Primary care bonus payments and patient-reported access in urban Ontario: a cross-sectional study.

BACKGROUND: Rurality strongly correlates with higher pay-for-performance access bonuses, despite higher emergency department use and fewer primary care services than in urban settings. We sought to evaluate the relation between patient-reported access to primary care and access bonus payments in urban settings. METHODS: We conducted a cross-sectional, secondary data analysis using Ontario survey and health administrative data from 2013 to 2017. We used administrative data to calculate annual access bonuses for eligible urban family physicians. We linked this payment data to adult (≥ 16 yr) patient data from the Health Care Experiences Survey to examine the relation between access bonus achievement (in quintiles of the proportion of bonus achieved, from lowest [Q1, reference category] to highest [Q5]) and 4 patient-reported access outcomes. The average survey response rate to the patient survey during the study period was 51%. We stratified urban geography into large, medium and small settings. In a multilevel regression model, we adjusted for patient-, physician- and practice-level covariates. We tested linear trends, adjusted for clustering, for each outcome. RESULTS: We linked 18 893 respondents to 3940 physicians in 414 bonus-eligible practices. Physicians in small urban settings earned the highest proportion of their maximum potential access bonuses. Access bonus achievement was positively associated with telephone access (Q2 odds ratio [OR] 1.18, 95% confidence interval [CI] 0.98-1.42; Q3 OR 1.34, 95% CI 1.10-1.63; Q4 OR 1.46, 95% CI 1.19-1.79; Q5 OR 1.87, 95% CI 1.50-2.33), after hours access (Q2 OR 1.26, 95% CI 1.09-1.47; Q3 OR 1.46, 95% CI 1.23-1.74; Q4 OR 1.77, 95% CI 1.46-2.15; Q5 OR 1.88, 95% CI 1.52-2.32), wait time for care (Q2 OR 1.01, 95% CI 0.85-1.20; Q3 OR 1.17, 95% CI 0.97-1.41; Q4 OR 1.27, 95% CI 1.05-1.55; Q5 OR 1.63, 95% CI 1.32-2.00) and timeliness (Q2 OR 1.29, 95% CI 0.98-1.69; Q3 OR 1.29, 95% CI 0.94-1.77; Q4 OR 1.58, 95% CI 1.16-2.13; Q5 OR 1.98, 95% CI 1.38-2.82). When stratified by geography, we observed several of these associations in large urban settings, but not in small urban settings. Trend tests were statistically significant for all 4 outcomes. INTERPRETATION: Although the access bonus correlated with access in larger urban settings, it did not in smaller settings, aligning with previous research questioning its utility in smaller geographies. The access bonus may benefit from a redesign that considers geography and patient experience.

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.

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.

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.

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.

Computer use in primary care practices in Canada.

OBJECTIVE: To examine the use of computers in primary care practices. DESIGN: The international Quality and Cost of Primary Care study was conducted in Canada in 2013 and 2014 using a descriptive cross-sectional survey method to collect data from practices across Canada. Participating practices filled out several surveys, one of them being the Family Physician Survey, from which this study collected its data. SETTING: All 10 Canadian provinces. PARTICIPANTS: A total of 788 family physicians. MAIN OUTCOME MEASURES: A computer use scale measured the extent to which family physicians integrated computers into their practices, with higher scores indicating a greater integration of computer use in practice. Analyses included t tests and 2 tests comparing new and traditional models of primary care on measures of computer use and electronic health record (EHR) use, as well as descriptive statistics. RESULTS: Nearly all (97.5%) physicians reported using a computer in their practices, with moderately high computer use scale scores (mean [SD] score of 5.97 [2.96] out of 9), and many (65.7%) reported using EHRs. Physicians with practices operating under new models of primary care reported incorporating computers into their practices to a greater extent (mean [SD] score of 6.55 [2.64]) than physicians operating under traditional models did (mean [SD] score of 5.33 [3.15]; t726.60 = 5.84; P < .001; Cohen d = 0.42, 95% CI 0.808 to 1.627) and were more likely to report using EHRs (73.8% vs 56.7%; [Formula: see text]; P < .001; odds ratio = 2.15). Overall, there was a statistically significant variability in computer use across provinces. CONCLUSION: Most family physicians in Canada have incorporated computers into their practices for administrative and scholarly activities; however, EHRs have not been adopted consistently across the country. Physicians with practices operating under the new, more collaborative models of primary care use computers more comprehensively and are more likely to use EHRs than those in practices operating under traditional models of primary care.

