the public places on their providers staying up to date with advances in care.

High-performing physicians are more likely to participate in a research study: findings from a quality improvement study.

BACKGROUND: Participants in voluntary research present a different demographic profile than those who choose not to participate, affecting the generalizability of many studies. Efforts to evaluate these differences have faced challenges, as little information is available from non-participants. Leveraging data from a recent randomized controlled trial that used health administrative databases in a jurisdiction with universal medical coverage, we sought to compare the quality of care provided by participating and non-participating physicians prior to the program's implementation in order to assess whether participating physicians provided a higher baseline quality of care. METHODS: We conducted clustered regression analyses of baseline data from provincial health administrative databases. Participants included all family physicians who were eligible to participate in the Improved Delivery of Cardiovascular Care (IDOCC) project, a quality improvement project rolled out in a geographically defined region in Ontario (Canada) between 2008 and 2011. We assessed 14 performance indicators representing measures of access, continuity, and recommended care for cancer screening and chronic disease management. RESULTS: In unadjusted and patient-adjusted models, patients of IDOCC-participating physicians had higher continuity scores at the provider (Odds Ratio (OR) [95% confidence interval]: 1.06 [1.03-1.09]) and practice (1.06 [1.04-1.08]) level, lower risk of emergency room visits (Rate Ratio (RR): 0.93 [0.88-0.97]) and hospitalizations (RR:0.87 [0.77-0.99]), and were more likely to have received recommended diabetes tests (OR: 1.25 [1.06-1.49]) and cancer screening for cervical cancer (OR: 1.32 [1.08-1.61] and breast cancer (OR: 1.32 [1.19-1.46]) than patients of non-participating physicians. Some indicators remained statistically significant in the model after adjusting for provider factors. CONCLUSIONS: Our study demonstrated a participation bias for several quality indicators. Physician characteristics can explain some of these differences. Other underlying physician or practice attributes also influence interest in participating in quality improvement initiatives and existing quality levels. The standard for addressing participation bias by controlling for basic physician and practice level variables is inadequate for ensuring that results are generalizable to primary care providers and practices.

Citizen perspectives on the use of publicly reported primary care performance information: Results from citizen-patient dialogues in three Canadian provinces.

OBJECTIVE: Performance measurement and reporting is proliferating in all sectors of the healthcare system, including primary care, despite a dearth of evidence on how the public uses reports on primary care performance. We explored how the public might use this information, to guide the development of effective reporting systems for primary care. METHODS: We conducted six full-day deliberative dialogue sessions with a purposive sample of 56 citizen-patients across three Canadian provinces (British Columbia, Ontario and Nova Scotia). Participants identified how they would use publicly reported performance data. We conducted a thematic analysis of the data by region. RESULTS: Common uses for primary care performance information emerged across all sessions. Participants most often discussed the utility of this information for community advocacy and participation in health system decision making. Similar barriers for using performance information to choose a primary care provider were identified in each region including the perceived lack of choice of providers and the high value placed on relationships with current providers. Finally, the value of public performance reporting in enhancing trust that people would receive good care was also a common theme. CONCLUSIONS: Citizen-patient perspectives highlight that public reporting on primary care performance could promote the health system's responsiveness by enabling public engagement in decision making at the community level. The role of public reporting in promoting trust rather than empowering patient choice may reflect unique elements of the Canadian health system's context.

Equity of primary care service delivery for low income "sicker" adults across 10 OECD countries.

