The impact of team-based primary care on health care services utilization and costs: Quebec's family medicine groups.

We investigate the effects on health care costs and utilization of team-based primary care delivery: Quebec's Family Medicine Groups (FMGs). FMGs include extended hours, patient enrolment and multidisciplinary teams, but they maintain the same remuneration scheme (fee-for-service) as outside FMGs. In contrast to previous studies, we examine the impacts of organizational changes in primary care settings in the absence of changes to provider payment and outside integrated care systems. We built a panel of administrative data of the population of elderly and chronically ill patients, characterizing all individuals as FMG enrollees or not. Participation in FMGs is voluntary and we address potential selection bias by matching on GP propensity scores, using inverse probability of treatment weights at the patient level, and then estimating difference-in-differences models. We also use appropriate modelling strategies to account for the distributions of health care cost and utilization data. We find that FMGs significantly decrease patients' health care services utilization and costs in outpatient settings relative to patients not in FMGs. The number of primary care visits decreased by 11% per patient per year among FMG enrolees and specialist visits declined by 6%. The declines in costs were of roughly equal magnitude. We found no evidence of an effect on hospitalizations, their associated costs, or the costs of ED visits. These results provide support for the idea that primary care organizational reforms can have impacts on the health care system in the absence of changes to physician payment mechanisms. The extent to which the decline in GP visits represents substitution with other primary care providers warrants further investigation.

Explaining time elapsed prior to cancer diagnosis: patients' perspectives.

BACKGROUND: Cancer is the leading cause of death in Canada. Early cancer diagnosis could improve patients' prognosis and quality of life. This study aimed to analyze the factors influencing elapsed time between the first help-seeking trigger and cancer diagnosis with respect to the three most common and deadliest cancer types: lung, breast, and colorectal. METHODS: This paper presents the qualitative component of a larger project based on a sequential explanatory design. Twenty-two patients diagnosed were interviewed, between 2011 to 2013, in oncology clinics of four hospitals in the two most populous regions in Quebec (Canada). Transcripts were analyzed using the Model of Pathways to Treatment. RESULTS: Pre-diagnosis elapsed time and phases are difficult to appraise precisely and vary according to cancer sites and symptoms specificity. This observation makes the Model of Pathways to Treatment challenging to use to analyze patients' experiences. Analyses identified factors contributing to elapsed time that are linked to type of cancer, to patients, and to health system organization. CONCLUSIONS: This research allowed us to identify avenues for reducing the intervals between first symptoms and cancer diagnosis. The existence of inequities in access to diagnostic services, even in a universal healthcare system, was highlighted.

Implementation of an integrated primary care cardiometabolic risk prevention and management network in Montréal: does greater coordination of care with primary care physicians have an impact on health outcomes? / Mise en oeuvre d'un réseau intégré de prévention et de gestion du risque cardiométabolique en première ligne à Montréal : une plus grande coordination des soins avec les médecins de première ligne a-t-elle un impact sur les résultats de santé?

INTRODUCTION: Chronic disease management requires substantial services integration. A cardiometabolic risk management program inspired by the Chronic Care Model was implemented in Montréal for patients with diabetes or hypertension. One of this study's objectives was to assess the impact of care coordination between the interdisciplinary teams and physicians on patient participation in the program, lifestyle improvements and disease control. METHODS: We obtained data on health outcomes from a register of clinical data, questionnaires completed by patients upon entry into the program and at the 12-month mark, and we drew information on the program's characteristics from the implementation analysis. We conducted multiple regression analyses, controlling for patient sociodemographic and health characteristics, to measure the association between interdisciplinary team coordination with primary care physicians and various health outcomes. RESULTS: A total of 1689 patients took part in the study (60.1% participation rate). Approximately 40% of patients withdrew from the program during the first year. At the 12-month follow-up (n = 992), we observed a significant increase in the proportion of patients achieving the various clinical targets. The perception by the interdisciplinary team of greater care coordination with primary care physicians was associated with increased participation in the program and the achievement of better clinical results. CONCLUSION: Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.

