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

Grant M. Russell; Simone Dahrouge; William Hogg; Robert Geneau; Laura Muldoon; Meltem Tuna

doi:10.1370/afm.982

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Table 1.

Comparing the Features of the Models in 2005–2006

Characteristic	Community Health CENTER (CHC)	Fee for Service (FFS)	Family Health Groups (FHG)^a	Family Health Network (FHN)	Health Service Organization (HSO)
Adapted from https://www.oma.org/PC/PCRComparisonJan0807.pdf (PCRComparisonJan0807.pdf).
THAS = Telephone Health Advisory Service, a patient telephone advisory system for which physicians are required to provide on-call services 24 hours a day, 7 days a week.
^aLate in 2004, the Ontario Ministry of Health (MOH) created a new model of care, the FHG, to which FFS practices could transition. A family health group (FHG) is a collaborative comprehensive primary care delivery model involving 3 or more physicians practicing together. These physicians need not be located in the same physical office space, but must be within reasonable distance of each other. FFS practices converted to this new model quickly, so that by early 2006 most FFS practices had become FHGs, and it became evident that the great majority would transition by the year end.
^bUnder capitation remuneration, family physicians received a fixed monthly fee per patient enrolled, independent of the number of visits made to the practice by that patient. The capitation fee is based on the enrolled patient sex and age. FHN physicians receive an additional 10% of the FFS structure for each visit. The latter is intended to allow better monitoring of services delivered. In 2008 all HSO were converted to family health organizations. Under that model, the practices today also receive 10% of the FFS structure for each visit.
^cThe base capitation rate is reduced to 50% for patients enrolled to a clinician with a practice size exceeding 2,400.
^dEach physician is required to provide at least 1, 3-hour session outside regular hours (evening/weekend) per week (up to 5 sessions per group/network/organization).
^eAn incentive bonus reduced in relation to number of visits patients make to nonspecialists outside the FHN.
^fA penalty incurred from the capitation fee for visits patients make to nonspecialists outside the FHN. Today, HSO practices are eligible for the access bonus are not subject to negation.
^gMultidisciplinarity refers to the presence of allied health professionals (eg, physiotherapist, social worker, and pharmacist), excluding nursing staff, but including nurse-practitioners.
Year introduced	1970s	–	2004	2001	1970s
Group size	Group practice, size unspecified	1 Physician	Minimum 3	Minimum 3	Minimum 3
Physician remuneration	Salary	FFS	FFS and incentives	Capitation^b with a 10% FFS component, and incentives	Capitation^b and incentives
Patient enrollment	Required	Not required	Required	Required	Required
	No roster size limit		No roster size limit	Disincentive to enroll >2,400^c	Disincentive to enroll >2,400^c
Access	No specified requirements	No specified requirements	THAS	THAS	THAS
			Extended hours^e	Extended hours^d	Extended hours^d
				Access bonuse^e	Access negation^f
Multidisciplinarity^g	Extensive	None	None	Some	Some
Assistance for information technology	Some	None	None	Yes	None
Objectives/priorities	Responsiveness to population needs, multidisciplinarity, prevention, focus on underserved, community governed¹⁸	–	Accessibility¹⁹	Accessibility, comprehensiveness, doctor- nurse collaboration, use of technology	Responsiveness to population needs, multidisciplinarity, health promotion, cost effectiveness²⁰

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Table 2.

Indicators Individually Reported

Maneuvers	Diabetes²¹^,²²	CAD²³^,²⁴	CHF²⁵^,²⁶	Hypertension²⁷
ACEI/ARB = angiotensin-converting enzyme inhibitor/angiotensin receptor blockers; HbA_1c=hemoglobin A_1c.
^aUsed to calculate disease score. Scoring method: the chronic disease management score is calculated for patients suffering from at least 1 of the chronic diseases listed above. Each eligible condition’s maneuvers are assigned a 1 if the maneuver was followed (or 0.5 if HbA_1c test in the previous year was done only once rather than twice) or a 0 if it was not. For each condition the ratio of maneuvers followed is estimated. Finally, a simple (not weighted) average of the applicable con
dition scores is calculated to obtain the patient’s chronic disease management score. ^bTarget blood pressure for patients with diabetes is set at 130/80 mm Hg and 140/90 mm Hg for other patients.
Foot examination in previous 2 years	X^a
Eye examination in previous 2 years	X^a
ACEI/ARB in previous 2 years	X^a		X^a
2 HbA_1c tests in the previous 1 year	X^a
Target blood pressure in past 6 months^b				X
Average blood pressure in past 6 months				X
Aspirin in previous 2 years		X^a
β Blocker in previous 2 years		X^a	X^a
Statin in previous 2 years		X^a
Target HbA_1c (<7.0%)	X
Average HbA_1c	X

