Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational ABSTRACT. Ann Fam Med 2009;7: doi: /afm.982.

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1 Mnging Chronic Disese in Ontrio Primry Cre: The Impct of Orgniztionl Fctors Grnt M. Russell, MBBS, FRACGP, MFM, PhD 1,2 Simone Dhrouge, MSc 1 Willim Hogg, MSc, MClSc, MD, FCFP 1-3 Roert Geneu, PhD 1,2 Lur Muldoon, MD, MPH, FCFP 1,2 Meltem Tun, PhD 1 1 C.T. Lmont Primry Helth Cre Reserch Centre, Éliseth Bruyère Reserch Institute, Ottw, Ontrio, Cnd 2 Deprtment of Fmily Medicine, University of Ottw, Ottw, Ontrio, Cnd 3 Institute of Popultion Helth, University of Ottw, Ottw, Ontrio, Cnd ABSTRACT PURPOSE New pproches to chronic disese mngement emphsize the need to improve the delivery of primry cre services to meet the needs of chroniclly ill ptients. This study (1) ssessed whether chronic disese mngement differed mong 4 models of primry helth cre delivery nd (2) identified which prctice orgniztionl fctors were independently ssocited with high-qulity cre. METHODS We undertook cross-sectionl survey with nested qulittive cse studies (2 prctices per model) in 137 rndomly selected primry cre prctices from 4 delivery models in Ontrio Cnd: fee for service, cpittion, lended pyment, nd community helth centers (CHCs). Prctice nd clinicin surveys were sed on the Primry Cre Assessment Tool. A chrt udit ssessed evidence-sed cre delivery for ptients with dietes, congestive hert filure, nd coronry rtery disese. Intermedite outcomes were clculted for ptients with dietes nd hypertension. Multiple liner regression identified those orgniztionl fctors independently ssocited with chronic disese mngement. RESULTS Chronic disese mngement ws superior in CHCs. Clinicins in CHCs found it esier thn those in the other models to promote high-qulity cre through longer consulttions nd interprofessionl collortion. Across the whole smple nd independent of model, high-qulity chronic disese mngement ws ssocited with the presence of nurse-prctitioner. It ws lso ssocited with lower ptient-fmily physicin rtios nd when prctices hd 4 or fewer full-time-equivlent fmily physicins. CONCLUSIONS The study dds to the literture supporting the vlue of nurseprctitioners within primry cre tems nd vlidtes the contriutions of Ontrio s CHCs. Our oservtion tht qulity of cre decresed in lrger, usier prctices suggests tht moves towrd lrger prctices nd greter ptientphysicin rtios my hve unnticipted negtive effects on processes of cre qulity. Ann Fm Med 2009;7: doi: /fm.982. Confl icts of interest: none reported CORRESPONDING AUTHOR Grnt M. Russell, MBBS, PhD C.T. Lmont Primry Helth Cre Reserch Centre Éliseth Bruyère Reserch Institute 43 Bruyère St Ottw, Ontrio K1N 5C8 Cnd grussell@ruyere.org INTRODUCTION Chronic helth conditions re sustntil chllenge to glol helth. 1 By 2020 they will ccount for 73% of ll deths nd 60% of the glol urden of disese. 2-5 Cnd s experience mtches tht of much of the developed world, where in the next decde deths cused y chronic diseses will increse y 15%. 6 The growing urden of chronic diseses thretens the sustinility of helth cre systems. 7,8 In the United Sttes, for exmple, the nnul economic effect on the US economy of the most common chronic diseses is more thn $1 trillion nd could rech nerly $6 trillion y the middle of the century. 4 Cnd stnds to lose $9 illion in the next decde from premture deths cused y hert disese, stroke, nd dietes

2 Policy mkers hve ecome incresingly interested in the potentil of high-qulity primry cre to help del with the chronic disese chllenge. Primry cre is well positioned to hve n importnt impct on outcomes of cre for ptients with chronic conditions. 9 There re, however, importnt vritions in the delivery of chronic disese mngement progrms nd services in primry cre. 10,11 Recent studies suggest tht the wy chronic disese mngement is delivered in generl prctice is highly infl uenced y orgniztionl fctors. 12,13 Vrious studies hve suggested tht highqulity chronic disese mngement cn e promoted y fi nncil incentives, cpitted pyment structures, improved Internet technology infrstructure, nd the wider use of nonmedicl helth cre professionls In Cnd, severl provinces re in the process of redesigning their primry cre system with the cler purpose of improving chronic illness cre. 10 This report origintes from mixed methods study, Comprison of Models of Primry Helth Cre in Ontrio, funded y the Ontrio Ministry of Helth nd Long Term Cre. The study ws designed to descrie nd compre the structure nd process of cre within 4 primry helth cre delivery models in Ontrio, Cnd: fee for service (FFS), fmily helth networks (FHNs), helth service orgniztions (HSOs), nd community helth centers (CHCs). 