Increasing access to primary health care services is an important feature of NPLCs, however, it is only one measure of quality of care. Some indicators that define quality PHC are the accessibility to health care services, interpersonal relationships between health care providers and patients, effectiveness of care (Campbell, Roland & Buetow, 2000; Haddad, Fournier, Machouf & Yatara, 1998; Roland, 1999), the comprehensiveness of the clinical care delivered and productive interprofessional team relationships (Stevenson, Baker, Farooqi, Sorrie & Khunti, 2001; Levesque, Feldman, Lemieux, Tourigny, Lavoie & Tousignant, 2012). Some specific indicators related to quality in PHC practices are the interval from scheduling and appointment time and the team climate, which have been associated with access to care, continuity of care and overall satisfaction (Campbell, 2001).
Research of quality of primary health care is a priority in Ontario as evidenced by the government funding of several large evaluative studies. First is The Comparison of Models of Primary Care in Ontario (COMPS-PC) study was a comprehensive review of the performance of four types of PHC agencies in Ontario in 2003-2004 including family health groups, family health networks, CHCs and health service organizations. Organizational structural components such as organizational governance, human resources, office infrastructure and organizational structure (length of time in operation, length of time for visits, hours of operation etc.) were analyzed against performance measures including such things as access, patient-provider relationship continuity of care, chronic disease management, disease prevention and health promotion (Dahrouge et al., 2009). For one set of analysis, a score was calculated which outlined the comprehensiveness of care provided in each model. This analysis found that CHCs offered significantly more comprehensive services than other models. Comprehensiveness was
associated with the presence of an interprofessional team as well as the level of maturity of the organization (Russell, Dahrouge, Tuna, Hogg, Geneau & Gebremichael, 2010).
Another component of the COMPS-PC study evaluated community orientation of the various PHC models of care. Community orientation was defined as “care providers’ knowledge of community needs and involvement in the community” (Muldoon, Dahrouge, Hogg, Geneau, Russell & Shortt, 2010, p. 678). A survey adapted from the adult version of the Primary Care Assessment Tool was utilized including items about the practice environment and demographic information. A second phase of the study included provider interviews. Findings revealed that primary care providers at the PHC models in the study gave themselves high ratings for community orientation, but that indicators of community orientation were significantly higher in CHCs (Muldoon et al., 2010).
In addition to community orientation, data from the same survey tools were analyzed to determine the level of health promotion activities in the PHC models. After controlling for patient and family physician profiles, CHCs had significantly higher rates of health promotion than other models of care (Hogg et al., 2009).
Another, separate analysis in the COMPS-PC study reviewed age equity in the different PHC models (Dahrouge et al., 2011). Assessment was completed using data from patient surveys based on the Primary Care Assessment Tool and indicators from chronic disease management Canadian best practice guidelines. All models included in the study demonstrated a reduction in adherence to recommended guidelines for care of diabetes, coronary artery disease and congestive heart failure for patients age 70 and older. The exception was CHCs, which
demonstrated equivalent evidence-based care across all age groups. The authors concluded that…
the salaried model might have an organizational structure that is more conducive to providing appropriate care across age groups and that the thrust toward adopting a capitation-based payment model is unlikely to have an effect on age disparities (Dahrouge et al., 2011, p. 1309).
Several research studies focused on PHC organizations in Ontario have been undertaken by the Institute of Clinical and Evaluative Studies. The first report compared data from CHCs, family health networks, family health groups, family health organizations and FHTs in Ontario from 2008/09 to 2009/10. Indicators were the assumed socioeconomic characteristics of patients determined by postal code, practice location of clinic, case mix and use of the Emergency Department (Glazier, Zagorski & Rayner, 2012). Compared with the Ontario population, patients at CHCs were from lower income, had higher rates on social assistance, more severe mental illness and chronic diseases than the other models of PHC. Despite the differences in patient demographics, CHCs had considerably lower rates of emergency department visits than expected (Glazier, Zagorski & Rayner, 2012).
In a separate Institute for Clinical and Evaluative Studies research study, a comparison of FHTs with CHCs, enhanced fee-for-service models (family health groups and comprehensive care model), family health organizations, family health networks, and fee-for-service family practices was undertaken (Glazier, Hutchison & Kopp, 2015). Physicians in CHCs are paid by salary. The remaining models are either blended payments (capitation or fee-for-service) in varying proportions. The study evaluated the models of care by comparing demographics, case mix, health care utilization, cancer screening and diabetes care. The results demonstrated that FHTs and other capitation models have wealthier and healthier populations than the other models. In
morbidity and comorbidity. While there were substantial case mix and demographic differences among the models, no model was superior to another. Fee-for-service was poorest on cancer screening and diabetes care (Glazier, Hutchison & Kopp, 2015).
Another study compared the extent to which evidence-based indicators for cardiac care were achieved in three PHC models of physician remuneration in Ontario. Chart audits were conducted at fee-for-service (N = 43), blended-capitation (N = 27) and salary-based CHC (N = 12) practices. Findings demonstrated that overall the quality of diabetes care was higher in CHCs, while offering smoking cessation medication and measuring waist circumference was higher in the blended-capitation model. Fee-for-service practices had the greatest gaps in care (Liddy, Singh, Hogg, Dahrouge & Talkjaard, 2011).