Validation of 2 new measures of continuity of care based on year-to-year follow-up with known providers of health care.

PURPOSE: In a primary care context favoring group practices, we assessed the validity of 2 new continuity measures (both versions of known provider continuity, KPC) that capture the concentration of care over time from multiple physicians (multiple provider continuity, KPC-MP) or from the physician seen most often (personal provider continuity, KPC-PP). METHODS: Patients with diabetes or cardiovascular disease (N = 765) were approached in the waiting rooms of 28 primary care clinics in 3 regions of the province of Quebec, Canada; answered a survey questionnaire measuring relational continuity, interpersonal communication, coordination within the clinic, coordination with specialists, and overall coordination; and gave permission for their medical records to be reviewed and their medical services utilization data for the previous 2 years to be accessed to measure KPC. Using generalized linear mixed models, we assessed the association between KPC and the patients' responses. RESULTS: Among the 5 different patient-reported measures or their combination, KPC-MP was significantly related with overall coordination of care: for high continuity, the odds ratio (OR) = 2.02 (95% CI, 1.33-3.07), and for moderate continuity, OR = 1.61 (95% CI, 1.06-2.46). KPC-MP was also related with the combined continuity score: for high continuity, OR = 1.52 (95% CI, 1.11-2.09), and for moderate continuity, OR = 1.48 (95% CI, 1.10-2.00). KPC-PP was not significantly associated with any of the survey measures. CONCLUSIONS: The KPC-MP measure, based on readily available administrative data, is associated with patient-perceived overall coordination of care among multiple physicians. KPC measures are potentially a valuable and low-cost way to follow the effects of changes favoring group practice on continuity of care for entire populations. They are easy to replicate over time and across jurisdictions.

Characteristics of physicians and patients who join team-based primary care practices: evidence from Quebec's Family Medicine Groups.

PURPOSE: New models of delivering primary care are being implemented in various countries. In Quebec, Family Medicine Groups (FMGs) are a team-based approach to enhance access to, and coordination of, care. We examined whether physicians' and patients' characteristics predicted their participation in this new model of primary care. METHODS: Using provincial administrative data, we created a population cohort of Quebec's vulnerable patients. We collected data before the advent of FMGs on patients' demographic characteristics, chronic illnesses and health service use, and their physicians' demographics, and practice characteristics. Multivariate regression was used to identify key predictors of joining a FMG among both patients and physicians. RESULTS: Patients who eventually enrolled in a FMG were more likely to be female, reside outside of an urban region, have a lower SES status, have diabetes and congestive heart failure, visit the emergency department for ambulatory sensitive conditions and be hospitalized for any cause. They were also less likely to have hypertension, visit an ambulatory clinic and have a usual provider of care. Physicians who joined a FMG were less likely to be located in urban locations, had fewer years in medical practice, saw more patients in hospital, and had patients with lower morbidity. CONCLUSIONS: Physicians' practice characteristics and patients' health status and health care service use were important predictors of joining a FMG. To avoid basing policy decisions on tenuous evidence, policymakers and researchers should account for differential selection into team-based primary health care models.

Consultation with cardiologists for persons with new-onset chronic heart failure: a population-based study.

BACKGROUND: It is recommended that persons recently diagnosed with heart failure consult with a specialist in heart failure. OBJECTIVES: To determine whether patients who were diagnosed with new-onset chronic heart failure (CHF) by a noncardiologist consulted with a cardiologist, and identify the factors associated with delayed consultation. METHODS: Physician reimbursement administrative data were obtained for all adults with suspected new-onset CHF in the year 2000 in Quebec, defined operationally as a physician visit for CHF (based on the International Classification of Diseases, 9th Revision diagnostic codes), with no previous physician visit code for CHF in the preceding three years. Among those first diagnosed by a noncardiologist, Cox regression modelling was used to identify patient and physician characteristics associated with time to cardiology consultation. RESULTS: Of the 13,523 persons coded as having incident CHF, 54.9% consulted a cardiologist within the next 2.5 to 3.5 years, and 67.4% were seen by an internist or cardiologist. Older patients, women, and those with lower comorbidity and socioeconomic status had significantly longer times to cardiology consultation. CONCLUSION: The data suggest that many patients with suspected new-onset CHF do not receive prompt cardiology care, as stipulated by current recommendations. Equity of access for women and those with lower socioeconomic status appears to be problematic.