BACKGROUND: Despite significant investments to support primary care internationally, income-based inequities in access to quality health care are present in many high-income countries. This study aims to determine whether low- and middle-income groups are more likely to report poor quality of primary care (PC) than high-income groups cross-nationally. METHODS: The 2011 Commonwealth Fund Telephone Survey of Sicker Adults is a cross-sectional study across eleven countries. Respondents were recruited from randomly selected households. We used data from surveys conducted in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, the United Kingdom, and the United States. We identified all questions relating to primary care performance, and categorized these into five dimensions: 1) access to care, 2) coordination 3) patient-centered care, and 4) technical quality of care. We used logistic regression with low and middle-income as the comparison groups and high-income as the referent. RESULTS: Fourteen thousand two hundred sixty-two respondents provided income data. Countries varied considerably in their extent of income disparity. Overall, 24.7% were categorized as low- and 13.9% as high-income. The odds of reporting poor access to care were higher for low- and middle-income than high-income respondents in Canada, New Zealand and the US. Similar results were found for Sweden and Norway on coordination; the opposite trend favoring the low- and middle-income groups was found in New Zealand, United Kingdom, and the United States. The odds of reporting poor patient-centered care were higher for low-income than high-income respondents in the Netherlands, Norway, and the US; in Australia, this was true for low- and middle-income respondents. On technical quality of care, the odds of reporting poor care were higher for the low- and middle-income comparisons in Canada and Norway; in Germany, the odds were higher for low-income respondents only. The odds of reporting poor technical quality of care were higher for high-income than low-income respondents in the Netherlands. CONCLUSION: Inequities in quality PC for low and middle income groups exist on at least one dimension in all countries, including some that in theory provide universal access. More research is needed to fully understand equity in the PC sector.

Dimensions and intensity of inter-professional teamwork in primary care: evidence from five international jurisdictions.

Background: Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients' needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated. Objective: The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams. Methods: Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with face-to-face group retreats, using a Collaborative Reflexive Deliberative Approach. Results: Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team's production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team's activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts. Conclusion: The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes.

Uncovering the wisdom hidden between the lines: the Collaborative Reflexive Deliberative Approach.

Background: Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit 'between the lines' knowledge generated during many research projects that are not intrinsic to the main objectives of studies. Objective: To develop a novel approach to expand and deepen meta-syntheses using researchers' experience, tacit knowledge and relevant unpublished materials. Methods: We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants' studies to identify new patterns and insights. Results: CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions. Conclusions: The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies.

Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries.

Background: Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm. Objective: To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices. Methods: An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies. Results: Seven common levers influence a jurisdiction's ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations' attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect. Conclusion: The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC.

Using the CollaboraKTion framework to report on primary care practice recruitment and data collection: costs and successes in a cross-sectional practice-based survey in British Columbia, Ontario, and Nova Scotia, Canada.

BACKGROUND: Across Canada and internationally we have poor infrastructure to regularly collect survey data from primary care practices to supplement data from chart audits and physician billings. The purpose of this work is to: 1) examine the variable costs for carrying out primary care practice-based surveys and 2) share lessons learned about the level of engagement required for recruitment of practices in primary care. METHODS: This work was part of a larger study, TRANSFORMATION that collected data from three provincial study sites in Canada. We report here on practice-based engagement. Surveys were administered to providers, organizational practice leads, and up to 20 patients from each participating provider. We used the CollaboraKTion framework to report on our recruitment and engagement strategies for the survey work. Data were derived from qualitative sources, including study team meeting minutes, memos/notes from survey administrators regarding their interactions with practice staff, and patients and stakeholder meeting minutes. Quantitative data were derived from spreadsheets tracking numbers for participant eligibility, responses, and completions and from time and cost tracking for patient survey administration. RESULTS: A total of 87 practices participated in the study (n = 22 in BC; n = 26 in ON; n = 39 in NS). The first three of five CollaboraKTion activities, Contacting and Connecting, Deepening Understandings, and Adapting and Applying the Knowledge Base, and their associated processes were most pertinent to our recruitment and data collection. Practice participation rates were low but similar, averaging 36% across study sites, and completion rates were high (99%). Patient completion rates were similarly high (99%), though participation rates in BC were substantially lower than the other sites. Recruitment and data collection costs varied with the cost per practice ranging from $1503 to $1792. CONCLUSIONS: A comprehensive data collection system in primary care is possible to achieve with partnerships that balance researcher, clinical, and policy maker contexts. Engaging practices as valued community members and independent business owners requires significant time, and financial and human resources. An integrated knowledge translation and exchange approach provides a foundation for continued dialogue, exchange of ideas, use of the information produced, and recognises recruitment as part of an ongoing cycle.

Assessing the representativeness of physician and patient respondents to a primary care survey using administrative data.

