Impact of a provincial quality-improvement program on primary health care in Ontario: a population-based controlled before-and-after study

Green, Michael E.; Harris, Stewart B.; Webster-Bogaert, Susan; Han, Han; Kotecha, Jyoti; Kopp, Alexander; Ho, Martin; Birtwhistle, Richard; Glazier, Richard H.

doi:10.9778/cmajo.20160104

Cited by 8 publications

(10 citation statements)

References 27 publications

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“…It highlights not only the importance of a pilot phase to assess “real-world” feasibility [ 18 ] but also the dependence—and interaction—of our intervention on “usual care” and the implications of this relationship for future integration of MyDiabetesPlan into clinical care. Literature suggests that only 27.6% to 34.4% of physicians conduct two or more comprehensive diabetes visits per patient per year, corroborating findings from our trial [ 41 ]. Barriers to primary care attendance included medical factors (such as feeling unwell, hospital admission, or resolution of symptoms), appointment system factors (such as forgetfulness or confusion about appointment time), and other logistical factors (such as traffic or oversleeping) [ 42 ].…”

Section: Discussionsupporting

confidence: 90%

Integrating shared decision-making into primary care: lessons learned from a multi-centre feasibility randomized controlled trial

Medleg

Choi

et al. 2021

BMC Med Inform Decis Mak

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Background MyDiabetesPlan is a web-based, interactive patient decision aid that facilitates patient-centred, diabetes-specific, goal-setting and shared decision-making (SDM) with interprofessional health care teams. Objective Assess the feasibility of (1) conducting a cluster randomized controlled trial (RCT) and (2) integrating MyDiabetesPlan into interprofessional primary care clinics. Methods We conducted a cluster RCT in 10 interprofessional primary care clinics with patients living with diabetes and at least two other comorbidities; half of the clinics were assigned to MyDiabetesPlan and half were assigned to usual care. To assess recruitment, retention, and resource use, we used RCT conduct logs and financial account summaries. To assess intervention fidelity, we used RCT conduct logs and website usage logs. To identify barriers and facilitators to integration of MyDiabetesPlan into clinical care across the IP team, we used audiotapes of clinical encounters in the intervention groups. Results One thousand five hundred and ninety-seven potentially eligible patients were identified through searches of electronic medical records, of which 1113 patients met the eligibility criteria upon detailed chart review. A total of 425 patients were randomly selected; of these, 213 were able to participate and were allocated (intervention: n = 102; control: n = 111), for a recruitment rate of 50.1%. One hundred and fifty-one patients completed the study, for a retention rate of 70.9%. A total of 5745 personnel-hours and $6104 CAD were attributed to recruitment and retention activities. A total of 179 appointments occurred (out of 204 expected appointments—two per participant over the 12-month study period; 87.7%). Forty (36%), 25 (23%), and 32 (29%) patients completed MyDiabetesPlan at least twice, once, and zero times, respectively. Mean time for completion of MyDiabetesPlan by the clinician and the patient during initial appointments was 37 min. From the clinical encounter transcripts, we identified diverse strategies used by clinicians and patients to integrate MyDiabetesPlan into the appointment, characterized by rapport building and individualization. Barriers to use included clinician-related, patient-related, and technical factors. Conclusion An interprofessional approach to SDM using a decision aid was feasible. Lower than expected numbers of diabetes-specific appointments and use of MyDiabetesPlan were observed. Addressing facilitators and barriers identified in this study will promote more seamless integration into clinical care. Trial registration Clinicaltrials.gov Identifier: NCT02379078. Date of Registration: February 11, 2015. Protocol version: Version 1; February 26, 2015.

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Section: Discussionsupporting

confidence: 90%

Integrating shared decision-making into primary care: lessons learned from a multi-centre feasibility randomized controlled trial

Medleg

Choi

et al. 2021

BMC Med Inform Decis Mak

View full text Add to dashboard Cite

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“…D2D was made possible through the investment in more than 30 Quality Improvement Decision Support Specialists (QIDS Specialists) across Ontario to help interprofessional teams to access and use better data to improve care [ 38 ]. Timely access to care and emergency department use were among the measurement areas monitored through this initiative [ 39 ]. The Quality Improvement and Innovation Partnership (QIIP) was another province wide quality-improvement program implemented between 2008 and 2010 to support interprofessional teams to improve the care they provide [ 40 ].…”

Section: Discussionmentioning

confidence: 99%

Comparing primary care Interprofessional and non-interprofessional teams on access to care and health services utilization in Ontario, Canada: a retrospective cohort study

