Department of Family Medicine, Schulich School of Medicine & Dentistry (Premji, Freeman, Ryan), Western University, London, Ont.; Department of Family Medicine (Premji), University of Ottawa; ICES uOttawa (Sucha, Hogg), Ottawa Hospital Research Institute, Ottawa, Ont.; ICES Toronto (Glazier, Kiran); Department of Family and Community Medicine and MAP Centre for Urban Health Solutions (Glazier, Kiran), St. Michael's Hospital, University of Toronto, Toronto, Ont.; ICES Queen's (Green); Department of Family Medicine (Green); Health Services and Policy Research Institute (Green, Frymire), Queen's University, Kingston, Ont.; Institute of Health Policy Management and Evaluation (Wodchis), University of Toronto, Toronto, Ont.; Institute for Better Health (Wodchis), Trillium Health Partners, Mississauga, Ont.; Institut du Savoir Montfort (Hogg), Ottawa, Ont.; Centre for Studies in Family Medicine (Freeman), Department of Family Medicine; Department of Epidemiology and Biostatistics (Ryan), Schulich School of Medicine & Dentistry, Western University, London, Ont.
CMAJ Open. 2021 Nov 30;9(4):E1080-E1096. doi: 10.9778/cmajo.20200235. Print 2021 Oct-Dec.
Rurality strongly correlates with higher pay-for-performance access bonuses, despite higher emergency department use and fewer primary care services than in urban settings. We sought to evaluate the relation between patient-reported access to primary care and access bonus payments in urban settings.
We conducted a cross-sectional, secondary data analysis using Ontario survey and health administrative data from 2013 to 2017. We used administrative data to calculate annual access bonuses for eligible urban family physicians. We linked this payment data to adult (≥ 16 yr) patient data from the Health Care Experiences Survey to examine the relation between access bonus achievement (in quintiles of the proportion of bonus achieved, from lowest [Q1, reference category] to highest [Q5]) and 4 patient-reported access outcomes. The average survey response rate to the patient survey during the study period was 51%. We stratified urban geography into large, medium and small settings. In a multilevel regression model, we adjusted for patient-, physician- and practice-level covariates. We tested linear trends, adjusted for clustering, for each outcome.
We linked 18 893 respondents to 3940 physicians in 414 bonus-eligible practices. Physicians in small urban settings earned the highest proportion of their maximum potential access bonuses. Access bonus achievement was positively associated with telephone access (Q2 odds ratio [OR] 1.18, 95% confidence interval [CI] 0.98-1.42; Q3 OR 1.34, 95% CI 1.10-1.63; Q4 OR 1.46, 95% CI 1.19-1.79; Q5 OR 1.87, 95% CI 1.50-2.33), after hours access (Q2 OR 1.26, 95% CI 1.09-1.47; Q3 OR 1.46, 95% CI 1.23-1.74; Q4 OR 1.77, 95% CI 1.46-2.15; Q5 OR 1.88, 95% CI 1.52-2.32), wait time for care (Q2 OR 1.01, 95% CI 0.85-1.20; Q3 OR 1.17, 95% CI 0.97-1.41; Q4 OR 1.27, 95% CI 1.05-1.55; Q5 OR 1.63, 95% CI 1.32-2.00) and timeliness (Q2 OR 1.29, 95% CI 0.98-1.69; Q3 OR 1.29, 95% CI 0.94-1.77; Q4 OR 1.58, 95% CI 1.16-2.13; Q5 OR 1.98, 95% CI 1.38-2.82). When stratified by geography, we observed several of these associations in large urban settings, but not in small urban settings. Trend tests were statistically significant for all 4 outcomes.
Although the access bonus correlated with access in larger urban settings, it did not in smaller settings, aligning with previous research questioning its utility in smaller geographies. The access bonus may benefit from a redesign that considers geography and patient experience.
尽管农村地区的绩效薪酬附加津贴较高，但其急诊就诊率高于城市，初级保健服务也少于城市。我们旨在评估城市环境中患者报告的初级保健可及性与附加津贴支付之间的关系。
我们使用安大略省 2013 年至 2017 年的调查和健康管理数据进行了横断面、二次数据分析。我们使用管理数据为符合条件的城市家庭医生计算了年度附加津贴。我们将该支付数据与健康护理体验调查的成年（≥16 岁）患者数据相链接，以研究附加津贴实现情况（根据获得的附加津贴比例分为五分位数，从最低分位[Q1，参考类别]到最高分位[Q5]）与 4 项患者报告的可及性结果之间的关系。在研究期间，患者调查的平均调查应答率为 51%。我们将城市地理区域分为大、中、小区域。在多水平回归模型中，我们调整了患者、医生和实践层面的协变量。我们为每个结果检验了线性趋势，并根据聚类进行了调整。
我们将 18893 名受访者与 414 个符合附加津贴条件的实践中的 3940 名医生相链接。在小型城市环境中工作的医生获得的最大潜在附加津贴比例最高。附加津贴的实现与电话可及性呈正相关（Q2 比值比[OR]1.18，95%置信区间[CI]0.98-1.42；Q3 OR 1.34，95% CI 1.10-1.63；Q4 OR 1.46，95% CI 1.19-1.79；Q5 OR 1.87，95% CI 1.50-2.33），下班后可及性（Q2 OR 1.26，95% CI 1.09-1.47；Q3 OR 1.46，95% CI 1.23-1.74；Q4 OR 1.77，95% CI 1.46-2.15；Q5 OR 1.88，95% CI 1.52-2.32）、护理等待时间（Q2 OR 1.01，95% CI 0.85-1.20；Q3 OR 1.17，95% CI 0.97-1.41；Q4 OR 1.27，95% CI 1.05-1.55；Q5 OR 1.63，95% CI 1.32-2.00）和及时性（Q2 OR 1.29，95% CI 0.98-1.69；Q3 OR 1.29，95% CI 0.94-1.77；Q4 OR 1.58，95% CI 1.16-2.13；Q5 OR 1.98，95% CI 1.38-2.82）。按地理位置分层时，我们在大型城市环境中观察到了其中的一些关联，但在小型城市环境中没有观察到。所有 4 项结果的趋势检验均具有统计学意义。
尽管附加津贴与较大城市地区的可及性相关，但在较小地区则不然，这与之前质疑其在较小地理区域实用性的研究结果一致。附加津贴可能需要重新设计，以考虑地理和患者体验。
