The impact of leadership style in team-based primary care - staff satisfaction and motivation.

BACKGROUND: Leadership styles, beliefs, and behaviours are an important and critical component to the delivery of quality care in any primary care organisation. The health human resource crisis has resulted in greater investments in team-based care however some leaders may not have experience working in team-based settings. AIM: This study aimed to explore what leadership characteristics, styles and behaviours were most conducive to employee satisfaction, motivation, and delivery of care in a team-based primary care setting. DESIGN & SETTING: 21 Community Health Centre staff from six Community Health Centres across Ontario, Canada. METHOD: Thematic analysis of qualitative interviews with using a framework based on transformational leadership theory. RESULTS: Three themes emerged from our findings as having a significant impact on staff motivation, morale, delivery of care and client outcomes: transparent and open communication, opportunities to collaborate in decision-making, and staff recognition and appreciation. The results of our study indicate it is critical that leaders adopt leadership styles and approaches in which every team member is informed, heard, and appreciated. CONCLUSION: This study described the leadership styles and characteristics that lead to improved employee satisfaction, motivation and morale in a team-based primary care setting, and the impact this could and does have on quality and delivery of care. Future research is needed to better understand the impact of leadership in a variety of roles within a team-based environment, specifically in a multi-disciplinary setting.

Engaging community organizations for undergraduate medical education curriculum renewal.

As part of its social accountability mission, the University of Ottawa Faculty of Medicine invited community service learning (CSL) partner organizations to a guided, virtual conversation on April 12, 2021 to contribute to the future strategic directions for our curriculum. Representatives of 15 organizations participated and provided insights into how they perceive CSL students, the Faculty of Medicine, and the process of assessment. This workshop forged stronger bonds between the university and these community organizations and led to recommendations for their greater involvement going forward, an approach that could be considered by other Faculties of Medicine.

Dans le cadre de sa mission de responsabilité sociale, la Faculté de médecine de l'Université d'Ottawa a invité les organismes partenaires de l'apprentissage par le service communautaire (ASC) à contribuer aux futures orientations stratégiques de notre programme d'études par le biais d'une discussion virtuelle guidée, tenue le 12 avril 2021. Les représentants des 15 organismes qui y ont participé ont donné leur avis sur la façon dont ils perçoivent les étudiants en ASC, la Faculté de médecine et le processus d'évaluation. Cet atelier a permis de resserrer les liens entre l'université et ces organismes communautaires et a débouché sur des recommandations visant à renforcer leur participation à l'avenir, une approche qui pourrait être envisagée par d'autres facultés de médecine.

Social accountability in undergraduate medical education: A narrative review.

Background: Medical schools have been increasingly called upon to augment and prioritize their social accountability (SA). Approaches to increasing SA may include reorienting and focusing curricular activities on the priority health needs of the region that they serve. To inform the undergraduate medical education (UGME) curriculum renewal at our school, we examined how SA has been expressed in medical education across several countries and the impacts of SA activities on medical student experience and community-level outcomes. Methods: We conducted a narrative literature review using two electronic databases and searched for studies that reported on SA UGME activities implemented in Canada, Australia, New Zealand, the United States, and the United Kingdom. Studies were screened for inclusion based on predetermined eligibility criteria. Results: We included 40 studies for descriptive analysis and categorized UGME activities into five categories: (1) distributed medical education and community-specific placements/services (32; 80%), (2) community engagement and advocacy activities (23; 58%), (3) international elective preparation and experiences (8; 20%), (4) classroom-based learning of SA-related concepts (17; 43%), and (5) student engagement in SA UGME activities (6; 15%). We categorized impact into four main outcomes: student experience (21; 53%), student competencies (11; 28%), future career choice/practice setting (15; 38%), and community feedback (7; 18%). Student experience was most frequently examined, followed by future career choice/practice setting. Discussion: SA was primarily expressed in UGME activities through placement/service activities and most frequently assessed through student experiences. Student experiences of SA UGME activities have been reported to be largely positive, with benefits also reported for student competencies and influences on future career choice/practice setting. The expression of SA through community engagement in the development of curricular activities indicates a positive shift from social responsibility to SA, but a highly socially accountable curriculum would increasingly consider measures of community impact.