BACKGROUND: QUALICOPC is an international survey of primary care performance. QUALICOPC data have been used in several studies, yet the representativeness of the Canadian QUALICOPC survey is unknown, potentially limiting the generalizability of findings. This study examined the representativeness of QUALICOPC physician and patient respondents in Ontario using health administrative data. METHODS: This representativeness study linked QUALICOPC physician and patient respondents in Ontario to health administrative databases at the Institute for Clinical Evaluative Sciences. Physician respondents were compared to other physicians in their practice group and all Ontario primary care physicians on demographic and practice characteristics. Patient respondents were compared to other patients rostered to their primary care physicians, patients rostered to their physicians' practice groups, and a random sample of Ontario residents on sociodemographic characteristics, morbidity, and health care utilization. Standardized differences were calculated to compare the distribution of characteristics across cohorts. RESULTS: QUALICOPC physician respondents included a higher proportion of younger, female physicians and Canadian medical graduates compared to other Ontario primary care physicians. A higher proportion of physician respondents practiced in Family Health Team models, compared to the provincial proportion for primary care physicians. QUALICOPC patient respondents were more likely to be older and female, with significantly higher levels of morbidity and health care utilization, compared with the other patient groups examined. However, when looking at the QUALICOPC physicians' whole rosters, rather than just the patient survey respondents, the practice profiles were similar to those of the other physicians in their practice groups and Ontario patients in general. CONCLUSIONS: Comparisons revealed some differences in responding physicians' demographic and practice characteristics, as well as differences in responding patients' characteristics compared to the other patient groups tested, which may have resulted from the visit-based sampling strategy. Ontario QUALICOPC physicians had similar practice profiles as compared to non-participating physicians, providing some evidence that the participating practices are representative of other non-participating practices, and patients selected by visit-based sampling may also be representative of visiting patients in other practices. Those using QUALICOPC data should understand this limited representativeness when generalizing results, and consider the potential for bias in their analyses.

Patients' perceptions of access to primary care: Analysis of the QUALICOPC Patient Experiences Survey.

OBJECTIVE: To gain a more comprehensive understanding of patients' perceptions of access to their primary care practice and how these relate to patient characteristics. DESIGN: Cross-sectional study. SETTING: Ontario. PARTICIPANTS: Adult primary care patients in Ontario (N = 1698) completing the Quality and Costs of Primary Care (QUALICOPC) Patient Experiences Survey. MAIN OUTCOME MEASURES: Responses to 11 access-related survey items, analyzed both individually and as a Composite Access Score (CAS). RESULTS: The mean (SD) CAS was 1.78 (0.16) (the highest possible CAS was 2 and the lowest was 1). Most patients (68%) waited more than 1 day for their appointment. By far most (96%) stated that it was easy to obtain their appointment and that they obtained that appointment as soon as they wanted to (87%). There were no statistically significant relationships between CAS and sex, language fluency, income, education, frequency of emergency department use, or chronic disease status. A higher CAS was associated with being older and being born in Canada, better self-reported health, and increased frequency of visits to a doctor. CONCLUSION: Despite criticisms of access to primary care, this study found that Ontario patients belonging to primary care practices have favourable impressions of their access. There were few statistically significant relationships between patient characteristics and access, and these relationships appeared to be weak.

Experiences of practice facilitators working on the Improved Delivery of Cardiovascular Care project: Retrospective case study.

OBJECTIVE: To examine the barriers to and facilitators of practice facilitation experienced by participants in the Improving Delivery of Cardiovascular Care (IDOCC) project. DESIGN: Case studies of practice facilitators' narrative reports. SETTING: Eastern Ontario. PARTICIPANTS: Primary care practices that participated in the IDOCC project. MAIN OUTCOME MEASURES: Cases were identified by calculating sum scores in order to determine practices' performance relative to their peers. Two case exemplars were selected that scored within ± 1 SD of the total mean score, and a qualitative analysis of practice facilitators' narrative reports was conducted using a 5-factor implementation framework to identify barriers and facilitators. Narratives were divided into 3 phases: planning, implementation, and sustainability. RESULTS: Barriers and facilitators fluctuated over the intervention's 3 phases. Site A reported more barriers (n = 47) than facilitators (n = 38), while site B reported a roughly equal number of barriers (n = 144) and facilitators (n = 136). In both sites, the most common barriers involved organizational and provider factors and the most common facilitators were associated with innovation and structural factors. CONCLUSION: Both practices encountered various barriers and facilitators throughout the IDOCC's 3 phases. The case studies reveal the complex interactions of these factors over time, and provide insight into the implementation of practice facilitation programs.

