Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational Factors

Abstract

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...

The nursing contribution to chronic disease management: A case of public expectation? Qualitative findings from a multiple case study design in England and Wales

“…In Canada, high quality chronic disease management was found to be associated with the presence of a nurse practitioner (Russell et al, 2009), and an evaluation of nurse-led shared care in the Netherlands (Irmgard et al, 2002), where generalists and specialists work together with the focus on the patients needs, suggested that many participants preferred the treatment by the nurse practitioner in the GPs office to traditional care by the medical specialist at the outpatient clinic. However, patients felt it was important to maintain a direct link with the medical specialist, and the nurse practitioner model had limitations such as the requirement for the nurse to contact the medical specialist in case of a complication as this was felt to be too time consuming.…”

Practice Context Affects Efforts to Improve Diabetes Care for Primary Care Patients: A Pragmatic Cluster Randomized Trial

“…Other studies investigating relationships between diabetes/ chronic disease care and practice characteristics (including EHR, 33 Medicaid percentage, 34 community health centers, [35][36][37] and practice size 38,39 ) have reported mixed results. Interestingly, we find that rural and smaller practices, which often do not have as many connections to resources as urban practices, showed significantly greater improvement in both the CQI-and RAP-facilitated arms, while urban practices, usually with more available resources, saw more improvement in the self-directed arm.…”

Les pratiques infirmières avancées

“…Des études canadiennes récentes ont montré que les modèles de soins primaires qui incluent des infirmières praticiennes amélioraient la gestion des maladies chroniques (Russell et al, 2009) et l'accessibilité, en particulier dans les zones peu desservies (Centre for Rural and Northern Health Research, 2006;Martin-Misener et al, 2009). La satisfaction des patients pour ce rôle continue à être élevée (Thrasher et al, 2008).…”

“…Au Canada, les résultats d'une étude de 2009 évaluant la gestion d'un ensemble de maladies chroniques dans les soins primaires ont établi que la qualité des soins (en termes de mesures de processus) était supérieure dans les centres de santé « communautaires » qui impliquaient au moins une infirmière praticienne et où tout personnel était salarié (Russell et al, 2009). Parmi les différents types de modèles de soins primaires, une plus grande qualité de prestations de soins de maladies chroniques était plus probable lorsqu'une infirmière praticienne intervenait.…”

“…Il faut aussi identifier les « facteurs de succès » qui contribuent à optimiser les résultats par rapport aux coûts dans la prestation des services, incluant le rôle joué par les infirmières en pratique avancée. De telles évaluations nécessitent des méthodes statistiques avancées, mais il est encourageant de constater que certaines des évaluations présentées dans cette section ont déjà progressé dans cette direction (e.g., Russell et al, 2009;Litaker et al, 2003;Mousquès et al, 2010).…”