11 From 2004 through 2006 prctices operting within these 4 models were responsile for delivering primry cre to most of the Ontrio popultion. Tle 1 displys these models, s well s the fmily helth groups (FHGs) to which most prctices in the FFS group eventully trnsitioned, nd their essentil chrcteristics In this rticle we ddress 2 questions: (1) does chronic disese mngement differ etween the 4 models of primry helth cre delivery in Ontrio, nd Tle 1. Compring the Fetures of the Models in Chrcteristic Community Helth Center (CHC) Fee for Service (FFS) Fmily Helth Groups (FHG) Fmily Helth Network (FHN) Helth Service Orgniztion (HSO) Yer introduced 1970s s Group size Group prctice, size 1 Physicin Minimum 3 Minimum 3 Minimum 3 unspecified Physicin remunertion Slry FFS FFS nd incentives Cpittion with 10% FFS component, nd incentives Cpittion nd incentives Ptient enrollment Required No roster size limit Not required Required No roster size limit Required Disincentive to enroll >2,400 c Required Disincentive to enroll >2,400 c Access No specified requirements No specified requirements THAS Extended hours e THAS Extended hours d Access onuse e THAS Extended hours d Access negtion f Multidisciplinrity g Extensive None None Some Some Assistnce for informtion Some None None Yes None technology Ojectives/priorities Responsiveness to popultion needs, multidisciplinrity, prevention, focus on underserved, community governed 18 Accessiility 19 Accessiility, comprehensiveness, doctornurse collortion, use of technology Responsiveness to popultion needs, multidisciplinrity, helth promotion, cost effectiveness 20 Adpted from (PCRComprisonJn0807.pdf). THAS = Telephone Helth Advisory Service, ptient telephone dvisory system for which physicins re required to provide on-cll services 24 hours dy, 7 dys week. Lte in 2004, the Ontrio Ministry of Helth (MOH) creted new model of cre, the FHG, to which FFS prctices could trnsition. A fmily helth group (FHG) is collortive comprehensive primry cre delivery model involving 3 or more physicins prcticing together. These physicins need not e locted in the sme physicl office spce, ut must e within resonle distnce of ech other. FFS prctices converted to this new model quickly, so tht y erly 2006 most FFS prctices hd ecome FHGs, nd it ecme evident tht the gret mjority would trnsition y the yer end. Under cpittion remunertion, fmily physicins received fixed monthly fee per ptient enrolled, independent of the numer of visits mde to the prctice y tht ptient. The cpittion fee is sed on the enrolled ptient sex nd ge. FHN physicins receive n dditionl 10% of the FFS structure for ech visit. The ltter is intended to llow etter monitoring of services delivered. In 2008 ll HSO were converted to fmily helth orgniztions. Under tht model, the prctices tody lso receive 10% of the FFS structure for ech visit. c The se cpittion rte is reduced to 50% for ptients enrolled to clinicin with prctice size exceeding 2,400. d Ech physicin is required to provide t lest 1, 3-hour session outside regulr hours (evening/weekend) per week (up to 5 sessions per group/network/orgniztion). e An incentive onus reduced in reltion to numer of visits ptients mke to nonspecilists outside the FHN. f A penlty incurred from the cpittion fee for visits ptients mke to nonspecilists outside the FHN. Tody, HSO prctices re eligile for the ccess onus re not suject to negtion. g Multidisciplinrity refers to the presence of llied helth professionls (eg, physiotherpist, socil worker, nd phrmcist), excluding nursing stff, ut including nurse-prctitioners. 310