Using the quadruple aim to understand the impact of virtual delivery of care within Ontario community health centres: a qualitative study.

BACKGROUND: The onset of the COVID-19 pandemic and introduction of various restrictions resulted in drastic changes to 'traditional' primary healthcare service delivery modalities. AIM: To understand the impact of virtual care on healthcare system performance within the context of Ontario community health centres (CHCs). DESIGN & SETTING: Thematic analysis of qualitative interviews with 36 providers and 31 patients. METHOD: Semi-structured phone interviews were conducted in the autumn of 2020. Interviews were recorded, transcribed verbatim, and analysed thematically using the quadruple aim framework. RESULTS: The transition to virtual delivery of services has had both positive and negative impacts on care. Virtual care removed certain barriers to care such as access. However, patients and providers found that phone visits impacted quality of care owing to the inability to read body language and having to rely solely on patient descriptions. Video visits allowed for a similar experience to in-person visits but technical issues constrained this interaction. Depending on the service provided, some providers felt they were not providing the same quality of care. However, providers reported reductions in no-show rates and highlighted the efficiency of virtual appointments. Providers also found they were able to collaborate at a similar level before the pandemic and saw improvements in work-life balance. Overall, patients and providers alike preferred virtual visits with those known to them, and for less complex or transactional aspects of care. CONCLUSION: The study described positive and negative impacts on patient care, population health, health system costs, and provider experience. These results will be useful for primary care organisations in post-pandemic planning; however, future research is needed for a deeper exploration of the impact on quality of care specifically for more complex health concerns.

Virtual care in Ontario community health centres: a cross-sectional study to understand changes in care delivery.

BACKGROUND: There has been a large-scale adoption of virtual delivery of primary care as a result of the COVID-19 pandemic. AIM: In this descriptive study, an equity lens is used to explore the impact of transitioning to greater use of virtual care in community health centres (CHCs) across Ontario, Canada. DESIGN & SETTING: A cross-sectional survey was administered and electronic medical record (EMR) data were extracted from 36 CHCs. METHOD: The survey captured CHCs' experiences with the increased adoption of virtual care. A longitudinal analysis of the EMR data was conducted to evaluate changes in health service delivery. EMR data were extracted monthly for a period of time before the pandemic (April 2019-February 2020) and during (April 2020-February 2021). RESULTS: In comparison with the pre-pandemic period, CHCs experienced a moderate decline in visits made (11%), patients seen (9%), issues addressed (9%), and services provided (15%). During the pandemic period, an average of 54% of visits were conducted virtually, with telephone as the leading virtual modality (96%). Drops in service types ranged from 28%-82%. The distribution of virtual modalities varied according to the provider type. Access to in-person and virtual care did not vary across patient characteristics. CONCLUSION: The results demonstrate a large shift towards virtual delivery while maintaining in-person care. No meaningful differences were found in virtual versus in-person care related to patient characteristics or rurality of centres. Future studies are needed to explore how to best select the appropriate modality for patients and service types.

Prevalence of chronic conditions in Syrian refugees to Ottawa.

OBJECTIVE: To study the prevalence of chronic conditions (ie, anemia, glucose-6-phosphate dehydrogenase [G6PD] deficiency, hepatitis B virus (HBV) and hepatitis C virus (HCV) infection, and tobacco use) in Syrian refugees. DESIGN: Cross-sectional study. Four primary care health clinics received Syrian refugees from December 2015 to April 2016, and each followed a standard protocol for refugee health assessments. SETTING: Ottawa, Ont. PARTICIPANTS: Arabic-speaking Syrian refugees were invited for early primary care health assessment. Most participants arrived in Ottawa from temporary refugee encampments in Lebanon and Jordan between December 2015 and April 2016. MAIN OUTCOME MEASURES: Following a protocol, family physicians and nurse practitioners systematically documented age, sex, education, hemoglobin level, G6PD status, HBV and HCV infection, and tobacco use. RESULTS: The study included 669 of the 916 government-assisted refugees, which represents most of the 1087 Syrian refugees to Ottawa: 373 male and 296 female participants. Overall, 28.5% of women and adolescent girls had anemia, and 2.0% of men had G6PD deficiency. The seroprevalence of HBV and HCV infection in the overall population was 0.9% and 0.7%, respectively. Tobacco use was reported in 60.3% of men and 11.7% of women. Overall, alcohol use (3.7%) and other substance use (0.5%) were uncommon. CONCLUSION: Anemia was a common health problem in women of reproductive age, while the prevalence of chronic HBV and HCV infection was lower than the prevalence in the general Canadian population. Results showed substantial sex differences in tobacco use, with Syrian men using it at a rate much higher than Canadian men and Syrian women. The health assessment did not document chronic conditions affecting dental or mental health.