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Table 3.

Patient, Clinician, and Practice Characteristics by Care Model

	Practice Model				Association With CDM^a
Characteristic	CHC	FFS	FHN	HSO	β	PValue
CDM = chronic disease management; CFPC = The College of Family Physicians of Canada; CHC = community health center; FSS = fee for service; FHN = family health network; HSO=health service organization.
^aResult of unadjusted regression analysis between CDM score and each variable separately.
^bIncludes all charts in sample meeting criteria for diabetes, coronary artery disease, congestive hearth failure, and hypertension.
^cThe relationship between CDM and age is best represented by the following second-order equation: age β = 0.027+age². β = 0.00019.
^dIncludes registered practical nurses, nurses, and nursing assistants.
Patients included in CDM score	120	115	138	141	–	–
Diabetes, n	82	69	80	82	–	–
Coronary artery disease, n	50	57	72	84	–	–
Congestive heart failure, n	8	15	15	19	–	–
Hypertension, n	201	221	257	236	–	–
Chronic diseases, average, n^b	1.8	1.8	1.9	2.0	0.043	.019
Age, y^c	59.6	62.6	63.8	65.1	0.0022	.016
Sex, male, %	39	49	49	50	0.057	.027
Practice profile n (% response)	35 (69)	35 (23)	35 (37)	32 (49)
Solo practices, %	0	26	37	38	0.0041	.87
Practice size >4 family physicians, %	17	14	40	3	−0.044	.188
Practice full-time equivalent, n
Family physicians	3.0	2.4	3.6	1.7	−0.0039	.50
Nurse-practitioners	2.5	0.1	0.3	0.2	0.035	.001
Nurses^d	2.7	0.6	1.9	1.0	0.012	.19
Presence of nurse-practitioner, %	100	8.6	31.4	18.8	0.097	<.001
No. of patients per family physician, ×1,000	1.3	1.8	1.5	2.0	−0.032	.033
Booking time for routine visit, min	25	13	14	14	0.0063	.004
Setting
Hospital within 10 km	71	85	94	84	−0.031	.35
Rurality index	14.2	12.6	16.2	8.0	−0.0010	.16
Length of practice operation, y	18.3	16.4	24.4	26.7	0.00029	.80
Information technologies, %
Electronic patient records	29	14	57	44	−0.021	.44
Electronic reminder system	26	14	46	28	0.036	.19
Clinician profile, n	182	58	81	42
Years since graduation, n	19	22	23	29	0.0021	.15
Female clinician, %	58	45	41	26	−0.023	.47
Foreign-trained clinician, %	9	17	3	14	−0.0065	.90
Clinicians with CFPC degree, %	79	85	78	68	−0.0017	.96

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Table 4.