INTRODUCTION: La gestion des maladies chroniques nécessite une grande intégration des services. Un programme de gestion du risque cardiométabolique inspiré du Chronic Care Model a été implanté à Montréal pour les patients atteints de diabète ou d'hypertension. Un des objectifs de notre étude était d'apprécier l'impact de la coordination des soins entre les équipes interdisciplinaires et les médecins sur la participation des patients au programme et sur l'amélioration des habitudes de vie et le contrôle de la maladie. MÉTHODOLOGIE: Nous avons utilisé des données sur les résultats de santé issues d'un registre de données cliniques et de questionnaires aux patients à leur entrée dans le programme et à 12 mois de suivi, ainsi que des données sur les caractéristiques du programme provenant de l'analyse de son implantation. Nous avons réalisé des analyses de régression multiple, contrôlant pour les caractéristiques sociodémographiques et de santé des patients, pour mesurer l'association entre la coordination de l'équipe interdisciplinaire avec les médecins de première ligne et différents résultats de santé. RÉSULTATS: Au total, 1689 patients ont participé à l'évaluation (taux de participation 60,1 %). Environ 40 % des patients ont abandonné le programme durant la première année. À 12 mois de suivi (n = 992), nous avons observé une augmentation significative de la proportion des patients atteignant les différentes cibles cliniques. La perception par l'équipe interdisciplinaire d'une meilleure coordination des soins avec les médecins de première ligne était associée à une plus grande participation des patients au programme et à l'atteinte de meilleurs résultats cliniques. CONCLUSION: Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.

Does enrollment in multidisciplinary team-based primary care practice improve adherence to guideline-recommended processes of care? Quebec's Family Medicine Groups, 2002-2010.

BACKGROUND: We investigated whether multidisciplinary team-based primary care practice improves adherence to process of care guidelines, in the absence of financial incentives related to pay-for-performance. METHODS: We conducted a natural experiment including 135,119 patients, enrolled with a general practitioner (GP) in a multidisciplinary team Family Medicine Group (FMG) or non-FMG practice, using longitudinal data from Quebec's universal insurer over the relevant time period (2000-2010). All study subjects had diabetes, chronic obstructive pulmonary disease, or heart failure and were followed over a 7-year period, 2 years prior to enrollment and 5 years after. We constructed indicators on adherence to disease-specific guidelines and composite indicators across conditions. We evaluated the effect of FMGs using propensity score methods and Difference-in-Differences (DD) models. RESULTS: Rates of adherence to chronic disease guidelines increased for both FMG and non-FMG patients after enrollment, but not differentially so. Adherence to prescription-related guidelines improved less for FMG patients (DD [95% CI]=-2.83% [-4.08%, -1.58%]). We found no evidence of an FMG effect on adherence to consultation-related guidelines, (DD [95% CI]=-0.24% [-2.24%; 1.75%]). CONCLUSIONS: We found no evidence that FMGs increased adherence to the guidelines we evaluated. Future research is needed to assess why this reform did not improve performance on these quality-of-care indicators.

Evolution of Experience of Care of Patients with and without Chronic Diseases following a Québec Primary Healthcare Reform.

Objectives. To assess the extent to which new primary healthcare (PHC) models implemented in two regions of Quebec have improved patient experience of care, unmet needs, and use of services for individuals with and without chronic diseases, compared with other forms of PHC practices. Methods. In 2005 and 2010, we carried out population and organization surveys. We divided PHC organizations into new model practices and other practices and followed the evolution over time of patient experience of care. Results. Patients with chronic diseases had better accessibility but worse continuity of care in the new model practices than in the other practices at both time periods. Through the reform, accessibility decreased evenly in both groups, but continuity and perceived outcomes improved more in the other practices. Use of primary care services decreased more in the new model practices. Among patients without chronic disease, accessibility decreased much less in the new models and responsiveness increased more. There was no significant change in ER attendance and hospitalization. Conclusion. The evolution of patient experience of care has been more favorable for patients without chronic diseases. These findings raise concerns about equity since the aim of the PHC reform was targeting in priority individuals with the greatest needs.

Impacts of Québec Primary Healthcare Reforms on Patients' Experience of Care, Unmet Needs, and Use of Services.

