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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Context, practices and individuals
Organisational Factors Influencing the Management of Chronic Disease
Managing Chronic Disease in Ontario Primary Care.
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Grant M Russell, Ottawa, Canada Associate Professor. Department of Family Medicine, University of Ottawa., Simone Dahrouge, William Hogg, Robert Geneau
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We appreciate Prof Harris (1) and Ms Planavsky’s (2) comments on our paper (3) evaluating factors associated with quality chronic disease management in our large sample of primary care practices in Ontario. Our findings of better performance in Community Health Centres (CHCs) highlights how good performance can follow when, as in the CHCs, primary care delivery system are designed in part to optimise the care of patients with complex problems. As Professor Harris suggests, such an orientation brings with it the need to provide the structure to deliver such care – a principle linked with our finding that smaller practice size, smaller list sizes and presence of nurse practitioners were associated with better processes of primary care delivery. Policy makers should take note of the fact that this strength of association was enough to account for any observed differences between different organisational models of care. Professor Harris reminds of the importance of providing an environment to nurture the provision of care required as our health systems reorient themselves to the demands of chronic illness. Our study is one of a series that are beginning to look at how structural features of primary care influence health care outcomes. One of these structural features, the incorporation of nurse practitioners, is the subject of Ms Planavsky’s letter. She highlights recent literature comparing the performance of nurse practitioners (NPs) and primary care physicians and wonders whether our study was able to generate data on the nurse practitioner and physician experience. She suggests a series of other interesting comparisons between physicians and NPs. Professional organizations, clinicians and policy makers will always be interested in comparisons between NPs and physicians (and for that matter other primary care clinicians such as registered nurses and medical assistants). Our study was not designed to make these comparisons – we used, first, the model of care delivery, and second, the practice, as units of analysis. As such it’s difficult for us to separate individual provider contributions from the activities of the practice as a whole. It may well be that with the reality of the primary care team and the continuing evolution of the patient centred medical home, simple comparisons between physicians and nurse practitioners will become less and less important as research efforts move towards optimising the contributions and balance between each member of the primary care team. References:
Competing interests: None declared |
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Mark F Harris, Sydney, Australia Professor, Centre for Primary Health Care and Equity, University of New South Wales
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The paper by Russell et al. on “Managing Chronic Disease in Ontario Primary Care: The Impact of Organisational Factors”[1] has important implications in the Australian context. The finding that models of care in Canada differ in their performance is relevant to the current moves in Australia to establish more integrated multidisciplinary primary health care services especially for those with chronic illness. The finding that Community Health Centres performed best adds to findings in relation to the impact of Community Health Centres in the US especially in disadvantaged communities [2,3]. The study also found that better care processes were associated with lower patient to family physician ratios and workloads. This is an important reminder that ervices need to have sufficient capacity to deliver better care especially longer consultations. In Australia we have demonstrated that while there is good access into primary medical care, the inverse care law applies in relation to consultation length because of higher demands on doctors working in disadvantaged areas [4]. Services providing care to disadvantaged population need to have sufficient staff to provide better care especially preventive and chronic disease care. The finding that smaller practices provide better process of care is also consistent with the findings of our own research on the management of diabetes, cardiovascular disease and asthma in Australia [5]. As the authors discuss, this is a challenge as we develop new models of multidisciplinary primary health care. One option being explored in Australia at present is the creation of more virtual integration between relatively smaller services to try and provide the best of both the larger and smaller services. Finally, the lack of difference in outcome measures (except for diastolic blood pressure) is an important reminder that recorded processes of care are not necessarily associated with health outcomes. It is important that these continue to be monitored along with patient assessments of the quality care when evaluating service models. Mark Harris, Centre for Primary Health Care and Equity, University of New South Wales, Sydney Australia. References
Competing interests: None declared |
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Loretta A. Planavsky, Cleveland, US Nurse Practitioner, Cleveland Clinic
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Thank you for the opportunity to read this paper and for citing our paper from the Journal of Interprofessional Care, 2003. I have been working as an adult NP since 1996, and the past several years in an out- patient Preventive Cardiology Department, working with management of cardiovascular disease risk factors and/or chronic diseases, specifically dyslipidemia, diabetes & hypertension. As I read this paper, I experienced the following thoughts. With the reality of our growing health care systems as a competitive business, NP's must be careful to not be forced into seeing a set volume of patients in a set time frame as some MD's during their office visits. NP's are seeing similar patient types as their MD colleagues, but our service should be unique with how each patient visit is accomplished in order to support our NP role as having unique benefit to our mutual patients and to the organization as a whole. You may be interested in reviewing a qualitative paper based on our 2003 study and published in the JAANP, September 2001, vol.13, issue 9 entitled, Ending A Nurse Practitioner-Patient Relationship." This paper reports patients' reactions & perceptions to ending a year-long relationship with the NP. It would also be interesting to consider publishing data on the NP's & MD's experience. Other factors to consider in looking at chronic disease management by
NP's vs. MD's would be:
Thanks for this opportunity and best wishes-
Competing interests: None declared |
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