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Background: Practice facilitation has been associated with meaningful improvements in disease prevention and quality of patient care. Using practice facilitation, the Improved Delivery of Cardiovascular Care (IDOCC) project aimed to improve the delivery of evidence-based cardiovascular care in primary care practices across a large health region. Our goal was to evaluate IDOCC's impact on adherence to processes of care delivery.Methods: A pragmatic stepped wedge cluster randomized trial recruiting primary care providers in practices located in Eastern Ontario, Canada (ClinicalTrials.gov: NCT00574808). Participants were randomly assigned by region to one of three steps. Practice facilitators were intended to visit practices every 3-4 (year 1-intensive) or 6-12 weeks (year 2-sustainability) to support changes in practice behavior. The primary outcome was mean adherence to indicators of evidence-based care measured at the patient level. Adherence was assessed by chart review of a randomly selected cohort of 66 patients per practice in each pre-intervention year, as well as in year 1 and year 2 post-intervention.Results: Eighty-four practices (182 physicians) participated. On average, facilitators had 6.6 (min: 2, max: 11) face-to-face visits with practices in year 1 and 2.5 (min: 0 max: 10) visits in year 2. We collected chart data from 5292 patients. After adjustment for patient and provider characteristics, there was a 1.9 % (95 % confidence interval (CI): -2.9 to -0.9 %) and 4.2 % (95 % CI: -5.7 to -2.6 %) absolute decrease in mean adherence from baseline to intensive and sustainability years, respectively.Conclusions: IDOCC did not improve adherence to best-practice guidelines. Our results showed a small statistically significant decrease in mean adherence of questionable clinical significance. Potential reasons for this result include implementation challenges, competing priorities in practices, a broad focus on multiple chronic disease indicators, and use of an overall index of adherence. These results contrast with findings from previously reported facilitation trials and highlight the complexities and challenges of translating research findings into clinical practice.Trial Registration: ClinicalTrials.gov NCT00574808. [ABSTRACT FROM AUTHOR]

Background Several new primary care models have been implemented in Ontario, Canada over the past two decades. These practice models differ in team structure, physician remuneration, and group size. Few studies have examined the impact of these models on specialist referrals. We compared specialist referral rates amongst three primary care models: 1) Enhanced Fee-for service, 2) Capitation- Non-Interdisciplinary (CAP-NI), 3) Capitation - Interdisciplinary (CAP-I). Methods We conducted a cross-sectional study using health administrative data from primary care practices in Ontario from April 1st, 2008 to March 31st, 2010. The analysis included all family physicians providing comprehensive care in one of the three models, had at least 100 patients, and did not have a prolonged absence (eight consecutive weeks). The primary outcome was referral rate (# of referrals to all medical specialties/1000 patients/year). A multivariable clustered Poisson regression analysis was used to compare referral rates between models while adjusting for provider (sex, years since graduation, foreign trained, time in current model) and patient (age, sex, income, rurality, health status) characteristics. Results Fee-for-service had a significantly lower adjusted referral rate (676, 95% CI: 666-687) than the CAP-NI (719, 95% confidence interval (CI): 705-734) and CAP-I (694, 95% CI: 681- 707) models and the interdisciplinary CAP-I group had a 3.5% lower referral rate than the CAP-NI group (RR = 0.965, 95% CI: 0.943-0.987, p = 0.002). Female and Canadian-trained physicians referred more often, while female, older, sicker and urban patients were more likely to be referred. Conclusions Primary care model is significantly associated with referral rate. On a study population level, these differences equate to 111,059 and 37,391 fewer referrals by fee-for-service versus CAP-NI and CAP-I, respectively - a difference of $22.3 million in initial referral appointment costs. Whether a lower rate of referral is more appropriate or not is not known and requires further investigation. Physician remuneration and team structure likely account for the differences; however, further investigation is also required to better understand whether other organizational factors associated with primary care model also impact referral. [ABSTRACT FROM AUTHOR]