Consultation with an arthritis specialist for children with suspected juvenile rheumatoid arthritis: a population-based study.

OBJECTIVES: To describe consultation with an arthritis specialist because of suspected new-onset juvenile rheumatoid arthritis (JRA) and to determine factors associated with prompt consultation. DESIGN: Retrospective cohort study. SETTING: Physician reimbursement administrative data were obtained for all children aged 16 years or younger in the Province of Québec (Canada). PARTICIPANTS: Suspected new-onset cases of JRA in 2000 were defined by a physician visit because of JRA, providing there had been no such claims in the preceding 3 years. MAIN EXPOSURE: First JRA diagnosis made by a non-arthritis specialist. MAIN OUTCOME MEASURES: First consultation with an arthritis specialist subsequent to diagnosis by a non-arthritis specialist and time to first consultation with an arthritis specialist. RESULTS: Of 352 children and adolescents with suspected new-onset JRA identified by non-arthritis specialists, 159 (45.2%) were subsequently seen by an arthritis specialist. Mean (SD) time to consultation for those seen was 115.3 (213.8) days (median, 28 days). Younger children were more likely to obtain care from an arthritis specialist compared with those having JRA first diagnosed by a general practitioner. CONCLUSION: Most patients with suspected new-onset JRA do not obtain prompt care from an arthritis specialist. Further research and action should focus on this issue so that outcomes may be optimized.

Delay in consultation with specialists for persons with suspected new-onset rheumatoid arthritis: a population-based study.

OBJECTIVE: Care in rheumatoid arthritis (RA) is optimized by involvement of rheumatologists. We wished to determine whether patients suspected of having new-onset RA in Québec consulted with a rheumatologist, to document any delay in these consultations, and to determine factors associated with prompt consultation. METHODS: Physician reimbursement administrative data were obtained for all adults in Québec. Suspected new-onset cases of RA in the year 2000 were defined operationally as a physician visit for RA (based on the International Classification of Diseases, Ninth Revision diagnostic codes), where there had been no prior visit code to any physician for RA in the preceding 3 years. For those patients who were first diagnosed by a nonrheumatologist, Cox regression modeling was used to identify patient and physician characteristics associated with time to consultation with a rheumatologist. RESULTS: Of the 10,001 persons coded as incident RA by a nonrheumatologist, only 27.3% consulted a rheumatologist within the next 2.5-3.5 years. Of those who consulted, the median time from initial visit to a physician for RA to consultation with a rheumatologist was 79 days. The strongest predictors of shorter time to consultation were female sex, younger age, being in a higher socioeconomic class, and having greater comorbidity. CONCLUSION: Our data suggest that the vast majority of patients suspected of having new-onset RA do not receive rheumatology care. Further action should focus on this issue so that outcomes in RA may be optimized.

Kinematic analysis of upper limbs and trunk movement during bilateral movement after stroke.