3 (2) wht prctice-sed orgniztionl fctors re ssocited with high-qulity chronic disese mngement. METHODS Design Ours ws cross-sectionl study with concurrent nested qulittive component. The study ws set in primry cre prctices in Ontrio etween Octoer 2005 nd June Dt were gthered from primry cre prctices, clinicins (fmily physicins nd nurse-prctitioners), nd ptients (surveys nd chrt strctions) receiving cre t these prctices. The study ws pproved y the Ottw Hospitl Reserch Ethics Bord. Smple We imed to recruit 35 prctices of ech model from smpling frme tht included ll known nd eligile FHNs (94), CHCs (51), nd HSOs (65) in the province. The FFS smpling se comprised 155 rndomly selected prctices from list of 1,884 prctices. Eligile prctices were required to hve offered comprehensive primry cre services for dults, hve elonged to their respective model for t lest 1 yer, nd hve t lest 50% of their primry cre clinicins consent to the study. The ptient smple for chrt review ws otined from rndom smple of 30 chrts in ech prctice. We included chrts of ptients ged 17 yers or older Tle 2. Indictors Individully Reported DELIVERING CHRONIC DISEASE MANAGEMENT Mneuvers Dietes 21,22 CAD 23,24 CHF 25,26 Hypertension 27 Foot exmintion in previous 2 yers Eye exmintion in previous 2 yers ACEI/ARB in previous 2 yers X X 2 HA 1c tests in the previous 1 yer Trget lood pressure in pst 6 months Averge lood pressure in pst 6 months Aspirin in previous 2 yers X ß Blocker in previous 2 yers X X Sttin in previous 2 yers X Trget HA 1c (<7.0%) X Averge HA 1c X X X X ACEI/ARB = ngiotensin-converting enzyme inhiitor/ngiotensin receptor lockers; HA 1c = hemogloin A 1c. Used to clculte disese score. Scoring method: the chronic disese mngement score is clculted for ptients suffering from t lest 1 of the chronic diseses listed ove. Ech eligile condition s mneuvers re ssigned 1 if the mneuver ws followed (or 0.5 if HA 1c test in the previous yer ws done only once rther thn twice) or 0 if it ws not. For ech condition the rtio of mneuvers followed is estimted. Finlly, simple (not weighted) verge of the pplicle condition scores is clculted to otin the ptient s chronic disese mngement score. Trget lood pressure for ptients with dietes is set t 130/80 mm Hg nd 140/90 mm Hg for other ptients. who hd een ptient of the prctice for more thn 2 yers nd hd visited the prctice in the yer efore the chrt review. For the qulittive cse study, we purposefully selected 2 typicl prctices per model. In ech prctice, we conducted semi-structured interviews with etween 1 nd 4 fmily physicins in ech prctice. In the 2 CHCs nd HSOs we lso interviewed nurse-prctitioners. Finlly, 6 of the 50 rndomly selected ptients who completed ptient questionnire t ech site were lso interviewed. Instruments Three instruments comprised the dt sources for this study. A clinicin questionnire (pproprite for fmily physicins nd nurse-prctitioners) nd prctice questionnire were modifi ed from the clinicin survey tool of the Primry Cre Assessment Tool (PCAT)-Adult edition, originl nd ridged versions. 20 These questionnires contined items eliciting sociodemogrphic informtion out the clinicins nd descriptive informtion out the prctice environment (including the tem structure, setting, hours of opertion, vilility of medicl nd socil services in the surroundings, nd use of informtion technology). A chrt strction tool comprised ptient demogrphic dt (ge, sex, nd insurnce sttus) with series of items ssessing evidence-sed cre delivery for dietes, congestive hert filure, nd coronry rtery disese, s well s intermedite outcomes for dietes nd hypertension. Evidence-sed indictors were sed on the most recent guidelines for the mngement of these conditions nd re X X shown in Tle Disesespecifi c composite scores were clculted for ech ptient with dignosis of dietes, coronry rtery disese, or congestive hert filure s the sum of ech indictor vlue divided y the numer of indictors evluted for tht condition. An overll chronic disese mngement score ws computed s the verge of individul disese-specifi c composite scores for ech ptient. This score constituted the primry outcome mesure for the study. Two secondry outcome mesures represented intermedite clinicl outcomes relting R clinicl trgets for dietes (HA 1c ) nd hypertension. Smple size clcultion for the lrger study ws sed on 311

4 the ility to detect difference in nother outcome mesure: disese prevention. The study ws powered to detect difference of 0.5 stndrd devition in the disese prevention score, with n intrclss correltion of 0.2, n α vlue of.05, nd β vlue of Power nlysis ws performed for the overll chronic disese mngement. The chronic disese mngement score ws computed through use of the G-power progrm ( free sttisticl progrm developed y Frnz Ful,Uni Kiel,Germny: de/teilungen/p/gpower3/). We clculted the difference etween models tht could e detected with n 80% power to e 12%. Dt Anlysis Dt were nlyzed using SPSS-PC version 15.0 (SPSS Inc, Chicgo, Illinois). The unit of nlysis ws the model for the fi rst