Exploring fetal fibronectin testing as a predictor of labour onset: In parturient women from isolated communities.

OBJECTIVE: To investigate whether the fetal fibronectin assay would be useful for determining if a woman was close to a term delivery. If effective, this test would allow parturient women to stay in their communities longer. DESIGN: This feasibility study used a prospective cohort design to examine the negative predictive value of the fetal fibronectin test at term. SETTING: Iqaluit, NU. PARTICIPANTS: A total of 30 parturient women from rural and isolated communities in Nunavut. INTERVENTION: Starting at 36 weeks' gestation, women were tested every 2 days, and after 39 weeks this increased to every day until labour. MAIN OUTCOME MEASURES: The negative predictive value of the fetal fibronectin test was assessed. RESULTS: Women were no more likely to give birth at 7 or more days after their last negative fetal fibronectin test result relative to their likelihood of giving birth at 6 or fewer days after their last negative test result. Hence, the presence of fetal fibronectin in cervical secretion did not predict term delivery. CONCLUSION: This project indicated that the fetal fibronectin test did not have adequate sensitivity or specificity as a diagnostic measure to predict a delay of labour at term.

Alignment of Canadian Primary Care With the Patient Medical Home Model: A QUALICO-PC Study.

PURPOSE: The patient medical home (PMH) model aims to improve patient satisfaction and health outcomes in Canada, but since its introduction in 2009, there has been no evaluation of the extent to which primary care conforms with PMH attributes. Our objective was to compare current primary care across Canada with the 10 goals of the PMH model. METHODS: A cross-sectional survey of primary care organization and delivery was conducted in Canadian provinces to evaluate the PMH-based attributes of primary care practices. Family physician and patient responses were mapped to the 10 goals of the PMH model. We used regression models to describe the provinces' success in meeting the goals, taking specific practice characteristics into account. We created a PMH composite score by weighting each goal equally for each practice and aggregating these by province. The PMH score is the sum of the values for each goal, which were scored from 0 to 1; a score of 10 indicates that all 10 goals of the PMH model were achieved. RESULTS: Seven hundred seventy-two primary care practices and 7,172 patients participated in the survey. The average national PMH score was 5.36 (range 4.75-6.23) of 10. Ontario was the only province to score significantly higher than Canada as a whole, whereas Québec, Newfoundland/Labrador, and New Brunswick/Prince Edward Island scored below the national average. There was little variation, however, among provinces in achieving the 10 PMH goals. CONCLUSIONS: Provincial PMH scores indicate considerable room for improvement if the PMH goals are to be fully implemented in Canada.

Regional variations in ambulatory care and incidence of cardiovascular events.

BACKGROUND: Variations in the prevalence of traditional cardiac risk factors only partially account for geographic variations in the incidence of cardiovascular disease. We examined the extent to which preventive ambulatory health care services contribute to geographic variations in cardiovascular event rates. METHODS: We conducted a cohort study involving 5.5 million patients aged 40 to 79 years in Ontario, Canada, with no hospital stays for cardiovascular disease as of January 2008, through linkage of multiple population-based health databases. The primary outcome was the occurrence of a major cardiovascular event (myocardial infarction, stroke or cardiovascular-related death) over the following 5 years. We compared patient demographics, cardiac risk factors and ambulatory health care services across the province's 14 health service regions, known as Local Health Integration Networks (LHINs), and evaluated the contribution of these variables to regional variations in cardiovascular event rates. RESULTS: Cardiovascular event rates across LHINs varied from 3.2 to 5.7 events per 1000 person-years. Compared with residents of high-rate LHINs, those of low-rate health regions received physician services more often (e.g., 4.2 v. 3.5 mean annual family physician visits, p value for LHIN-level trend = 0.01) and were screened for risk factors more often. Low-rate LHINs were also more likely to achieve treatment targets for hypercholes-terolemia (51.8% v. 49.6% of patients, p = 0.03) and controlled hypertension (67.4% v. 53.3%, p = 0.04). Differences in patient and health system factors accounted for 74.5% of the variation in events between LHINs, of which 15.5% was attributable to health system factors alone. INTERPRETATION: Preventive ambulatory health care services were provided more frequently in health regions with lower cardiovascular event rates. Health system interventions to improve equitable access to preventive care might improve cardiovascular outcomes.