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) identifi ed which practice organizational factors were independently associated with high-quality care. METHODSWe 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 identifi ed those organizational factors independently associated with chronic disease management. RESULTSChronic 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. CONCLUSIONSThe study adds to the literature supporting the value of nursepractitioners 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 patientphysician ratios may have unanticipated negative effects on processes of care quality. 2009;7:309-318. doi:10.1370/afm.982. Ann Fam Med INTRODUCTIONC hronic health conditions are a substantial challenge to global health.1 By 2020 they will account for 73% of all deaths and 60% of the global burden of disease.2-5 Canada's experience matches that of much of the developed world, where in the next decade deaths caused by chronic diseases will increase by 15%. 6 The growing burden of chronic diseases threatens the sustainability of health care systems. 7,8 In the United States, for example, the annual economic effect on the US economy of the most common chronic diseases is more than $1 trillion and could reach nearly $6 trillion by the middle of the century. 4 Canada stands to lose $9 billion in the next decade from premature deaths caused by heart disease, stroke, and diabetes. Policy makers have become increasingly interested in the potential of high-quality primary care to help deal with the chronic disease challenge. Primary care is well positioned to have an important impact on outcomes of care for patients with chronic conditions. 9 The...

PurposeConceptual frameworks for primary care have evolved over the last 40 years, yet little attention has been paid to the environmental, structural and organizational factors that facilitate or moderate service delivery. Since primary care is now of more interest to policy makers, it is important that they have a comprehensive and balanced conceptual framework to facilitate their understanding and appreciation. We present a conceptual framework for primary care originally developed to guide the measurement of the performance of primary care organizations within the context of a large mixed-method evaluation of four types of models of primary care in Ontario, Canada.MethodsThe framework was developed following an iterative process that combined expert consultation and group meetings with a narrative review of existing frameworks, as well as trends in health management and organizational theory.ResultsOur conceptual framework for primary care has two domains: structural and performance. The structural domain describes the health care system, practice context and organization of the practice in which any primary care organization operates. The performance domain includes features of health care service delivery and technical quality of clinical care.ConclusionAs primary care evolves through demonstration projects and reformed delivery models, it is important to evaluate its structural and organizational features as these are likely to have a significant impact on performance.

Primary Care and Primary Health Care are very similar terms which are often employed interchangeably, but which are also used to denote quite different concepts. Much time and energy is spent discussing which term is the appropriate one for a particular application. There is a growing recognition internationally that the two terms describe two quite distinct entities. Recent Canadian uses of the two terms are, for the most part, consistent with the international uses. Primary Care, the shorter term, describes a narrower concept of "family doctor-type" services delivered to individuals. Primary Health Care is a broader term which derives from core principles articulated by the World Health Organization and which describes an approach to health policy and service provision that includes both services delivered to individuals (Primary Care services) and populationlevel "public health-type" functions. MeSH terms: Primary care; primary health care; primary healthcare RÉSUMÉ « Soins primaires » et « soins de santé primaires » sont des expressions très semblables que l'on emploie souvent de façon interchangeable, mais qui peuvent aussi désigner des notions assez différentes. On consacre parfois beaucoup de temps et d'énergie à discuter de l'expression appropriée dans tel ou tel contexte. Partout dans le monde, on commence à reconnaître qu'elles décrivent deux entités bien distinctes. Les emplois récents de ces deux expressions au Canada sont, pour la plupart, conformes à leurs emplois ailleurs dans le monde. La plus courte des deux, « soins primaires », a un sens restreint et désigne les services comme ceux fournis par les médecins de famille à des particuliers. L'expression « soins de santé primaires » a un sens plus large qui découle des principes de base énoncés par l'Organisation mondiale de la santé; elle désigne une approche des politiques sanitaires et de la prestation de services qui englobe à la fois les services aux particuliers (les services de soins de première ligne) et les fonctions de « santé publique » qui s'adressent à des populations entières.

P rimary care providers are increasingly in terested in ensuring that preventive health care be part of their work routines.1 This reorientation fits with the evidence that recommendations from family practitioners increase substantially the likelihood of patients undergoing preventive manoeuvres, 2 whereas the lack of such recommendations has been linked with patient noncompliance. 3,4 Studies evaluating adherence to recommended preventive care suggest that the most pervasive barriers rest with the organization of the health care system and the practice itself, such as the absence of external financial incentives for the work done and the lack of a reminder system in the office. 3,5−9 Countries attempting to reform their delivery of primary care and improve the delivery of preventive services have often directed their efforts in finding alternatives to the traditional fee-forservice model, in which providers receive payment for each service provided. There are two predominant alternative funding models: capitation (pro viders receive a fixed lump-sum payment per pa tient per period, independent of the number of services performed) and salaried remuneration. Some health care systems blend components of fee for service with either of these models or offer additional incentives for reaching defined qualityof-care targets. Despite considerable rhetoric, there is little evidence to point to the remuneration models associated with superior delivery of primary care services. 10 The complexity of health