question (compring the models) nd the prctice for the second question (scertining orgniztionl fctors ssocited with etter chronic disese mngement.) Description of the Models Descriptive profi les of the models chrcteristics ssessed intermodel vriility. Ptient, clinicin, nd prctice fctor ssocitions with the chronic disese mngement score were evluted individully using liner regression nlyses. Linerity of continuous vriles ws verifi ed. Comprison of Models Differences in the models chronic disese mngement scores were fi rst ssessed through nlyses of vrince. Liner nd logistic regressions were used to exmine individul indictors nd secondry clinicl outcomes. To djust for the infl uence of ptient nd clinicin chrcteristics on the models differences in score, 2 seprte multiple liner regressions were performed (ech controlled for ptient chrcteristics nd rurlity; the second dded control for clinicin chrcteristics). Orgniztionl Fctors Orgniztionl fctors (clinicin nd prctice chrcteristics) ssocited with performnce of chronic disese mngement were identifi ed y pplying multiple liner regression nlysis with forwrd selection (entry of P =.10 nd exit of P =.15) while controlling for ptient chrcteristics. To evlute the trnsferility of ssocitions cross models, the fi ndings were pplied to ech model individully. For the qulittive nlysis, interviews were tperecorded, trnscried vertim, then coded nd nlyzed with the support of N6 softwre. 28 We used coding tree informed y the literture on primry cre orgniztions, which ws then refined through n itertive process using n open coding strtegy. 29 Susequent nlysis involved xil nd selected coding to explore interconnections etween existing ctegories nd suctegories. 30 Finlly, we used n immersion/crystlliztion pproch 31 to identify nd rticulte the themes nd ptterns emerging from the empiricl dtset. RESULTS Prctice nd ptient survey response rtes rnged etween 23% to 69% nd 74% to 85%, respectively. Secondry nlysis of province-wide helth dministrtive dtses showed tht the physicins from ech model prticipting in the study were similr to ll physicins prcticing in tht model in Ontrio. Four prctice ptterns could lso e evluted in FFS nd FHN prctices. These ptterns were found to differ y less 25% in 7 of 8 comprisons (results not shown). Descriptive nd Bivrite Anlyses Dt were collected from 137 prctices nd 363 helth clinicins. We interviewed 46 clinicins nd 22 ptients. Among the 4,108 ptients included in the chrt strctions, 514 (12.5%) hd t lest 1 chronic condition nd re included in the chronic disese mngement score. A further 899 chrts were included from ptients with hypertension. Tle 3 displys the models in terms of ptient, clinicin, nd prctice chrcteristics nd indictes ivrite ssocition with the chronic disese mngement score. Adherence to recommended cre ws 6% higher in men. Performnce incresed with ge until pproximtely 65 to 70 yers, fter which it dropped (dt not shown). Comprison of Models After we djusted the regression nlysis for potentil confounding fctors, CHCs hd higher overll performnce of chronic disese mngement (y 10% to 15%), result lrgely explined y their etter performnce in evidence-sed processes ssocited with dietic cre (Tle 4). No differences etween models were detected for the clinicl intermedite outcomes except for distolic lood pressure redings, which were signifi cntly lower in HSO ptients. Orgniztionl Fctors Associted With Chronic Disese Mngement Performnce Tle 5 shows the orgniztionl fctors independently ssocited with chronic disese mngement scores fter djusting for signifi cnt ptient fctors. The presence of nurse-prctitioner ws ssocited with 312

5 10% solute increse in disese mngement scores, wheres lrger prctices (with more thn 4 full-timeequivlent fmily physicins) hd 7% lower score thn smller prctices. Higher ptient lod per physicin (numer of ptients per fmily physicin) ws lso ssocited with lower scores. The reltionship ws liner, with ech dditionl 1,000 ptients eing ssocited with 3% drop in the score. The multivrite model ccounted for 9% (R 2 =.09) of score vriility. In this multivrite eqution, the ddition of the model vriles did not dd signifi cnt explntory vlue, suggesting tht much of the impct of the model vrile ws cptured in the 3 predictive fctors. Tle 6 shows strtifi ed nlysis y model. The results indicte tht, with the exception of the ptient lod vrile, which ppers to e driven y its effect within FFS nd HSO prctices, the