Do new and traditional models of primary care differ with regard to access?: Canadian QUALICOPC study.

OBJECTIVE: To examine access to primary care in new and traditional models using 2 dimensions of the concept of patient-centred access. DESIGN: An international survey examining the quality and costs of primary health care (the QUALICOPC study) was conducted in 2013 in Canada. This study adopted a descriptive cross-sectional survey method using data from practices across Canada. Each participating practice filled out the Family Physician Survey and the Practice Survey, and patients in each participating practice were asked to complete the Patient Experiences Survey. SETTING: All 10 Canadian provinces. PARTICIPANTS: A total of 759 practices and 7172 patients. MAIN OUTCOME MEASURES: Independent t tests were conducted to examine differences between new and traditional models of care in terms of availability and accommodation, and affordability of care. RESULTS: Of the 759 practices, 407 were identified as having new models of care and 352 were identified as traditional. New models of care were distinct with respect to payment structure, opening hours, and having an interdisciplinary work force. Most participating practices were from large cities or suburban areas. There were few differences between new and traditional models of care regarding accessibility and accommodation in primary care. Patients under new models of care reported easier access to other physicians in the same practice, while patients from traditional models reported seeing their regular family physicians more frequently. There was no difference between the new and traditional models of care with regard to affordability of primary care. Patients attending clinics with new models of care reported that their physicians were more involved with them as a whole person than patients attending clinics based on traditional models did. CONCLUSION: Primary care access issues do not differ strongly between traditional and new models of care; however, patients in the new models of care believed that their physicians were more involved with them as people.

The team climate inventory as a measure of primary care teams' processes: validation of the French version.

PURPOSE: Evaluate the psychometric properties of the French version of the short 19-item Team Climate Inventory (TCI) and explore the contributions of individual and organizational characteristics to perceived team effectiveness. METHOD: The TCI was completed by 471 of the 618 (76.2%) healthcare professionals and administrative staff working in a random sample of 37 primary care practices in the province of Quebec. RESULTS: Exploratory factor analysis confirmed the original four-factor model. Cronbach's alphas were excellent (from 0.88 to 0.93). Latent class analysis revealed three-class response structure. Respondents in practices with professional governance had a higher probability of belonging to the "High TCI" class than did practices with community governance (36.7% vs. 19.1%). Administrative staff tended to fall into the "Suboptimal TCI" class more frequently than did physicians (36.5% vs. 19.0%). CONCLUSION: Results confirm the validity of our French version of the short TCI. The association between professional governance and better team climate merits further exploration.

Primary care quality improvement from a practice facilitator's perspective.

BACKGROUND: Practice facilitation has proven to be effective at improving care delivery. Practice facilitators are healthcare professionals who work with and support other healthcare providers. To the best of our knowledge, very few studies have explored the perspective of facilitators. The objective of this study was to gain insight into the barriers that facilitators face during the facilitation process and to identify approaches used to overcome these barriers to help practices move towards positive change. METHODS: We conducted semi-structured interviews with four practice facilitators who worked with 84 primary care practices in Eastern Ontario, Canada over a period of five years (2007-2012). The transcripts were analyzed independently by three members of the research team using an open coding technique. A qualitative data analysis using immersion/crystallization technique was applied to interpret the interview transcripts. RESULTS: Common barriers identified by the facilitators included accessibility to the practice (e.g., difficulty scheduling meetings, short meetings), organizational behaviour (team organization, team conflicts, etc.), challenges with practice engagement (e.g., lack of interest, lack of trust), resistance to change, and competing priorities. To help practices move towards positive change the facilitators had to tailor their approach, integrate themselves, be persistent with practices, and exhibit flexibility. CONCLUSIONS: The consensus on redesigning and transforming primary care in North America and around the world is rapidly growing. Practice facilitation has been pivotal in materializing the transformation in the way primary care practices deliver care. This study provides an exclusive insight into facilitator approaches which will assist the design and implementation of small- and large-scale facilitation interventions.