Background As health systems evolve, it is essential to evaluate their impact on the delivery of health services to socially disadvantaged populations. We evaluated the delivery of primary health services for different socio-economic groups and assessed the performance of different organizational models in terms of equality of health care delivery in Ontario, Canada. Methods Cross sectional study of 5,361 patients receiving care from primary care practices using Capitation, Salaried or Fee-For-Service remuneration models. We assessed self-reported health status of patients, visit duration, number of visits per year, quality of health service delivery, and quality of health promotion. We used multi-level regressions to study service delivery across socio-economic groups and within each delivery model. Identified disparities were further analysed using a t-test to determine the impact of service delivery model on equity. Results Low income individuals were more likely to be women, unemployed, recent immigrants, and in poorer health. These individuals were over-represented in the Salaried model, reported more visits/year across all models, and tended to report longer visits in the Salaried model. Measures of primary care services generally did not differ significantly between low and higher income/education individuals; when they did, the difference favoured better service delivery for at-risk groups. At-risk patients in the Salaried model were somewhat more likely to report health promotion activities than patients from Capitation and Fee-For-Service models. At-risk patients from Capitation models reported a smaller increase in the number of additional clinic visits/year than Fee-For-Service and Salaried models. At-risk patients reported better first contact accessibility than their non-at-risk counterparts in the Fee-For- Service model only. Conclusions Primary care service measures did not differ significantly across socio-economic status or primary care delivery models. In Ontario, capitation-based remuneration is age and sex adjusted only. Patients of low socio-economic status had fewer additional visits compared to those with high socio-economic status under the Capitation model. This raises the concern that Capitation may not support the provision of additional care for more vulnerable groups. Regions undertaking primary care model reforms need to consider the potential impact of the changes on the more vulnerable populations. [ABSTRACT FROM AUTHOR]

Background: Continuity is a fundamental tenet of primary care, and highly valued by patients; it may also improve patient outcomes and lower cost of health care. It is thus important to investigate factors that predict higher continuity. However, to date, little is known about the factors that contribute to continuity. The purpose of this study was to analyse practice, provider and patient predictors of continuity of care in a large sample of primary care practices in Ontario, Canada. Another goal was to assess whether there was a difference in the continuity of care provided by different models of primary care. Methods: This study is part of the larger a cross-sectional study of 137 primary care practices, their providers and patients. Several performance measures were evaluated; this paper focuses on relational continuity. Four items from the Primary Care Assessment Tool were used to assess relational continuity from the patient's perspective. Results: Multilevel modeling revealed several patient factors that predicted continuity. Older patients and those with chronic disease reported higher continuity, while those who lived in rural areas, had higher education, poorer mental health status, no regular provider, and who were employed reported lower continuity. Providers with more years since graduation had higher patient-reported continuity. Several practice factors predicted lower continuity: number of MDs, nurses, opening on weekends, and having 24 hours a week or less on-call. Analyses that compared continuity across models showed that, in general, Health Service Organizations had better continuity than other models, even when adjusting for patient demographics. Conclusions: Some patients with greater health needs experience greater continuity of care. However, the lower continuity reported by those with mental health issues and those who live in rural areas is concerning. Furthermore, our finding that smaller practices have higher continuity suggests that physicians and policy makers need to consider the fact that 'bigger is not always necessarily better'. [ABSTRACT FROM AUTHOR]