independent vriles ssocited with performnce of chronic disese mngement were consistent cross models. Lrger prctices were ssocited with lower levels of cre in CHC, FFS, nd HSO prctices, ut not in FHNs. The presence of nurse-prctitioner in prctice ws ssocited with pproximtely 6% etter performnce. The qulittive fi ndings shed light on some of the cre processes tht fcilitte effective chronic disese mngement. First, there ws generl consensus mong clinicins tht longer consulttions trnslte into etter cre for chroniclly ill ptients. CHC physicins nd nurse-prctitioners seemed less likely thn those working in other models to feel time-chllenged. Tle 3. Ptient, Clinicin, nd Prctice Chrcteristics y Cre Model Chrcteristic Prctice Model Assocition With CDM CHC FFS FHN HSO β P Vlue Ptients included in CDM score Dietes, n Coronry rtery disese, n Congestive hert filure, n Hypertension, n Chronic diseses, verge, n Age, y c Sex, mle, % Prctice profile n (% response) 35 (69) 35 (23) 35 (37) 32 (49) Solo prctices, % Prctice size >4 fmily physicins, % Prctice full-time equivlent, n Fmily physicins Nurse-prctitioners Nurses d Presence of nurse-prctitioner, % <.001 No. of ptients per fmily physicin, 1, Booking time for routine visit, min Setting Hospitl within 10 km Rurlity index Length of prctice opertion, y Informtion technologies, % Electronic ptient records Electronic reminder system Clinicin profile, n Yers since grdution, n Femle clinicin, % Foreign-trined clinicin, % Clinicins with CFPC degree, % CDM = chronic disese mngement; CFPC = The College of Fmily Physicins of Cnd; CHC = community helth center; FSS = fee for service; FHN = fmily helth network; HSO = helth service orgniztion. Result of undjusted regression nlysis etween CDM score nd ech vrile seprtely. Includes ll chrts in smple meeting criteri for dietes, coronry rtery disese, congestive herth filure, nd hypertension. c The reltionship etween CDM nd ge is est represented y the following second-order eqution: ge β = ge 2. β = d Includes registered prcticl nurses, nurses, nd nursing ssistnts. 313

6 for dietics to do the teching tht tkes time, the mount of time you need to spend with those people is signifi cnt...here you hve the fee structure set up where you re le to tke tht time it is not fctory. It is not n ssemly line. It s good helth cre (Nurse-prctitioner, CHC). Additionlly, mny CHC prticipnts suggested tht prticiption in collortive tem forces more comprehensive nd ccurte chrting. One CHC physicin with long experience in FFS settings noted: in privte prctice you re the only person who sees the fi le, so noody else hs to e le to interpret wht you hve written while here the chrts re much more comprehensive. I m not sying tht it is etter system thn in privte prctice, I just know tht the fi les re not s complete mye s they would e in plce like this (Fmily physicin, CHC). Tle 4. Chronic Disese Mngement Mesures Across Models Mesures CHC FFS FHN HSO P Vlue Process mesures Dietes, % Foot exmintion documented in previous 2 y <.001 Eye exmintion in previous 2 y ACEI/ARB in previous 2 y HA 1c tests in previous 1 y Overll dietes score <.001 Coronry rtery disese, % Aspirin documented in previous 2 y β-blocker documented in previous 2 y Sttin documented in previous 2 y Overll coronry rtery disese score Congestive hert filure, % ACEI/ARB in previous 2 y β-blocker in previous 2 y Overll congestive hert filure score Overll chronic disese mngement score, % Totl score, men Undjusted difference in score c Ref -11 d -12 e -8 f Adjusted difference in score g Ref -13 e -15 e -10 d Outcome mesures: intermedite clinicl outcome Dietes Trget HA 1c, % h Lst HA 1c level, men % Hypertension Trget lood pressure, % i Systolic lood pressure, men, mm Hg 138 j Distolic lood pressure, men, mm Hg 81.2 j 80.4 k 80.1 k ACEI/ARB = ntiotensin-converting enzyme inhiitors/ntiotensin receptor lockers; CHC = community helth center; FFS = fee for service; FHN = fmily helth network; HA1c = hemogloin A1c; HSO = helth service orgniztion. Note: Vlues, unless otherwise stted, re expressed s percentge of chrts on which the individul mnoeuvre ws noted. Generted from contingency tle using Person χ 2 sttistic. Generted with nlysis of vrince. c Result of regression nlysis with only model dummy vriles. d P <.01 compred with CHC s reference. e P <.001 compred with CHC s reference. f P <.05 compred with CHC s reference. g Result of regression nlysis with model dummy vriles nd