Diop Mamadou, Fiset-Laniel Julie, Provost Sylvie, Tousignant Pierre, Borgès Da Silva Roxane, Ouimet Marie-Jo, Latimer Eric, Strumpf Erin
McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada.
Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada; Institut de recherche en santé publique de l'Université de Montréal, Pavillon 7101 avenue du Parc, C.P. 6128, Succ. Centre-Ville, Montreal, QC H3C 3J7 Canada.
Health Policy. 2017 Apr;121(4):378-388. doi: 10.1016/j.healthpol.2017.02.001. Epub 2017 Feb 13.
We investigated whether multidisciplinary team-based primary care practice improves adherence to process of care guidelines, in the absence of financial incentives related to pay-for-performance.
We conducted a natural experiment including 135,119 patients, enrolled with a general practitioner (GP) in a multidisciplinary team Family Medicine Group (FMG) or non-FMG practice, using longitudinal data from Quebec's universal insurer over the relevant time period (2000-2010). All study subjects had diabetes, chronic obstructive pulmonary disease, or heart failure and were followed over a 7-year period, 2 years prior to enrollment and 5 years after. We constructed indicators on adherence to disease-specific guidelines and composite indicators across conditions. We evaluated the effect of FMGs using propensity score methods and Difference-in-Differences (DD) models.
Rates of adherence to chronic disease guidelines increased for both FMG and non-FMG patients after enrollment, but not differentially so. Adherence to prescription-related guidelines improved less for FMG patients (DD [95% CI]=-2.83% [-4.08%, -1.58%]). We found no evidence of an FMG effect on adherence to consultation-related guidelines, (DD [95% CI]=-0.24% [-2.24%; 1.75%]).
We found no evidence that FMGs increased adherence to the guidelines we evaluated. Future research is needed to assess why this reform did not improve performance on these quality-of-care indicators.
我们调查了在不存在与绩效薪酬相关的经济激励措施的情况下，基于多学科团队的初级保健实践是否能提高对护理流程指南的依从性。
我们进行了一项自然实验，纳入了135,119名患者，这些患者在相关时间段（2000 - 2010年）向多学科团队家庭医学组（FMG）或非FMG实践中的全科医生（GP）登记。所有研究对象均患有糖尿病、慢性阻塞性肺疾病或心力衰竭，并在入组前2年和入组后5年进行了7年的随访。我们构建了针对特定疾病指南的依从性指标以及跨疾病的综合指标。我们使用倾向评分法和差异 - 差异（DD）模型评估了FMG的效果。
入组后，FMG患者和非FMG患者对慢性病指南的依从率均有所提高，但提高程度无差异。FMG患者对与处方相关指南的依从性改善较少（DD [95%置信区间]= -2.83% [-4.08%，-1.58%]）。我们没有发现FMG对与咨询相关指南的依从性有影响的证据（DD [95%置信区间]= -0.24% [-2.24%；1.75%]）。
我们没有发现证据表明FMG提高了对我们评估的指南的依从性。需要进一步的研究来评估为什么这项改革没有改善这些护理质量指标的表现。