Introduction. Healthcare reforms launched in the early 2000s in Québec, Canada, involved the implementation of new forms of primary healthcare (PHC) organizations: Family Medicine Groups (FMGs) and Network Clinics (NCs). The objective of this paper is to assess how the organizational changes associated with these reforms have impact on patients' experience of care, use of services, and unmet needs. Methods. We conducted population and organization surveys in 2005 and 2010 in two regions of the province of Québec. The design was a before-and-after natural experiment. Changes over time between new models and other practices were assessed using difference-in-differences statistical procedures. Results. Accessibility decreased between 2003 and 2010, but less so in the treatment than in the comparison group. Continuity of care generally improved, but the increase was less for patients in the treatment group. Responsiveness also increased during the period and more so in the treatment group. There was no other significant difference between the two groups. Conclusion. PHC reform in Québec has brought about major organizational changes that have translated into slight improvements in accessibility of care and responsiveness. However, the reform does not seem to have had an impact on continuity, comprehensiveness, perceived care outcomes, use of services, and unmet needs.

Does the Primary Care Experience Influence the Cancer Diagnostic Process?

Objective. To analyze the impact of patients' experience of care at their usual source of primary care on their choice of point of entry into cancer investigation process, time to diagnosis, and presence of metastatic cancer at time of diagnosis. Method. A questionnaire was administered to 438 patients with cancer (breast, lung, and colorectal) between 2011 and 2013 in four oncology clinics of Quebec (Canada). Multiple regression analyses (logistic and Cox models) were conducted. Results. Among patients with symptoms leading to investigation of cancer (n = 307), 47% used their usual source of primary care as the point of entry for investigation. Greater comprehensiveness of care was associated with the decision to use this source as point of entry (OR = 1.25; CI 90% = 1.06-1.46), as well as with shorter times between first symptoms and investigation (HR = 1.11; p = 0.05), while greater accessibility was associated with shorter times between investigation and diagnosis (HR = 1.13; p < 0.01). Conclusion. Experience of care at the usual source of primary care has a slight influence on the choice of point of entry for cancer investigation and on time to diagnosis. This influence appears to be more related to patients' perceptions of the accessibility and comprehensiveness of their usual source of primary care.

The prevention and management of chronic disease in primary care: recommendations from a knowledge translation meeting.

BACKGROUND: Seven chronic disease prevention and management programs were implemented across Quebec with funding support from a provincial-private industry funding initiative. Given the complexity of implementing integrated primary care chronic disease management programs, a knowledge transfer meeting was held to share experiences across programs and synthesize common challenges and success factors for implementation. METHODS: The knowledge translation meeting was held in February 2014 in Montreal, Canada. Seventy-five participants consisting of 15 clinicians, 14 researchers, 31 knowledge users, and 15 representatives from the funding agencies were broken up into groups of 10 or 11 and conducted a strengths, weaknesses, opportunities, and threats analysis on either the implementation or the evaluation of these chronic disease management programs. Results were reported back to the larger group during a plenary and recorded. Audiotapes were transcribed and summarized using pragmatic thematic analysis. RESULTS AND DISCUSSION: Strengths to leverage for the implementation of the seven programs include: (1) synergy between clinical and research teams; (2) stakeholders working together; (3) motivation of clinicians; and (4) the fact that the programs are evidence-based. Weaknesses to address include: (1) insufficient resources; (2) organizational change within the clinical sites; (3) lack of referrals from primary care physicians; and (4) lack of access to programs. Strengths to leverage for the evaluation of these programs include: (1) engagement of stakeholders and (2) sharing of knowledge between clinical sites. Weaknesses to address include: (1) lack of referrals; (2) difficulties with data collection; and (3) difficulties in identifying indicators and control groups. Opportunities for both themes include: (1) fostering new and existing partnerships and stakeholder relations; (2) seizing funding opportunities; (3) knowledge transfer; (4) supporting the transformation of professional roles; (5) expand the use of health information technology; and (6) conduct cost evaluations. Fifteen recommendations related to mobilisation of primary care physicians, support for the transformation of professional roles, and strategies aimed at facilitating the implementation and evaluation of chronic disease management programs were formulated based on the discussions at this knowledge translation event. CONCLUSION: The results from this knowledge translation day will help inform the sustainability of these seven chronic disease management programs in Quebec and the implementation and evaluation of similar programs elsewhere.