djusted for ptient ge nd sex. h Percentge of ptients with HA 1c 7.0 i Percentge of ptients with verge trget lood pressure in previous 6 months. Trget lood pressure ws 130/80 mm Hg for ptients with dietes nd 140/90 mm Hg for ll others. j P <.05 compred to HSO s reference. k P <.001 compred to HSO s reference. Of importnce, CHCs hd degree of orgniztionl rediness for chnges imed t improving dietes cre, prticulrly in their use of dietes eduction nd cre tems. Nurse-prctitioners were n importnt prt of mny of these tems, with their ctivities rnging from consulttion-sed primry cre to the orgniztion of chronic disese clinics. The contriutions of dietes nurse specilists, dietitins, nd chiropodists re lso vlued y CHC physicins: ecuse of the wy the orgniztion is set up, it cn lmost e set up so tht the dietes is mnged with directives y the physicin nd ll of tht y the dietes nurse. So she cn increse their mediction, she cn dvise them on wht to do with their dietes, so tht helps lot ecuse then tht is one mjor chronic disese tht cn e cred for tht I don t hve to del with. I cn del with whtever else, or I cn del with the more complicted issues of the dietes. We hve diet counselor who cn help with ptients with prolems with weight, oesity, nd the like. Wht else do we hve? A chiropodist, so tht helps with the foot prolems. All of those help with the most complex ptients, you cn kind of help ech other out on tht. (Fmily physicin, CHC). Physicins prcticing in other models reported tht they re only slowly strting to tke dvntge of system chnge relted to dietes cre: There is specil code tht I cn use for seeing dietics (since I egn to use the code). I m strting to 314

7 ook longer visits for my dietic ptients in order to do those ssessments, which is ctully wht we should hve een doing, I wsn t relly wre tht there ws such comprehensive ssessment dole. I guess I ws wre ut I just wsn t orgnized enough to do it (Fmily physicin, FHN). DISCUSSION This study dds to the sprse literture compring chronic disese mngement etween differing models of primry cre. It lso offers insight into the orgniztionl fetures within primry cre prctice ssocited with high-qulity cre of chronic helth conditions. There re 2 key fi ndings. First, we found evidencesed processes ssocited with high-qulity chronic disese cre to e most common in Ontrio s CHCs. Second, cross the whole smple, high-qulity chronic cre delivery ws more likely with the presence of nurse-prctitioner. Qulity of cre decresed with ptient lod nd in those prctices with more thn 4 full-time-equivlent fmily physicins. These fctors outweighed ny independent infl uence of model of cre delivery. Ontrio s CHCs were estlished in the 1970s nd were prt of roder Cndin inititive to respond to perceived prolems in helth service delivery. Unlike DELIVERING CHRONIC DISEASE MANAGEMENT Tle 5. Orgniztionl Fctors Independently Associted With Chronic Disese Mngement Prctice Profile Predictors β P Vlue Confidence Intervl Presence of nurse-prctitioner < to Lrge prctices to Ptient lod to Note: Results of regression model showing the impct of ech fctor on chronic disese mngement performnce. The model is djusted for ptient ge nd sex. Prctices hosting more thn 4 fmily physicins. No. of ptients per fmily physicin ( 1,000). Tle 6. Orgniztionl Fctors Independently Associted With Chronic Disese Mngement Across Models (β Represented Only) Prctice Profile Predictors Overll CHC FFS FHN HSO Presence of nurse-prctitioner Lrge prctices Ptient lod c CHC = Community Helth Center; FFS = fee for service; FHN = fmily helth network; HSO = helth service orgniztion. Note: Results of regression model showing the impct of ech fctor on chronic disese mngement performnce. The model is djusted for ptient ge nd sex. All prticipting CHCs hosted nurse-prctitioners. Prctices hosting more thn 4 fmily physicins. c No. of ptients per fmily physicin 1,000. other models within our study, CHCs operte under community governnce, py physicins y slry, nd comine clinicl services with rnge of integrted community progrms. Severl hve implemented specifi c dietes cre progrms. We found tht mesures of dietic processes of cre were higher in CHCs, ut tht lood glucose control ws not. With the exception of HA 1c ssessments, the processes mesured in dietes were relted to the detection nd prevention of end-orgn dmge rther thn lood glucose control. Still, if the processes mesures used to evlute performnce were n indictor of overll cre, one my hve expected improved intermedite outcomes in tht popultion. Filure to oserve difference my relte to the gp etween recommended cre nd ptient complince or response to such cre. CHCs sed in the United Sttes hve een found to deliver higher stndrd of cre when compred with hospitl outptient clinics, nd physicin s offi ces. 32,33 Ptients rte them highly in service coordintion, comprehensiveness, nd community orienttion. 