Haj-Ali

Hutchison

Moineddin

et al. 2021

BMC Health Serv Res

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Background Many countries, including Canada, have introduced primary care reforms to improve health system functioning and value. The purpose of this study was to examine the association between receiving care from interprofessional primary care teams and after-hours access to care, patient-reported walk-in clinic visits and emergency department use. Methods We conducted a retrospective cohort study linking population-based administrative databases to Ontario’s Health Care Experience Survey (HCES) between 2012 and 2018. We adjusted for physician group characteristics as well as individual physician and patient characteristics while assessing the relationship between receiving care from interprofessional teams and the outcomes of interest. Results As of March 31st, 2015, there were 465 physician groups with HCES respondents of which 177 (38.0%) were interprofessional teams and 288 (62.0%) were non-interprofessional teams in the same blended capitation reimbursement model. In this period, there were 4518 physicians with HCES respondents, of whom 2131 (47.2%) were in interprofessional teams and 2387 (52.8%) were in non-interprofessional teams. There were 10,102 HCES respondents included in this study, of whom 42.4% were in interprofessional teams and 42.3% were in non-interprofessional teams. After adjustment, we found that being in an interprofessional team was associated with an increase in the odds of patients reporting same/next day access to care by 12.0% (OR = 1.12 CI = 1.00 to 1.24 p-value 0.0436) and a decrease in the odds of patients reporting walk-in clinic use by 16% (OR = 0.84 CI = 0.75 to 0.94 p-value 0.0019). After adjustment, there were no significant differences in patient-reported after-hours access to care and emergency department use. Conclusions Ontario has invested heavily in interprofessional primary care teams. As compared to patients in non-interprofessional teams, patients in interprofessional teams self-reported more timely access to care and less walk-in clinic use but no significant difference in self-reported access to after-hours care or in emergency department use. For jurisdictions aiming to expand physician voluntary participation in interprofessional teams, our study results inform expectations around access to care and health services utilization.

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“…21,22 There are also other contextual factors that may explain our findings. In Ontario, teams have specific accountabilities related to access and quality improvement as well as paid administrators, shared decision support specialists, and other supports 34,35 not present in other practices. Some teams have focused efforts specifically on reducing ED use.…”

Section: Findings In Contextmentioning

confidence: 99%

Impact of Team-Based Care on Emergency Department Use

et al. 2022

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PURPOSE We sought to assess the impact of team-based care on emergency department (ED) use in the context of physicians transitioning from fee-for-service payment to capitation payment in Ontario, Canada. METHODSWe conducted an interrupted time series analysis to assess annual ED visit rates before and after transition from an enhanced fee-for-service model to either a team capitation model or a nonteam capitation model. We included Ontario residents aged 19 years and older who had at least 3 years of outcome data both pretransition and posttransition (N = 2,524,124). We adjusted for age, sex, income quintile, immigration status, comorbidity, and morbidity, and we stratified by rurality. A sensitivity analysis compared outcomes for team vs nonteam patients matched on year of transition, age, sex, rurality, and health region. RESULTSWe compared 387,607 team and 1,399,103 nonteam patients in big cities, 213,394 team and 380,009 nonteam patients in small towns, and 65,289 team and 78,722 nonteam patients in rural areas. In big cities, after adjustment, the ED visit rate increased by 2.4% (95% CI, 2.2% to 2.6%) per year for team patients and 5.2% (95% CI, 5.1% to 5.3%) per year for nonteam patients in the years after transition (P <.001). Similarly, there was a slower increase in ED visits for team relative to nonteam patients in small towns (0.9% [95% CI, 0.7% to 1.1%] vs 2.9% [95% CI, 2.8% to 3.1%], P <.001) and rural areas (−0.5% [95% CI, -0.8% to 0.2%] vs 1.3% [95% CI, 1.0% to 1.6%], P <.001). Results were much the same in the matched analysis.CONCLUSIONS Adoption of team-based primary care may reduce ED use. Further research is needed to understand optimal team composition and roles.

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Impact of a provincial quality-improvement program on primary health care in Ontario: a population-based controlled before-and-after study

Cited by 8 publications

References 27 publications

Integrating shared decision-making into primary care: lessons learned from a multi-centre feasibility randomized controlled trial

Integrating shared decision-making into primary care: lessons learned from a multi-centre feasibility randomized controlled trial

Comparing primary care Interprofessional and non-interprofessional teams on access to care and health services utilization in Ontario, Canada: a retrospective cohort study

Impact of Team-Based Care on Emergency Department Use

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