An Algorithm Using Administrative Data to Identify Patient Attachment to a Family Physician.

Background. Commonly self-reported questions in population health surveys, such as "do you have a family physician?", represent one of the best-known sources of information about patients' attachment to family physicians. Is it possible to find a proxy for this information in administrative data? Objective. To identify the type of patient attachment to a family physician using administrative data. Methods. Using physician fee-for-service database and patients enrolment registries (Quebec, Canada, 2008-2010), we developed a step-by-step algorithm including three dimensions of the physician-patient relationship: patient enrolment with a physician, complete annual medical examinations (CME), and concentration of visits to a physician. Results. 68.1% of users were attached to a family physician; for 34.4% of them, attachment was defined by enrolment with a physician, for 31.5%, by CME without enrolment, and, for 34.1%, by concentration of visits to a physician without enrolment or CME. Eight types of patient attachment were described. Conclusion. When compared to findings with survey data, our measure comes out as a solid conceptual framework to identify patient attachment to a family physician in administrative databases. This measure could be of great value for physician/patient-based cohort development and impact assessment of different types of patient attachment on health services utilization.

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.

Effects of practice setting on GPs' provision of care.

OBJECTIVE: To define a physician classification system based on practice settings and to analyze the service provision associated with those classifications. DESIGN: A cross-sectional, retrospective study. SETTING: Province of Quebec. PARTICIPANTS: All GPs in Quebec in 2002 who had been practising for at least 2 years. MAIN OUTCOME MEASURES: Practice setting variables were based on physician income in the different settings. Service provision was assessed using indicators related to continuity, comprehensiveness, accessibility, and productivity of services provided by the GPs. A multiple correspondence analysis with ascending hierarchical classification was conducted to construct the taxonomy of GPs based on their practice settings. RESULTS: Our study produced 7 practice setting models. Two were essentially single-practice models. The 5 others combined several settings. Service provision varied from one model to another. Continuity was greater in the private practice model, in which older GPs were predominant, while accessibility was greater in multi-institutional practice models, in which younger GPs were more active. CONCLUSION: To ensure balance between continuity, accessibility, and comprehensiveness in primary care services provided by GPs, it is important to consider the service provision associated with different practice models.

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.

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.

Marginal structural models for skewed outcomes: identifying causal relationships in health care utilization.

Evaluating the impacts of clinical or policy interventions on health care utilization requires addressing methodological challenges for causal inference while also analyzing highly skewed data. We examine the impact of registering with a Family Medicine Group, an integrated primary care model in Quebec, on hospitalization and emergency department visits using propensity scores to adjust for baseline characteristics and marginal structural models to account for time-varying exposures. We also evaluate the performance of different marginal structural generalized linear models in the presence of highly skewed data and conduct a simulation study to determine the robustness of alternative generalized linear models to distributional model mis-specification. Although the simulations found that the zero-inflated Poisson likelihood performed the best overall, the negative binomial likelihood gave the best fit for both outcomes in the real dataset. Our results suggest that registration to a Family Medicine Group for all 3 years caused a small reduction in the number of emergency room visits and no significant change in the number of hospitalizations in the final year.

Characteristics of primary care practices associated with high quality of care.

BACKGROUND: No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care. METHODS: We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling. RESULTS: The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0-35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8-14.4), presence of allied health professionals (15.3; 95% CI 5.4-25.2) and/or specialist physicians (19.6; 95% CI 8.3-30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0-12.4) and average organizational access to the practice (4.9; 95% CI 2.6-7.2). The number of physicians (1.2; 95% CI 0.6-1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1-2.5) were modestly associated with high-quality care. INTERPRETATION: We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.

Factors predicting patient use of the emergency department: a retrospective cohort study.