34 In our study, 2 of 3 orgniztionl chrcteristics independently ssocited with qulity chronic disese mngement processes (the presence of nurse-prctitioner nd smller ptient-physicin rtios) were chrcteristic of CHC prctices. Our fi ndings dd to the literture suggesting tht nurse-prctitioners hve positive effect on numer of spects of primry cre delivery. 35,36 The presence of other clinicl disciplines did not hve positive ssocition with chronic disese mngement. Although there is evolving understnding of the enefi ts of, nd processes ssocited with, nurse-prctitioner physicin collortion, the resons underlying improved outcomes ssocited with nurse-prctitioner involvement in primry cre tems re uncler. There re severl possiilities. First, nurse-prctitioner my help ese physicin worklod through tking over some duties usully performed y physicins. Second, nurseprctitioners my ffect performnce through their involvement in delivering cre through orgnized cre mngement ctivities, such s dietes clinics. Finlly, it is fesile tht the incorportion of nurse-prctitioner, prticulrly in the non-chc prctices, is mrker of prctice-sed orgniztionl pproches towrd chnging the sttus quo. 315

8 Professionl orgniztions hve een incresingly preoccupied with the impct of workforce shortges of primry cre clinicins, in prticulr fmily physicins nd nurses. Our dt suggested tht prctices with smller numers of ptients per clinicin were more likely to provide higher cre qulity, principlly in FFS, the model serving the lrgest popultion of Ontrins. We found etter chronic disese mngement in prctices contining 4 or fewer fmily physicins fi nding consistent cross ech of the models. Although severl US-sed studies hve found modest direct correltion etween the numer of physicins nd the qulity of chronic cre processes, recent British studies hve found prctice size to e only modestly, 43 if t ll, predictive of qulity of cre processes. 44 Agin, our cross-sectionl design mkes it diffi cult to e certin out the resons ehind the ssocition etween smller prctices nd etter chronic disese mngement. The fi nding, however, my e ssocited with unique fetures of Ontrio primry cre. Unlike overses, physicins ssistnts re unknown in Ontrio, reducing the likelihood of the delegtion of ctivities often found in lrger prctices. With the province only eginning the process of primry cre reform, it my e tht lrger prctices re yet to perceive sufficient incentives to initite high-qulity cre processes. Accordingly, it my e tht the potentil economies of scle of lrger prctices my e outweighed y esier prctice decision mking in smller prctice sites. Unlike others, 32,40,45,46 we found no evidence tht prctice s use of electronic medicl records infl uenced the chronic disese mngement score. Similr fi ndings in studies compring chronic disese mngement in pper-sed nd electronic prctices in the United Sttes, 47 nd Queec 48 suggest tht lthough prctice informtion systems cn ssist chronic disese mngement, using such systems is no gurntee of effective chronic disese cre. This cross-sectionl study hs numer of limittions. Our prctice smple excluded prctices in the fr north of the province nd ws limited y low response rte in FFS prctices (23%). Nevertheless, our FFS smple hd similr demogrphic profi le to grouped dt on ll FFS prctices within Ontrio. Our ssessment of chronic disese cre excluded the considertion of chronic disese mngement in children nd ws restricted to the considertion of 3 conditions. Our outcome mesures were scertined y chrt strctions, well known to underestimte cre processes through their inility to cpture processes of cre tht re delivered, ut not documented. This pproch cn lso led to ised model comprison if differentil chrting prctices exist cross models, prmeter we did not mesure. Even so, differences in the qulity of cre oserved etween models were not exclusively found in processes tht re less likely to e documented. They were lso found, for exmple, in the frequency of hemogloin A 1c evlution, suggesting tht document