Delivering primary health care as envisioned: A model of health and well-being guiding community-governed primary care organizations.

PURPOSE: For over 40 years, Canadian and international bodies have endorsed comprehensive primary health care (PHC), yet very little work has been done to describe how services and programs are delivered within these organizations. Because health equity is now of greater interest to policy makers and the public, it is important to describe an evidence-informed framework for the delivery of integrated and equitable PHC. The purpose of this paper is to describe the development of a "Model of Health and Well-being" (MHWB) that provides a roadmap to the delivery of PHC in a successful network of community-governed PHC organizations in Ontario, Canada. DESIGN/METHODOLOGY/APPROACH: The MHWB was developed through an iterative process that involved members of community-governed PHC organizations in Ontario and key stakeholders. This included literature review and consultation to ensure that the model was evidence informed and reflected actual practice. FINDINGS: The MHWB has three guiding principles: highest quality health and well-being for people and communities; health equity and social justice; and community vitality and belonging. In addition, there are eight attributes that describe how services are provided. There is a reasonable evidence base underpinning the all principles and attributes. ORIGINALITY/VALUE: As comprehensive, equitable PHC organizations become increasingly recognized as critical parts of the health care system, it is important to have a means to describe their approach to care and the values that drive their care. The MHWB provides a blueprint for comprehensive PHC as delivered by over 100 Community Governed Primary Health Care (CGPHC) organizations in Ontario. All CGPHC organizations have endorsed, adopted and operationalized this model as a guide for optimum care delivery.

Cardiovascular preventive care for patients with serious mental illness.

OBJECTIVE: To determine whether patients with serious mental illness (SMI) are receiving preventive care for cardiovascular disease at the same rate as those without SMI in an interprofessional practice with a mandate to care for persons with barriers to access to the health care system. DESIGN: Quality improvement exercise using a case-matched retrospective chart review. SETTING: Somerset West Community Health Centre in downtown Ottawa, Ont. PARTICIPANTS: All patients with SMI were adult, current primary care patients from the Somerset West Community Health Centre with a recorded diagnosis of SMI (bipolar affective disorder, schizophrenia, or other psychosis) during the 2-year period from June 1, 2013, to May 31, 2015. Two control patients (current primary care patients without SMI and matched for age and sex) were randomly chosen for each patient with SMI. MAIN OUTCOME MEASURES: They had at least 1 record in their electronic chart during the 2-year study period of measurement of blood pressure, weight, body mass index, smoking status, lipid screening results, or diabetes screening results. Prevention score was calculated as the number of preventive tests documented out of the possible 6. Secondary measures included age, sex, comorbidities (diabetes, hypertension, or hyperlipidemia), mental illness diagnosis, involvement of a psychiatrist, and involvement of a mental health case worker. RESULTS: Patients with SMI had higher rates of diabetes, hypertension, and dyslipidemia. Screening rates for the 6 outcome measures were very similar between patients with and without SMI. Patients with SMI who were under the care of a psychiatrist or who had a case worker had more complete screening results than those who had neither provider. CONCLUSION: As expected, patients with SMI had higher rates of metabolic comorbidities than control patients had. Screening rates for cardiovascular risk factors were similar in the 2 groups. Involvement of mental health case workers and psychiatrists in the patients' care might be linked to more complete preventive screening.

Staff perceptions of community health centre team function in Ontario.