BACKGROUND: Many studies have shown the tendency for people without a regular care provider or primary physician to make greater use of emergency departments. We sought to determine the effects of three aspects of care provided by primary physicians (physician specialty, continuity of care and comprehensiveness of care) on their patients' use of the emergency department. METHODS: Using provincial administrative databases, we created a cohort of 367,315 adults aged 18 years and older. Participants were residents of urban areas of Quebec. Affiliation with a primary physician, the specialty of this physician (i.e., family physician v. specialist), continuity of care (as measured using the Usual Provider Continuity index) and comprehensiveness of care (i.e., number of complete annual examinations) were measured among participants (n = 311,701) who had visited a physician three or more times during a two-year baseline period. We used multivariable negative binomial regression to investigate the relationships between measures of care and the number of visits to emergency departments during a 12-month follow-up period. RESULTS: Among participants under 65 years of age, emergency department use was higher for those not affiliated than for those affiliated with a family physician (incidence rate ratio [IRR] 1.11, 95% confidence interval [CI] 1.05-1.16) or a specialist (IRR 1.10, 95% CI 1.04-1.17). Among patients aged 65 years and older, having a specialist primary physician, as opposed to a family physician, predicted increased use of the emergency department (IRR 1.13, 95% CI 1.09-1.17). Greater continuity of care with a family physician predicted less use of the emergency department only among participants who made 25 or more visits to a physician during the baseline period. Greater continuity of care with a specialist predicted less use of the emergency department overall, particularly among participants with intermediate numbers of multimorbidities and admissions to hospital. Greater comprehensiveness of care by family physicians predicted less use of the emergency department. INTERPRETATION: Efforts to increase the proportion of adults affiliated with a family physician should target older adults, people who visit physicians more frequently and people with multiple comorbidities and admissions to hospital.

Different outcomes for different health measures in immigrants: evidence from a longitudinal analysis of the National Population Health Survey (1994-2006).

The response of immigrants to new societies is dynamic. There may be an initial period of happiness followed by peaks of stressful periods. These reactions along with socio-economic changes are likely to influence their health, which may start converging towards the average health of the host population. We used a longitudinal analysis to assess the differences in health outcomes (mental health and self-rated health), separately in men and women, in Canadian born and immigrants over a 12-year period (and the associated socio-economic factors). We used random effects logistic regression models for evaluation of these health outcomes in 3,081 men and 4,187 women from the National Population Health Survey (1994/95 to 2006/07). After adjusting for all the covariates, non-white immigrants were less likely to have severe psychological distress compared with the Canadian born individuals [odds ratio (OR) Men: 0.49, 95% confidence intervals (CI) 0.24-1.00, Women-OR: 0.54; 95% CI: 0.32-0.92]. Immigrant women (white and non-white) were more likely to rate their health as poor through this 12-year period than the Canadian born women (White-OR: 1.64, 95% CI: 1.17-2.64; Non-white-OR: 1.82, 95% CI: 1.01-3.28). Immigrants in the lowest income adequacy category reported higher psychological distress and poorer health than those in the highest income categories. We did not find any significant differences in the mental health and self-rated health of Canadian men and white male immigrants throughout this 12-year period. Though, non-white immigrant women were less likely to have severe psychological distress through this 12 year period, they were the ones most likely to rate their health as poor.

Variations in patients' assessment of chronic illness care across organizational models of primary health care: a multilevel cohort analysis.

PURPOSE: To measure patients' assessment of chronic illness care and its variation across primary healthcare (PHC) models. METHODS: We recruited 776 patients with diabetes, heart failure, arthritis or chronic obstructive pulmonary disease from 33 PHC clinics. Face-to-face interviews, followed by a telephone interview at 12 months, were conducted using the Patient Assessment of Chronic Illness Care (PACIC). Multilevel regression was used in the analysis. RESULTS: The mean PACIC score was low at 2.5 on a scale of 1 to 5. PACIC scores were highest among patients affiliated with family medicine groups (mean, 2.78) and lowest for contact models (mean, 2.35). Patients with arthritis and older persons generally reported a lower assessment of chronic care. CONCLUSION: Family medicine groups represent an integrated model of PHC associated with higher levels of achievement in chronic care. Variations across PHC organizations suggest that some models are more appropriate for improving management of chronic illness.

Primary Healthcare Organization and Quality-of-Life Outcomes for Persons with Chronic Disease.

