CT Lamont Primary Health Care Research Centre, Élisabeth Bruyère Research Institute, Ottawa, Ontario, K1N 5C8, Canada.
BMC Fam Pract. 2011 Oct 18;12:114. doi: 10.1186/1471-2296-12-114.
Primary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models.
This is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practice's adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models.
The percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management.
This study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice.
ClinicalTrials.gov: NCT00574808.
初级保健提供者在预防和管理心血管疾病方面发挥着重要作用。本研究比较了不同初级保健模式下预防心血管保健服务的质量。
这是一项更大的随机对照试验（称为通过外展促进改善心血管保健服务（IDOCC））的二次分析。使用通过 IDOCC 收集的基线数据，我们对来自加拿大安大略省东部的三种交付模式的 82 个初级保健实践进行了横断面研究：43 个按服务收费、27 个混合按人头付费和 12 个基于薪酬的医生社区卫生中心。对 4808 名患有或有发展为心血管疾病风险的患者的病历进行审核，以检查每个实践对糖尿病、慢性肾脏病、血脂异常、高血压、体重管理和戒烟护理的十种基于证据的护理过程的依从性。使用广义估计方程模型，根据年龄、性别、农村/城市情况、心血管相关合并症数量和数据收集年份调整，比较三种模型的指南依从性。
在研究年内接受两次血红蛋白 A1c 检测的糖尿病患者比例，社区卫生中心（69%）明显高于按服务收费（45%）实践（调整后的优势比（AOR）=2.4[95%CI 1.4-4.2]，p=0.001）。混合按人头付费实践中，监测腰围的患者比例明显高于按服务收费实践（19%比 5%，AOR=3.7[1.8-7.8]，p=0.0006），与社区卫生中心相比，建议使用戒烟药物的患者比例也更高（33%比 16%，AOR=2.4[1.3-4.6]，p=0.007）。总体而言，社区卫生中心的糖尿病护理质量较高，而混合按人头付费模式的戒烟护理和体重管理质量较高。按服务收费实践在护理方面的差距最大，尤其是在糖尿病护理和体重管理方面。
本研究为初级保健服务模式影响护理质量的观点提供了更多证据。这些发现支持安大略省目前向传统按服务收费模式转变的改革。
ClinicalTrials.gov：NCT00574808。