OBJECTIVE: To examine perceptions of different staff groups about team functioning in mature, community-governed, interprofessional primary health care practices. DESIGN: Cross-sectional online survey. SETTING: The 75 community health centres (CHCs) in Ontario at the time of the study, which have cared for people with barriers to access to traditional health services in community-governed, interprofessional settings, providing medical, social, and community services since the 1970s. PARTICIPANTS: Managers and staff of primary care teams in the CHCs. MAIN OUTCOME MEASURES: Scores on the short version of the Team Climate Inventory (with subscales addressing vision, task orientation, support for innovation, and participative safety), the Organizational Justice Scale (with subscales addressing procedural justice and interactional justice), and the Organizational Citizenship Behavior Scale, stratified by staff group (clinical manager, FP, nurse practitioner [NP], registered nurse, medical secretary, social worker, allied health provider, counselor, outreach worker, and administrative assistant). RESULTS: A total of 674 staff members in 58 of 75 (77%) CHCs completed surveys. All staff groups generally reported positive perceptions of team function. The procedural justice subscale showed the greatest variation between groups. Family physicians and NPs rated procedural justice much lower than nurses and administrators did. CONCLUSION: This study provides a unique view of the perceptions of different groups of staff in a long-standing interprofessional practice model. Future research is needed to understand why FPs and NPs perceive procedural justice more negatively than other team members do, and whether such perceptions affect outcomes such as staff turnover and health outcomes for patients.

Patient-reported access to primary care in Ontario: effect of organizational characteristics.

OBJECTIVE: To describe patient-reported access to primary health care across 4 organizational models of primary care in Ontario, and to explore how access is associated with patient, provider, and practice characteristics. DESIGN: Cross-sectional survey. SETTING: One hundred thirty-seven randomly selected primary care practices in Ontario using 1 of 4 delivery models (fee for service, established capitation, reformed capitation, and community health centres). PARTICIPANTS: Patients included were at least 18 years of age, were not severely ill or cognitively impaired, were not known to the survey administrator, had consenting providers at 1 of the participating primary care practices, and were able to communicate in English or French either directly or through a translator. MAIN OUTCOME MEASURES: Patient-reported access was measured by a 4-item scale derived from the previously validated adult version of the Primary Care Assessment Tool. Questions were asked about physician availability during and outside of regular office hours and access to health information via telephone. Responses to the scale were normalized, with higher scores reflecting greater patient-reported access. Linear regressions were used to identify characteristics independently associated with access to care. RESULTS: Established capitation model practices had the highest patient-reported access, although the difference in scores between models was small. Our multilevel regression model identified several patient factors that were significantly (P = .05) associated with higher patient-reported access, including older age, female sex, good-to-excellent self-reported health, less mental health disability, and not working. Provider experience (measured as years since graduation) was the only provider or practice characteristic independently associated with improved patient-reported access. CONCLUSION: This study adds to what is known about access to primary care. The study found that established capitation models outperformed all the other organizational models, including reformed capitation models, independent of provider and practice variables save provider experience. This suggests that the capitation models might provide better access to care and that it might take time to realize the benefits of organizational reforms.

Roles of nurse practitioners and family physicians in community health centres.

OBJECTIVE: To describe the models of practice used by nurse practitioners (NPs) and FPs in community health centres (CHCs), and to examine the roles of NPs and FPs in these models. DESIGN: Cross-sectional study using an organizational survey completed by managers of the CHC sites, as well as administrative data on patient sociodemographic characteristics and encounter activities. SETTING: A total of 21 CHCs (13 main sites and 8 satellite sites) operating in eastern Ontario during the period from December 1, 2006, to November 30, 2008. PARTICIPANTS: A total of 44 849 patients, 53 full-time equivalent FPs, and 41 full-time equivalent NPs. MAIN OUTCOME MEASURES: Family physicians' and NPs' models of practice, the sociodemographic characteristics and medical profiles of patients who were treated in each model of practice, and FPs' and NPs' use of time. RESULTS: Patients were attributed to 1 of 3 models of practice in CHCs based on the proportion of visits to FPs and NPs: FP care (53% of patients), NP care (29%), and shared care (18%). Patients who received care in the NP model of practice were younger and more likely to be female, be homeless, and not have postsecondary education.Patients who received care in the FP model of practice had more complex medical conditions (cardiovascular disease, mental illness, lung disease, and diabetes) and more annual visits. Patients who received care in the shared care model had intermediate profiles. Nurse practitioners performed more off-site care and walk-in visits. Family physicians and NPs spent a similar proportion of time performing various duties such as direct clinical care and administration tasks. CONCLUSION: Although NPs mainly cared for their own patient panels (in the NP care model), they did share some patients with FPs and provide some care to patients under the FP model of practice. Patients who were cared for by FPs and NPs had quite different characteristics.

