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

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
[1]Russell GM, Dahrouge S, Hogg W, Geneau R, Muldoon L, Tuna M. Managing Chronic Disease in Ontario Primary Care: The Impact of Organizational Factors. Annals of Family Medicine 2009; 7:309-318.
[2] Shi, L., G. D. Stevens, Politzer, R. Access to Care for U.S. Health Center Patients and Patients Nationally: How Do the Most Vulnerable Populations Fare? Medical Care 2007 45: 206-213.
[3] Eisert, SL, Mehler PS, Gabow PA. Can America’s Urban Safety Net Systems be a Solution to Unequal Treatment? Journal of Urban Health 2008; 85: 766-778.
[4] Furler JS, Harris E, Chondros P, Powell Davies PG, Harris MF, Young DYL. The inverse care law revisited: impact of disadvantaged location on accessing longer GP consultation times. Med J Aust 2002; 177: 80-83.
[5] Jayasinghe UJ, Proudfoot J, Holton C, Powell Davies G, Amoroso C, Bubner T, Beilby J, Harris MF. Chronically ill Australians' satisfaction with accessibility and patient-centredness. International Journal for Quality in Health Care 2008 20: 105-114

Competing interests:   None declared