The cost of integrating a physical activity counselor in the primary health care team.

OBJECTIVE: This article assesses direct costs of integrating a physical activity counselor (PAC) into primary health care teams to improve physical activity levels of inactive patients. METHODS: A monthly cost analysis was conducted using data from 120 inactive patients, aged 18 to 69 years, who were recruited from a community-based family medicine practice. Relevant cost items for the intensive counseling group included (1) office expenses; (2) equipment purchases; (3) operating costs; (4) costs of training the PAC; and (5) labor costs. Physical and human capital were amortized over a 5-year horizon at a discount rate of 5%. RESULTS: Integrating a PAC into the primary health care team incurred an estimated one-time cost of CA$91.43 per participant per month. Results were very sensitive to the number of patients counseled. CONCLUSIONS: The costs associated with the intervention are lower than many other intervention studies attempting to improve population physical activity levels. Demonstrating this competitive cost base should encourage additional research to assess the effectiveness of integrating a PAC into primary health care teams to promote active living among patients who do not meet recommended physical activity levels.

Impact of remuneration and organizational factors on completing preventive manoeuvres in primary care practices.

BACKGROUND: Several jurisdictions attempting to reform primary care have focused on changes in physician remuneration. The goals of this study were to compare the delivery of preventive services by practices in four primary care funding models and to identify organizational factors associated with superior preventive care. METHODS: In a cross-sectional study, we included 137 primary care practices in the province of Ontario (35 fee-for-service practices, 35 with salaried physicians [community health centres], 35 practices in the new capitation model [family health networks] and 32 practices in the established capitation model [health services organizations]). We surveyed 288 family physicians. We reviewed 4108 randomly selected patient charts and assigned prevention scores based on the proportion of eligible preventive manoeuvres delivered for each patient. RESULTS: A total of 3284 patients were eligible for at least one of six preventive manoeuvres. After adjusting for patient profile and contextual factors, we found that, compared with prevention scores in practices in the new capitation model, scores were significantly lower in fee-for-service practices (ß estimate for effect on prevention score = -6.3, 95% confidence interval [CI] -11.9 to -0.6) and practices in the established capitation model (ß = -9.1, 95% CI -14.9 to -3.3) but not for those with salaried remuneration (ß = -0.8, 95% CI -6.5 to 4.8). After accounting for physician characteristics and organizational structure, the type of funding model was no longer a statistically significant factor. Compared with reference practices, those with at least one female family physician (ß = 8.0, 95% CI 4.2 to 11.8), a panel size of fewer than 1600 patients per full-time equivalent family physician (ß = 6.8, 95% CI 3.1 to 10.6) and an electronic reminder system (ß = 4.6, 95% CI 0.4 to 8.7) had superior prevention scores. The effect of these three factors was largely but not always consistent across the funding models; it was largely consistent across the preventive manoeuvres. INTERPRETATION: No funding model was clearly associated with superior preventive care. Factors related to physician characteristics and practice structure were stronger predictors of performance. Practices with one or more female physicians, a smaller patient load and an electronic reminder system had superior prevention scores. Our findings raise questions about reform initiatives aimed at increasing patient numbers, but they support the adoption of information technology.

Interdisciplinary physical activity counseling in primary care: a qualitative inquiry of the patient experience.

The Physical Activity Counseling randomized controlled trial integrated a physical activity (PA) counselor into a primary care practice to provide intensive counseling to sedentary patients following brief counseling from their regular health care provider. This article presents the voices of 15 patients, who through a series of 3 interviews, described their experience with this 3-month combined provider PA counseling intervention. Patient satisfaction was a dominant emergent theme, and the patients were particularly positive about the quality of care and educational support for lifestyle change. They favored the tailored approach and felt the strategies for overcoming PA barriers were helpful.

Home-based intermediate care program vs hospitalization: Cost comparison study.