Patient poverty and workload in primary care: study of prescription drug benefit recipients in community health centres.

OBJECTIVE: To determine if patient poverty is associated with increased workload for primary care providers (PCPs). DESIGN: Linkage of administrative data identifying patient poverty and comorbidity with survey data about the organizational structure of community health centres (CHCs). SETTING: Ontario's 73 CHCs. PARTICIPANTS: A total of 64 CHC sites (N=63 included in the analysis). MAIN OUTCOME MEASURES: Patient poverty was determined in 2 different ways: based on receipt of Ontario Drug Benefits (identifying recipients of welfare, provincial disability support, and low-income seniors' benefits) or residence in low-income neighbourhoods. Patient comorbidities were determined through administrative diagnostic data from the CHCs and the Institute for Clinical Evaluative Sciences. Primary care workload was determined by examining PCP panel size (the number of patients cared for by a full-time-equivalent PCP during a 2-year interval). RESULTS: The CHCs with higher proportions of poor patients had smaller panel sizes. The smaller panel sizes were entirely explained by the medical comorbidity profile of the poor patients. CONCLUSION: Poor patients generate a higher workload for PCPs in CHCs; however, this is principally because they are sicker than higher-income patients are. Further information is required about the spectrum of services used by poor patients in CHCs.

Estimating patient demographic profiles from practice location.

OBJECTIVE: To test the accuracy of imputing a practice population's average socioeconomic characteristics (such as average education levels and average income) using census data centred on the location of the practice. DESIGN: Comparison of census data with survey data collected in primary care offices. SETTING: Ontario. PARTICIPANTS: A cross-sectional sample of patients from 116 urban practices. MAIN OUTCOME MEASURES: Patient data were compared with census data at different levels of aggregation using mean absolute relative error (ARE), median ARE, and Spearman rank correlations. RESULTS: A total of 4413 patient surveys were collected. Differences between patient profiles and census data were large. Most mean AREs were clustered between 0.70 and 0.80, and median AREs were as high as 1.67. Correlations were low (ρ = 0.02) to moderate (ρ = 0.48). These results held across both levels of aggregation. CONCLUSION: The use of imputation techniques based on practice location is inadvisable, given the large differences that were observed.

How many patients should a family physician have? Factors to consider in answering a deceptively simple question.

The ratio of patients to physicians has long been used as a tool for measuring and planning healthcare resources in Canada. Some current changes in primary care, such as enrolment of patients with physicians, make this ratio easier to calculate, while others, such as changing practice structure, make it more complex to interpret. Based on information gleaned from a review of the literature, we argue that before panel size can be used as an accountability measure for individual physicians or practices in primary care, we must understand its relationship to quality and outcomes at individual and population levels, as well as the contextual factors that affect it.

Le ratio patients­médecins a longtemps été utilisé comme outil pour les mesures et la planification des ressources humaines de la santé au Canada. Certains changements actuels dans les soins primaires, tels que l'inscription des patients auprès des médecins, facilitent le calcul de ce ratio, tandis que d'autres, tels que les changements dans la structure de la pratique, les rendent plus complexes à interpréter. Selon l'information recueillie par une revue de la littérature, nous stipulons qu'avant d'utiliser le nombre de patients comme mesure de comptabilisation pour les médecins ou les établissements de soins primaires, il faut comprendre la relation entre cette mesure et la qualité ou les résultats aux niveaux individuel et populationnel, de même que les facteurs contextuels qui l'affectent.

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.

Community orientation in primary care practices: Results from the Comparison of Models of Primary Health Care in Ontario Study.

