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...