Practice size, financial sharing and quality of care.

BACKGROUND: Although we are observing a general move towards larger primary care practices, surprisingly little is known about the influence of key components of practice organization on primary care. We aimed to determine the relationships between practice size, and revenue sharing agreements, and quality of care. METHODS: As part of a large cross sectional study, group practices were randomly selected from different primary care service delivery models in Ontario. Patient surveys and chart reviews were used to assess quality of care. Multilevel regressions controlled for patient, provider and practice characteristics. RESULTS: Positive statistically significant associations were found between the logarithm of group size and access, comprehensiveness, and disease prevention. Negative significant associations were found between logarithm group size and continuity. No differences were found for chronic disease management and health promotion. Practices that shared revenues were found to deliver superior health promotion compared to those who did not. Interacting group size with the presence of a revenue-sharing arrangement had a negative impact on health promotion. CONCLUSIONS: Despite the limitations of our study, our findings have provided preliminary evidence of the tradeoffs inherent with increasing practice size. Larger group size is associated with better access and comprehensiveness but worse continuity of care. Revenue sharing in group practices was associated with higher health promotion compared to sharing only common costs. Further work is required to better inform policy makers and practitioners as to whether the pattern revealed in larger practices mitigates any of the previously reported benefits of continuity of primary care. We found few benefits of revenue sharing--even then the effect of revenue sharing on health promotion seemed diminished in larger practices.

The efficacy of combined cryotherapy and compression compared with cryotherapy alone following anterior cruciate ligament reconstruction.

While cryotherapy has been shown to decrease postoperative pain after anterior cruciate ligament (ACL) reconstruction, less is known of the effects of combined cryotherapy and compression. The goal of this study was to compare subjective and objective patient outcomes following ACL reconstruction with combined compression and cryotherapy compared with traditional ice therapy alone. Patients undergoing ACL reconstruction were randomized to cryotherapy/compression device (group 1) or a standardized ice pack (group 2). Both groups were instructed to use the ice or cryotherapy/compression device three times per day and return to the clinic at 1, 2, and 6 weeks postoperatively. Patient-derived outcome measurements used in this study consisted of the visual analog scale (VAS), the Lysholm knee score, Short Form-36 (SF-36), and single assessment numerical evaluation (SANE). Circumferential measurements of the knee at three locations (1 cm proximal to patella, mid-patella, and 1 cm distal to patella) were also obtained as a measure of postoperative edema. Narcotic medication use was recorded by questionnaire. The primary outcome measure (VAS) was significantly different among groups in the preoperative measurement, despite similarities in group demographics. Baseline VAS for group 1 was 54.9 compared with group 2 at 35.6 (p = 0.01). By 6 weeks, this had lowered to 28.1 and 40.3, respectively, resulting in a significant 27-point decrease in mean VAS for group 1 (p < 0.0001). However, the small increase in VAS for group 2 was not significant (p = 0.34). No significant differences were noted for the Lysholm, SF-36, or SANE scores either between groups or time points. Furthermore, no significant differences were noted for any of the circumferential measurements either between groups or time points. Of all patients, 83% of group 1 discontinued narcotic use by 6 weeks, compared with only 28% of group 2 (p = 0.0008). The use of combined cryotherapy and compression in the postoperative period after ACL reconstruction results in improved, short-term pain relief and a greater likelihood of independence from narcotic use compared with cryotherapy alone.

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.

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.