PURPOSE: To explore the association between primary healthcare (PHC) organizational model and health-related quality of life (HRQoL) in persons with chronic disease. METHODS: We recruited 776 patients with a primary diagnosis of one of four chronic diseases from 33 PHC clinics. Patients were interviewed at baseline, 6, 12 and 18 months. We categorized PHC model by administrative type and by a taxonomy according to organizational attributes. HRQoL was measured by disease-specific questionnaires. RESULTS: Mean age was 67 years and 55.3% were female. PHC models differed with respect to case mix: community models served older patients with higher co-morbidity and lower health status. Multilevel logistic regression revealed that none of the PHC organizational models was associated with HRQoL. Having fewer co-morbidities, higher self-rated health and not using home care services were associated with higher HRQoL. CONCLUSION: Despite their having patients with more complex health problems, HRQoL in patients of community practices was equivalent to that of patients in other types of PHC organizations.

OBJET : Explorer les liens entre le modèle d'organisation des soins de santé primaires (SSP) et la qualité de vie liée à la santé (QVS) chez les personnes atteintes d'une maladie chronique. MÉTHODE : Nous avons interrogé 776 patients qui ont obtenu un diagnostic primaire pour une parmi quatre maladies chroniques dans 33 cliniques de SSP. Les patients ont été interrogés au début de l'étude, puis à 6, 12 et 18 mois. Nous avons classé les modèles de SSP selon le type d'établissement et selon une taxonomie des caractéristiques organisationnelles. Des questionnaires axés sur les maladies spécifiques ont servi à mesurer la QVS. RÉSULTATS : L'âge moyen des répondants était 67 ans et 55,3 % d'entre eux étaient des femmes. Les modèles de SSP différaient selon la composition des cas : les modèles communautaires offraient des services à une clientèle plus âgée présentant une plus grande comorbidité et un état de santé moindre. L'analyse de régression logistique multiniveau révèle qu'aucun des modèles d'organisation des SSP avait un lien avec la QVS. Une plus faible comorbidité, un plus haut taux d'autoévaluation en matière de santé et le non-usage des services de soins à domicile sont associés à une meilleure QVS. CONCLUSION : Malgré la présence de patients qui ont des problèmes de santé plus complexes, la QVS chez les patients des établissements communautaires est équivalente à celle des patients des autres types d'organisations de SSP.

Evaluation of the implementation of an integrated primary care network for prevention and management of cardiometabolic risk in Montréal.

BACKGROUND: The goal of this project is to evaluate the implementation of an integrated and interdisciplinary program for prevention and management of cardiometabolic risk (PCMR). The intervention is based on the Chronic Care Model. The study will evaluate the implementation of the PCMR in 6 of the 12 health and social services centres (CSSS) in Montréal, and the effects of the PCMR on patients and the practice of their primary care physicians up to 40 months following implementation, as well as the sustainability of the program. Objectives are: 1-to evaluate the effects of the PCMR and their persistence on patients registered in the program and the practice of their primary care physicians, by implementation site and degree of exposure to the program; 2-to assess the degree of implementation of PCMR in each CSSS territory and identify related contextual factors; 3-to establish the relationships between the effects observed, the degree of PCMR implementation and the related contextual factors; 4-to assess the impact of the PCMR on strengthening local services networks. METHODS/DESIGN: The evaluation will use a mixed design that includes two complementary research strategies. The first strategy is similar to a quasi-experimental "before-after" design, based on a quantitative approach; it will look at the program's effects and their variations among the six territories. The effects analysis will use data from a clinical database and from questionnaires completed by participating patients and physicians. Over 3000 patients will be recruited. The second strategy corresponds to a multiple case study approach, where each of the six CSSS constitutes a case. With this strategy, qualitative methods will set out the context of implementation using data from semi-structured interviews with program managers. The quantitative data will be analyzed using linear or multilevel models complemented with an interpretive approach to qualitative data analysis. DISCUSSION: Our study will identify contextual factors associated with the effectiveness, successful implementation and sustainability of such a program. The contextual information will enable us to extrapolate our results to other contexts with similar conditions. TRIAL REGISTRATION: ClinicalTrials.gov: NCT01326130.