OBJECTIVE: To determine which of 4 organizational models of primary care in Ontario were more community oriented. DESIGN: Cross-sectional investigation using practice and provider surveys derived from the Primary Care Assessment Tool, with nested qualitative case studies (2 practices per model). SETTING: Thirty-five fee-for-service family practices (including family health groups), 32 health service organizations, 35 family health networks, and 35 community health centres (CHCs) in Ontario. PARTICIPANTS: A total of 137 practices and 363 providers. MAIN OUTCOME MEASURES: Community orientation (CO) was assessed from the perspectives of the practices and the providers working in them. Practice CO scores reflect activities that practices use to reach out to their communities, assess the needs of their communities, and monitor or evaluate the effectiveness of their programs and services. The self-rated provider CO score reflects providers' participation in home visits and their perceptions of their own degree of CO. RESULTS: At the practice level, CHCs had significantly higher CO scores than the other models did (P < .001 for most differences); in fact, the other models rarely reported meaningful levels of CO. Self-rated provider CO scores were also higher in CHCs, but were present in other models as well. CONCLUSION: Primary care providers in Ontario give themselves high ratings for CO; however, indicators of CO activity at the practice level were found to a significantly higher degree in CHCs than in the other models.

Managing chronic disease in ontario primary care: the impact of organizational factors.

PURPOSE: New approaches to chronic disease management emphasize the need to improve the delivery of primary care services to meet the needs of chronically ill patients. This study (1) assessed whether chronic disease management differed among 4 models of primary health care delivery and (2) identified which practice organizational factors were independently associated with high-quality care. METHODS: We undertook a cross-sectional survey with nested qualitative case studies (2 practices per model) in 137 randomly selected primary care practices from 4 delivery models in Ontario Canada: fee for service, capitation, blended payment, and community health centers (CHCs). Practice and clinician surveys were based on the Primary Care Assessment Tool. A chart audit assessed evidence-based care delivery for patients with diabetes, congestive heart failure, and coronary artery disease. Intermediate outcomes were calculated for patients with diabetes and hypertension. Multiple linear regression identified those organizational factors independently associated with chronic disease management. RESULTS: Chronic disease management was superior in CHCs. Clinicians in CHCs found it easier than those in the other models to promote high-quality care through longer consultations and interprofessional collaboration. Across the whole sample and independent of model, high-quality chronic disease management was associated with the presence of a nurse-practitioner. It was also associated with lower patient-family physician ratios and when practices had 4 or fewer full-time-equivalent family physicians. CONCLUSIONS: The study adds to the literature supporting the value of nurse-practitioners within primary care teams and validates the contributions of Ontario's CHCs. Our observation that quality of care decreased in larger, busier practices suggests that moves toward larger practices and greater patient-physician ratios may have unanticipated negative effects on processes of care quality.

Health promotion activity in primary care: performance of models and associated factors.

BACKGROUND: Lifestyle behaviours have significant health and economic consequences. Primary care providers play an important role in promoting healthy behaviours. We compared the performance of primary care models in delivering health promotion and identified practice factors associated with its delivery. METHODS: Surveys were conducted in 137 randomly selected primary care practices in 4 primary care models in Ontario, Canada: 35 community health centres, 35 fee-for-service practices, 35 family health networks and 32 health service organizations. A total of 4861 adult patients who were visiting their family practice participated in the study. Qualitative nested case studies were also conducted at 2 practices per model. A 7-item question was used to evaluate health promotion. The main outcome was whether at least 1 of the 7 health promotion items was discussed at the survey visit. Multilevel logistic regressions were used to compare the models and determine performance-related practice factors. RESULTS: The rate of health promotion was significantly higher in community health centres than in the other models (the unadjusted difference ranged between 8% and 13%). This finding persisted after controlling for patient and family physician profiles. Factors independently positively associated with health promotion were as follows: reason for visit (for a general checkup: adjusted odds ratio [AOR] 3.34, 95% confidence interval [CI] 2.81-3.97; for care for a chronic disease: AOR 2.03, 95% CI 1.69-2.43), patients having and seeing their own provider (for those not: AOR 0.58, 95% CI 0.43-0.78), number of nurses in the practice (AOR 1.07, 95% CI 1.02-1.12), percentage of female family physicians (AOR 1.38, 95% CI 1.15-1.66), smaller physician panel size (AOR 0.92, 95% CI 0.85-1.01) and longer booking interval (AOR 1.03, 95% CI 1.01-1.04). Providers in interdisciplinary practices viewed health promotion as an integral part of primary care, whereas other providers emphasized the role of relational continuity in effective health promotion. CONCLUSION: We have identified several attributes associated with health promotion delivery. These results may assist practice managers and policy-makers in modifying practice attributes to improve health promotion in primary care.