Background: Primary care plays a key role in the prevention and management of cardiovascular disease (CVD). We examined primary care practice adherence to recommended care guidelines associated with the prevention and management of CVD for high risk patients. Methods: We conducted a secondary analysis of cross-sectional baseline data collected from 84 primary care practices participating in a large quality improvement initiative in Eastern Ontario from 2008 to 2010. We collected medical chart data from 4,931 patients who either had, or were at high risk of developing CVD to study adherence rates to recommended guidelines for CVD care and to examine the proportion of patients at target for clinical markers such as blood pressure, lipid levels and hemoglobin A1c. Results: Adherence to preventive care recommendations was poor. Less than 10% of high risk patients received a waistline measurement, half of the smokers received cessation advice, and 7.7% were referred to a smoking cessation program. Gaps in care exist for diabetes and kidney disease as 54.9% of patients with diabetes received recommended hemoglobin-A1c screenings, and only 55.8% received an albumin excretion test. Adherence rates to recommended guidelines for coronary artery disease, hypertension, and dyslipidemia were high (>75%); however <50% of patients were at target for blood pressure or LDL-cholesterol levels (37.1% and 49.7% respectively), and only 59.3% of patients with diabetes were at target for hemoglobin-A1c. Conclusions: There remain significant opportunities for primary care providers to engage high risk patients in prevention activities such as weight management and smoking cessation. Despite high adherence rates for hypertension, dyslipidemia, and coronary artery disease, a significant proportion of patients failed to meet treatment targets, highlighting the complexity of caring for people with multiple chronic conditions. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization calls for more work evaluating the effect of health care reforms on gender equity in developed countries. We performed this evaluation in Ontario, Canada where primary care models resulting from reforms co-exist.Methods: This cross sectional study of primary care practices uses data collected in 2005-2006. Healthcare service models included in the study consist of fee for service (FFS) based, salaried, and capitation based. We compared the quality of care delivered to women and men in practices of each model. We performed multi-level, multivariate regressions adjusting for patient socio-demographic and economic factors to evaluate vertical equity, and adjusting for these and health factors in evaluating horizontal equity. We measured seven dimensions of health service delivery (e.g. accessibility and continuity) and three dimensions of quality of care using patient surveys (n = 5,361) and chart abstractions (n = 4,108).Results: Health service delivery measures were comparable in women and men, with differences Conclusions: The observed differences in the type of health promotion subjects discussed are likely an appropriate response to the differential healthcare needs between genders. Chronic disease care is non equitable in FFS but not in capitation based models. We recommend that efforts to monitor and address gender based differences in the delivery of chronic disease management in primary care be pursued. [ABSTRACT FROM AUTHOR]

Plain English summary: Patient engagement in primary care research is an increasingly common requirement, as it helps make research more relevant to patients and therefore more valuable. However, there is limited evidence about the outcomes on engagement and actually how it affects research. In Canada, the Canadian Institutes of Health Research has a Strategy for Patient-Oriented Research (SPOR), which in 2016 funded Ontario's INSPIRE-PHC centre of excellence and its Patient Engagement Resource Centre (PERC). PERC conducted an online survey of the three INSPIRE-PHC studies that engaged patients to guide their research. We found that patient partners (PPs) were positive about their experience during research meetings, the value of collaboration, and the support that was provided. They were more involved in early stages of their research projects than in ongoing research activities. PPs valued their experience and also felt they had improved the research process and outcomes. This case study showed how PPs perceive their roles, but a more diverse group of PPs might have more differences in their experience. Background Patient engagement in primary care research is increasing and is now an expectation in many countries and funding agencies. In Canada, the Canadian Institutes of Health Research (CIHR) has mandated that patients be included as partners to guide the research process. Ontario's Patient Engagement Resource Centre (PERC) was established in 2016 by the INNOVATIONS STRENGTHENING PRIMARY HEALTH CARE THROUGH RESEARCH (INSPIRE-PHC), one of 12 centres of excellence in the province funded under the CIHR's Strategy for Patient-Oriented Research (SPOR) initiative. PERC's mission is to support the authentic engagement of patients in primary care research. The present case study examines patients' experience of engagement in INSPIRE-PHC research studies. Methods PERC conducted a web-based evaluation survey across the three INSPIRE-PHC studies that engaged patient partners (PPs). We used data collection tools developed by McMaster University (the Public and Patient Engagement Evaluation Tool (PPEET)) and the Patient-Centred Outcomes Research Institute (Ways of Engaging- ENgagement ACtivity Tool (WE-ENACT)) to assess patient experience and areas of involvement. These included both closed- and open-ended questions. Results The quantitative data showed that PPs were positive about their experience during research meetings, the value of collaboration, and the support that was provided to facilitate engagement. Most of them were highly involved in the initial stages of their research projects but much less involved in operational activities. The qualitative findings showed that, overall, PPs valued their experience, felt prepared to contribute and that their contributions were welcomed. In particular, they considered that they had improved the research process and outcomes. The majority also reported that they had learned from the experience and found it valuable. Conclusions This case study shows that patients engaged in three primary care research studies found the experience to be positive and felt that they had contributed to the research. This study adds to the literature on the evaluation of patient engagement in primary health care research. However, a study of a more diverse sample of PPs might elucidate differences in experience that could enrich future patient engagement activities. [ABSTRACT FROM AUTHOR]