OBJECTIVE: To explore whether a home-based intermediate care program in a large Canadian city lowers the cost of care and to look at whether such home-based programs could be a solution to the increasing demands on Canadian hospitals. DESIGN: Single-arm study with historical controls. SETTING: Department of Family Medicine at the Ottawa Hospital (Civic campus) in Ontario. PARTICIPANTS: Patients requiring hospitalization for acute care. Participants were matched with historical controls based on case-mix, most responsible diagnosis, and level of complexity. INTERVENTIONS: Placement in the home-based intermediate care program. Daily home visits from the nurse practitioner and 24-hour access to care by telephone. MAIN OUTCOME MEASURES: Multivariate regression models were used to estimate the effect of the program on 5 outcomes: length of stay in hospital, cost of care substituted for hospitalization (Canadian dollars), readmission for a related diagnosis, readmission for any diagnosis, and costs incurred by community home-care services for patients following discharge from hospital. RESULTS: The outcomes of 43 hospital admissions were matched with those of 363 controls. Patients enrolled in the program stayed longer in hospital (coefficient 3.3 days, P < .001), used more community care services following discharge (coefficient $729, P = .007), and were more likely to be readmitted to hospital within 3 months of discharge (coefficient 17%, P = .012) than patients treated in hospital. Total substituted costs of home-based care were not significantly different from the costs of hospitalization (coefficient -$501, P = .11). CONCLUSION: While estimated cost savings were not statistically significant, the limitations of our study suggest that we underestimated these savings. In particular, the economic inefficiencies of a small immature program and the inability to control for certain factors when selecting historical controls affected our results. Further research is needed to determine the economic effect of mature home-based programs.

Patient, informal caregiver and care provider acceptance of a hospital in the home program in Ontario, Canada.

BACKGROUND: Hospital in the home programs have been implemented in several countries and have been shown to be safe substitutions (alternatives) to in-patient hospitalization. These programs may offer a solution to the increasing demands made on tertiary care facilities and to surge capacity. We investigated the acceptance of this type of care provision with nurse practitioners as the designated principal home care providers in a family medicine program in a large Canadian urban setting. METHODS: Patients requiring hospitalization to the family medicine service ward, for any diagnosis, who met selection criteria, were invited to enter the hospital in the home program as an alternative to admission. Participants in the hospital in the home program, their caregivers, and the physicians responsible for their care were surveyed about their perceptions of the program. Nurse practitioners, who provided care, were surveyed and interviewed. RESULTS: Ten percent (104) of admissions to the ward were screened, and 37 patients participated in 44 home hospital admissions. Twenty nine patient, 17 caregiver and 38 provider surveys were completed. Most patients (88%-100%) and caregivers (92%-100%) reported high satisfaction levels with various aspects of health service delivery. However, a significant proportion in both groups stated that they would select to be treated in-hospital should the need arise again. This was usually due to fears about the safety of the program. Physicians (98%-100%) and nurse practitioners also rated the program highly. The program had virtually no negative impact on the physician workload. However nurse practitioners felt that the program did not utilize their full expertise. CONCLUSION: Provision of hospital level care in the home is well received by patients, their caregivers and health care providers. As a new program, investment in patient education about program safety may be necessary to ensure its long term success. A small proportion of hospital admissions were screened for this program. Appropriate dissemination of program information to family physicians should help buy-in and participation. Nurse practitioners' skills may not be optimally utilized in this setting.

Primary care (PC) and primary health care (PHC). What is the difference?

Primary Care and Primary Health Care are very similar terms which are often employed interchangeably, but which are also used to denote quite different concepts. Much time and energy is spent discussing which term is the appropriate one for a particular application. There is a growing recognition internationally that the two terms describe two quite distinct entities. Recent Canadian uses of the two terms are, for the most part, consistent with the international uses. Primary Care, the shorter term, describes a narrower concept of "family doctor-type" services delivered to individuals. Primary Health Care is a broader term which derives from core principles articulated by the World Health Organization and which describes an approach to health policy and service provision that includes both services delivered to individuals (Primary Care services) and population-level "public health-type" functions.