OBJECTIVE: To compare the kinematics of the upper limbs and trunk during unilateral and parallel bilateral tasks in subjects with hemiparesis and control subjects. DESIGN: Comparative study. SETTING: Geriatric center offering rehabilitation services. PARTICIPANTS: Convenience sample of 15 persons (age, 69.4 +/- 12.0 y; > or = 3 mo poststroke) recruited in a geriatric center with rehabilitation services, and 13 control persons (67.8 +/- 7.5 y) participated in the study. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Unilateral and bilateral movements toward 1 or 2 targets located beyond arm's length and positioned in 3 directions. Angular changes of both upper limbs and trunk were characterized in the sagittal, frontal, and horizontal planes. RESULTS: During the bilateral task, the deficits of the kinematic joints of the paretic upper limb persisted in subjects with hemiparesis as compared with the corresponding upper limb in the control subjects (abduction shoulder: subjects with hemiparesis, 5.7 degrees +/- 5.3 degrees; control subjects, 0.7 degrees +/- 4.8 degrees; extension elbow: subjects with hemiparesis, 38.2 degrees +/- 14.2 degrees; control subjects, 52.8 degrees +/- 12.5 degrees) with a marked flexion of the trunk (subjects with hemiparesis, 33.7 degrees +/- 8.7 degrees; control subjects, 26.8 degrees +/- 5.8 degrees). The elbow extension of the nonparetic upper limb was reduced (subjects with hemiparesis, 41.0 degrees +/- 13.6 degrees; control subjects, 52.8 degrees +/- 12.5 degrees). CONCLUSIONS: The use of parallel bilateral reaching tasks and placing movements of the upper extremities in the subjects with hemiparesis contributed an increase in the trunk flexion rather than improve the motor performance of the paretic upper limb, especially with regard to increasing elbow extension.

Weight-bearing on the lower limbs in a sitting position during bilateral movement of the upper limbs in post-stroke hemiparetic subjects.

OBJECTIVE: Verify weight-bearing on the feet in a sitting position during pointing in different directions with 1 or both upper limbs. DESIGN: Comparative study. SUBJECTS: Fifteen subjects with post-stroke hemiparesis with good to very good motor recovery and 13 healthy subjects participated in the study. METHODS: The subjects were seated on a chair with each foot resting on a force plate. They had to touch with 1 or, simultaneously with both hands, 2 target(s) located in front of them or at a 45 degrees angle on either side at a standardized distance beyond their upper limb's length. The percentage of weight loading variation under each foot was measured. RESULTS: Weight-bearing on the paretic foot is reduced during unilateral and bilateral pointing in the anterior direction and 45 degrees ipsilateral to the paretic side. However, both unilateral and bilateral pointing 45 degrees contralateral to the paretic side produced symmetrical weight-bearing on both feet, paretic and non-paretic. CONCLUSION: Since the paretic muscles of the trunk are probably used to control the leaning of the trunk towards the non-paretic side, the subjects with hemiparesis may put weight on the paretic foot to compensate for trunk weakness and maintain balance.

Dynamic analysis of trunk flexion after stroke.

OBJECTIVE: To quantify trunk movement and lower-extremity weight bearing in patients with stroke-associated hemiparesis compared with healthy subjects. DESIGN: Controlled study with 2 groups: persons with hemiparesis and healthy controls. SETTING: Geriatric center offering rehabilitation services. PARTICIPANTS: A convenience sample of 15 persons with poststroke hemiparesis (age, 69.4+/-12.0y; > or =3mo poststroke; total motor function range, 63-95/100) on the Fugl-Meyer Assessment and of 13 healthy persons (age, 67.8+/-7.5y). INTERVENTIONS: Subjects were seated on a chair placed on a forceplate with their feet on 2 additional forceplates. A target was placed directly in front of or at a 45 degrees angle from the midline at 66% of the nonparetic/dominant arm length. Subjects' task was to touch the target with their forehead. Main outcome measures Amplitude and speed of trunk movements, displacement of the global center of pressure (COP), and percentage of body weight distributed on the buttocks and the feet. RESULTS: Despite speed and amplitude comparable to that of the healthy subjects (NS), subjects with hemiparesis (HS) had less COP displacement (HS, 33.7+/-6.9; NS, 40.5+/-9.2), resulting in a lower weight-bearing value on the feet (HS for the paretic foot, 2.3%+/-3.6%; HS for the nonparetic foot, 2.2%+/-2.9%; NS for the nondominant foot, 5.4%+/-3.4%; NS for the dominant foot, 5.2%+/-4.0%). CONCLUSIONS: The similar amplitude of trunk flexion with a decreased displacement of COP and a lower weight bearing on the feet suggest smaller anterior displacement of the body mass. It is possible that trunk movements in persons with hemiparesis are executed by the upper trunk with very little anterior tilt of the pelvis.