is lone could not explin the differences in the performnce mesured. Finlly, wheres our ssessment of prctice fctors potentilly infl uencing qulity of cre ws lrge, it ws not comprehensive. For exmple, we did not collect dt on the clinicin s experience of, s well s chrcteristics of, the reltionships with their ptients or within tem memers. Implictions for Policy nd Prctice Our dt llowed us to evlute chronic cre outcomes in province undergoing considerle primry cre reform. The study dds to the evidence suggesting tht the orgniztion nd mkeup of the primry cre tem infl uences the delivery of cre qulity. Our fi ndings dd to the literture supporting the vlue of nurse-prctitioners within primry cre tems nd vlidte the contriutions of Ontrio s CHCs. Further work should exmine whether current moves towrd lrger prctices nd greter ptient physicin rtios my hve unnticipted negtive impcts on processes of qulity cre. To red or post commentries in response to this rticle, see it online t Key words: Primry helth cre; chronic disese; qulity of helth cre Sumitted June 16, 2008; sumitted, revised, Septemer 30, 2008; ccepted Octoer 8, Preliminry findings concerning the specific topic of this pper hve een presented t severl conferences: Geneu R, Dhrouge S, Russell G, et l. The orgniztionl determinnts of chronic disese mngement prctices. Annul Meeting of the North Americn Primry Cre Reserch Group. Vncouver, Octoer 2007; Russell GM. Access nd qulity of clinicl cre: results from the Comprison of Models of Primry Cre (COMPC) Study. Primry Helth Cre Reserch, Evlution nd Development Western Austrli: Seminr, Como, Austrli, Decemer 2006; Russell GM, Dhrouge S, Hogg W, Kristjnsson B. Does delivery model influence clinicl qulity? Interim findings from the Comprison of Models of Primry Cre in Ontrio study (pper), 34th NAPCRG Annul Meeting, Tucson, AZ, Octoer 2006; Hogg W, Russell GM, Dhrouge S, et l. Results from the Comprison of Models of Primry Cre in Ontrio study (pper), 34th NAPCRG Annul Meeting, Tucson, AZ, Octoer Funding support: Funding for this reserch ws provided y the Ontrio Ministry of Helth nd Long-Term Cre Primry Helth Cre Trnsition Fund. Disclimer: The views expressed in this report re the views of the uthors nd do not necessrily reflect those of the Ontrio Ministry of Helth nd Long-Term Cre. Acknowledgments: The uthors wish to cknowledge the ssistnce provided y Dr Enrique Soto in the preprtion of this mnuscript. 316

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10 41. Li R, Simon J, Bodenheimer T, et l. Orgniztionl fctors ffecting the doption of dietes cre mngement processes in physicin orgniztions. Dietes Cre. 2004;27(10): Schmittdiel JA, Shortell SM, Rundll TG, Bodenheimer T, Sely JV. Effect of primry helth cre orienttion on chronic cre mngement. Ann Fm Med. 2006;4(2): Millett C, Cr J, Eldred D, Khunti K, Minous AG III, Mjeed A. Dietes prevlence, process of cre nd outcomes in reltion to prctice size, cselod nd deprivtion: ntionl cross-sectionl study in primry cre. J R Soc Med. 2007;100(6): Wng Y, O Donnell CA, Mcky DF, Wtt GC. Prctice size nd qulity ttinment under the new GMS contrct: cross-sectionl nlysis. Br J Gen Prct. 2006;56(532): Bodenheimer T, Wng MC, Rundll TG, et l. Wht re the fcilittors nd rriers in physicin orgniztions use of cre mngement processes? Jt Comm J Qul Sf. 2004;30(9): Rundll TG, Shortell SM, Wng MC, et l. As good s it gets? Chronic cre mngement in nine leding US physicin orgnistions. BMJ. 2002;325(7370): Solerg LI, Scholle SH, Asche SE, et l. Prctice systems for chronic cre: frequency nd dependence on n electronic medicl record. Am J Mng Cre. 2005;11(12): Green CJ, Fortin P, Mclure M, Mcgregor A, Roinson S. Informtion system support s criticl success fctor for chronic disese mngement: Necessry ut not sufficient. Int J Med Inform. 2006;75(12): CHANGE-OF-ADDRESS FORM Plese complete this form nd mil to the following ddress or fx to Annls Circultion t : Annls of Fmily Medicine, Circultion Deprtment, Tomhwk Creek Pkwy, Lewood, KS Check if memer of sponsoring orgniztion: AAFP ABFM STFM ADFM AFMRD NAPCRG CFPC ID numer from lel on your journl cover OLD Informtion (Plese print.) NEW Informtion (Plese print.) Nme Nme Compny (if pplicle) Compny (if pplicle) Address (Street plus Apt or Ste) Address (Street plus Apt or Ste) City Stte City Stte Country Postl Code (9-digit ZIP for US) Country Postl Code (9-digit ZIP for US) Telephone Fx Telephone Fx E-Mil E-Mil 318