Chronic Disease Management Measures Across Models

Measures	CHC	FFS	FHN	HSO	PValue
ACEI/ARB = antiotensin-converting enzyme inhibitors/antiotensin receptor blockers; CHC = community health center; FFS = fee for service; FHN = family health network; HbA1c = hemoglobin A1c; HSO = health service organization.
Note: Values, unless otherwise stated, are expressed as percentage of charts on which the individual manoeuvre was noted.
^aGenerated from contingency table using Pearson χ² statistic.
^bGenerated with analysis of variance.
^cResult of regression analysis with only model dummy variables.
^dP <.01 compared with CHC as reference.
^eP <.001 compared with CHC as reference.
^fP <.05 compared with CHC as a reference.
^gResult of regression analysis with model dummy variables and adjusted for patient age and sex.
^hPercentage of patients with HbA_1c ≤ 7.0
ⁱPercentage of patients with average target blood pressure in previous 6 months. Target blood pressure was 130/80 mm Hg for patients with diabetes and 140/90 mm Hg for all others.
^jP <.05 compared to HSO as reference.
^kP <.001 compared to HSO as reference.
Process measures
Diabetes, %
Foot examination documented in previous 2 y	63	29	39	39	<.001^a
Eye examination in previous 2 y	61	44	38	37	.005^a
ACEI/ARB in previous 2 y	71	64	65	73	.536^a
2 HbA_1c tests in previous 1 y	73	57	54	48	.007^a
Overall diabetes score	69	52	53	54	<.001^b
Coronary artery disease, %
Aspirin documented in previous 2 y	80	75	72	75	.81^a
β-Blocker documented in previous 2 y	80	67	62	73	.18^a
Statin documented in previous 2 y	76	81	64	76	.14^a
Overall coronary artery disease score	79	74	66	75	.11^b
Congestive heart failure, %
ACEI/ARB in previous 2 y	63	93	93	84	.17^a
β-Blocker in previous 2 y	50	47	47	68	.51^a
Overall congestive heart failure score	56	70	70	76	.56^b
Overall chronic disease management score, %
Total score, mean	72	61	60	64	.003^b
Unadjusted difference in score^c	Ref	−11^d	−12^e	−8^f
Adjusted difference in score^g	Ref	−13^e	−15^e	−10^d
Outcome measures: intermediate clinical outcome
Diabetes
Target HbA_1c, %^h	56	54	61	55	.83^a
Last HbA_1c level, mean %	7.3	7.1	6.8	7.2	.23^b
Hypertension
Target blood pressure, %ⁱ	38	40	39	44	.65^a
Systolic blood pressure, mean, mm Hg	138^j	135.2	137	135.3	.055^b
Diastolic blood pressure, mean, mm Hg	81.2^j	80.4^k	80.1^k	76.7	.007^b

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Table 5.

Organizational Factors Independently Associated With Chronic Disease Management

Practice Profile Predictors	β	PValue	Confidence Interval
Note: Results of regression model showing the impact of each factor on chronic disease management performance. The model is adjusted for patient age and sex.
^aPractices hosting more than 4 family physicians.
^bNo. of patients per family physician (×1,000).
Presence of nurse-practitioner	0.101	<.001	0.051 to 0.152
Large practices^a	−0.067	.040	−0.13 to −0.003
Patient load^b	−0.032	.028	−0.060 to −0.004

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Table 6.

Organizational Factors Independently Associated With Chronic Disease Management Across Models (β Represented Only)

Practice Profile Predictors	Overall	CHC	FFS	FHN	HSO
CHC = Community Health Center; FFS = fee for service; FHN = family health network; HSO = health service organization.
Note: Results of regression model showing the impact of each factor on chronic disease management performance. The model is adjusted for patient age and sex.
^aAll participating CHCs hosted nurse-practitioners.
^bPractices hosting more than 4 family physicians.
^cNo. of patients per family physician ×1,000.
Presence of nurse-practitioner	0.101	–^a	0.062	0.054	0.060
Large practices^b	−0.067	−0.125	−0.076	0.0042	−0.087
Patient load^c	−0.032	0.021	−0.069	−0.0037	−0.026

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The Article in Brief

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

Grant M. Russell , and colleagues

Background Primary care is well-suited to treating patients with chronic diseases, but there are many differences in how chronic disease management programs and services are delivered. This study analyzes the impact of different primary care models and practice features on chronic disease management in Ontario, Canada.

What This Study Found Community health centers provided superior chronic disease management because of longer patient visits and collaboration with other professionals. Across all practice types, regardless of model, what accounted most for high-quality management was the presence of a nurse-practitioner, smaller practices, and lower patient load. Quality of care decreases with patient load and in practices with more than 4 full-time-equivalent family physicians. There is no evidence that a practice's use of electronic medical records influences the quality of chronic disease management.

Implications

These findings suggest that having a nurse-practitioner and the organization of the primary care team influences the delivery of quality care.
Further research should examine the effects of larger practices and greater patient-physician ratios on quality care.

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