Evidence of Value

Patients not attached to new primary care practices receive lower quality care, research suggests

Article published in Annals of Family Medicine on November 14, 2016

The accompanying news release and abstract are shown below.

One in six patients in Ontario does not belong to an organized primary care practice, new research suggests. These patients receive lower quality care and are more likely to be poor, urban and new immigrants, the study says.

The Ontario government has invested millions of dollars in reforming the primary care system to improve access and quality of care. Fifteen years ago, most doctors practiced alone and were paid by the visit (fee-for-service). Now, most doctors are part of groups where they formally enroll patients, provide after-hours care, and get some lump-sum payment per year for looking after their enrolled patients (capitation). Joining these new groups was voluntary for doctors and their patients.

When reforms are voluntary, there is a risk the most vulnerable in society will be left behind, said Dr. Tara Kiran, a family physician at St. Michael’s Hospital, an adjunct scientist at the Institute for Clinical Evaluative Sciences (ICES) and lead author of the study.

In the study, published today in Annals of Family Medicine, Dr. Kiran and colleagues analyzed Ontario data from 2001 to 2011. They found that patients who didn’t belong to these new primary care practices were more likely to reside in an urban area, live in a low-income neighbourhood and have immigrated to Canada in the last 10 years.

The study also found that patients left out of new primary care practices were less likely than those who were included to be screened for cervical, breast, and colorectal cancer (52 per cent vs. 66 per cent, 58 per cent vs. 73 per cent and 44 per cent vs. 62 per cent, respectively), and were less likely to receive recommended tests for diabetes (25 per cent vs. 34 per cent).

In 2011, 2, 376, 248 (18 per cent of) Ontarians did not belong to these new primary care practices.

“Some of these people that have been left behind are seeing traditional fee-for-service doctors,” said Dr. Kiran, “but others might not want a regular primary care doctor or perhaps couldn’t find one and are getting care from walk-in clinics.”

Dr. Kiran said that patients left behind from these new groups had poorer quality of care even before reforms were introduced and the gaps in quality of care seem to have widened over time.

The report follows the Ontario government’s introduction of the Patients First Act, a goal of which is to improve access to primary care. Dr. Kiran said there are lessons to be learned from what worked and what didn’t during the last round of reforms.

She said that new reforms need to specifically reach out to more vulnerable groups of patients to connect them with a primary care provider.

“We need to educate new Canadians about what good primary care looks like and how they can access it,” said Dr. Kiran.

Dr. Kiran said health care leaders should also be reaching out to doctors who still practice alone and finding ways to support them and their patients.

“To improve care for all Ontarians, there needs to be specific strategies to reach out to both patients and physicians who are not currently part of an organized primary care practice,” she said.

Abstract

Those left behind from voluntary medical home reforms in Ontario, Canada
Kiran T, Kopp A, Glazier RH. Ann Fam Med. 2016; Nov 14 [Epub ahead of print].

Purpose — Health systems are transitioning patients to medical homes to improve health outcomes and reduce cost. We sought to understand the characteristics and quality of care for patients who did and did not participate in the voluntary transition to medical homes.

Methods — We used administrative data to compare diabetes monitoring and cancer screening for patients attached to a medical home (N=10,785,687) versus a fee-for-service physician (N=1,321,800) in Ontario, Canada on March 31, 2011. We used Poisson regression to examine associations in 2011 after adjustment for patient factors and also assessed changes in outcomes between 2001 and 2011.

Results — Patients attached to a fee-for-service physician were more likely to be immigrants and live in a low-income neighbourhood, and urban area. They were less likely to receive recommended testing for diabetes (25% vs. 34%; adjusted relative risk [RR] 0.74, 95% confidence interval [CI] 0.73 to 0.75) and less likely to receive screening for cervical (52% vs. 66%; adjusted RR 0.79, 95% CI 0.79 to 0.79), breast (58% vs. 73%; adjusted RR 0.80, 95% CI 0.80 to 0.81), and colorectal cancer (44% vs. 62%; adjusted RR 0.72, 95% CI 0.71 to 0.72) compared to patients attached to a medical home physician in 2011. These differences in quality of care preceded medical home reforms.

Conclusion — Patients left behind from medical home reforms are more likely to be poor, urban, and new immigrants and receive lower quality care. Strategies are needed to reach out to these patients and their physicians to reduce gaps in care.

You can read the full article here.

Authors

  • Tara Kiran, MD, MSc, CCFP, St. Michael’s Hospital Academic Family Health Team
  • Alexander Kopp, BA, Institute for Clinical Evaluative Sciences
  • Richard H. Glazier, MD, MPH, CCFP, St. Michael’s Hospital Academic Family Health Team; Institute for Clinical Evaluative Sciences; Institute for Health Policy, Management and Evaluation, University of Toronto

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