Investigating quality of care for diabetes mellitus, congestive heart failure and chronic kidney disease in Ontario’s Family Health Group and Family Health Organization models

Background and objectives: In Ontario, primary care reform was initiated in the early 2000s with an aim to improve the quality of primary care. Hence, the provincial government restructured family physicians’ remuneration package. Prior to the reform, most physicians received majority of their income through fee-for-service (FFS). In Ontario, Family Health Group (FHG) and Family Health Organization (FHO) are dominant post-reform primary care models that remunerate family physicians through blended FFS and blended capitation, respectively. In three studies, we compared physicians in FHGs and FHOs in terms of their care provision for persons with diabetes mellitus (1st study), congestive heart failure (CHF) (2nd study) and chronic kidney disease (CKD) (3rd study). Methods: All data were obtained from the ICES (formerly known as the Institute for Clinical Evaluative Sciences). For the first and second studies, we employed propensity score-based weights and fixed effects regressions on a balanced panel of physicians spanning 10 years; all analyses were conducted at the physician level. In these two studies, the comparison was between physicians in FHG who never switched to FHO or other models (i.e., non-switchers); switchers were physicians who switched from FHG to FHO. For the third study, we performed two cross-sectional analyses at the physician level; lack of data availability for patients with CKD over time deterred us from conducting longitudinal analyses as in the first two studies. Results: We found that switching from FHG to FHO was associated with an improvement in some aspects of diabetes care. We found that CHF care—in terms of physicians’ follow-up of patients who are discharged—was not different between switchers and non-switchers. We found that some aspects of CKD care were better with physicians in FHG relative to their counterparts in FHO. Conclusions: Compared to blended FFS, blended capitation payment is associated with a small but statistically significant improvement in some aspects of diabetes care. Our findings suggest that follow-up care for patients with CHF is similar in Ontario’s blended FFS and blended capitation models. Though we found that blended FFS is associated with greater adherence to some CKD process measures, future studies could employ longitudinal regressions to account for more confounding

Quality of Diabetes Care in Blended Fee-for-Service and Blended Capitation Payment Systems.

OBJECTIVES: In the middle to late 2000s, many family physicians switched from a Family Health Group (FHG; a blended fee-for-service model) to a Family Health Organization (FHO; a blended capitation model) in Ontario, Canada. The evidence on the link between physician remuneration schemes and quality of diabetes care is mixed in the literature. We examined whether physicians who switched from the FHG to FHO model provided better care for individuals living with diabetes relative to those who remained in the FHG model. METHODS: Using longitudinal health administrative data from 2006 to 2016, we investigated the impact of physicians switching from FHG to FHO on 8 quality indicators related to diabetes care. Because FHO physicians are likely to be systematically different from FHGs, we employed propensity-score-based inverse probability-weighted fixed-effects regression models. All analyses were conducted at the physician level. RESULTS: We found that FHO physicians were more likely to provide glycated hemoglobin testing by 2.75% (95% confidence interval [CI], 1.89% to 3.60%), lipid assessment by 2.76% (CI, 1.95% to 3.57%), nephropathy screening by 1.08% (95% CI, 0.51% to 1.66%) and statin prescription by 1.08% (95% CI, 0.51% to 1.66%). Patients under FHOs had a lower estimated risk of mortality by 0.0124% (95% CI, 0.0123% to 0.0126%) per physician per year. However, FHG and FHO physicians were similar for annual eye examination, prescription of angiotensin-converting enzyme inhibitors (or angiotensin II receptor blockers) and patients\u27 risk of avoidable diabetes-related hospitalizations. CONCLUSIONS: Compared with blended fee-for-service, blended capitation payment is associated with a small, but statistically significant, improvement in some aspects of diabetes care

Prevalence of sexually transmitted infections based on syndromic approach and associated factors among Iranian women

Background and purpose: Reproductive and sexual health related problems constitute one third of health problems among women aged 15 to 44 years. Sexually transmitted infections are a significant challenge for human development. We aimed to assess the prevalence of STIs and identify factors associated with among Iranian women. Materials and Methods: Through a cross-sectional study, 399 women aged 10-49 years were recruited. These were women who referred to urban and rural health centers in a city in Iran. Through a behavioral questionnaire, high-risk behaviors of the sample were asked about. Syndromic STIs were also assessed through clinical examination. T-test and multivariable Modified Poisson Regression was used to estimate the Prevalence Risk Ratios (PRRs) in Stata 13. P-values less than 0.05 were considered as statistically significant. Results: About 64.2% of the participants had at least one of the STIs. STI prevalence was significantly higher among women who self-reported not using condoms in their last sexual contact (75% vs. 39.8%), whose spouse/sexual partners (SSP) had extramarital sex (87.7% vs. 59.6%), whose SSP had a past-year history of illicit substance use (72.9%vs. 60.9%), and whose SSP had a history of incarceration (91.5% vs. 59.1%). In multivariable analysis, it was shown that having first sexual intercourse before 20 years of age, history of abortion in the past year, low family income, not using condom in last sexual contact, and the partner’s incarceration history were identified as significant predictors. Conclusions: The knowledge produced from the current research can serve as evidence for the promotion of interventions and healthcare services related to sexual and reproductive health for Iranian women and their SSPs. The findings from the current study also support research on improving strategies for STI diagnosis and STI management. &nbsp

Refinement of variant selection for the LDL cholesterol genetic risk score in the diagnosis of the polygenic form of clinical familial hypercholesterolemia and replication in samples from 6 countries.

BACKGROUND: Familial hypercholesterolemia (FH) is an autosomal-dominant disorder caused by mutations in 1 of 3 genes. In the 60% of patients who are mutation negative, we have recently shown that the clinical phenotype can be associated with an accumulation of common small-effect LDL cholesterol (LDL-C)-raising alleles by use of a 12-single nucleotide polymorphism (12-SNP) score. The aims of the study were to improve the selection of SNPs and replicate the results in additional samples. METHODS: We used ROC curves to determine the optimum number of LDL-C SNPs. For replication analysis, we genotyped patients with a clinical diagnosis of FH from 6 countries for 6 LDL-C-associated alleles. We compared the weighted SNP score among patients with no confirmed mutation (FH/M-), those with a mutation (FH/M+), and controls from a UK population sample (WHII). RESULTS: Increasing the number of SNPs to 33 did not improve the ability of the score to discriminate between FH/M- and controls, whereas sequential removal of SNPs with smaller effects/lower frequency showed that a weighted score of 6 SNPs performed as well as the 12-SNP score. Metaanalysis of the weighted 6-SNP score, on the basis of polymorphisms in CELSR2 (cadherin, EGF LAG 7-pass G-type receptor 2), APOB (apolipoprotein B), ABCG5/8 [ATP-binding cassette, sub-family G (WHITE), member 5/8], LDLR (low density lipoprotein receptor), and APOE (apolipoprotein E) loci, in the independent FH/M- cohorts showed a consistently higher score in comparison to the WHII population (P 95% likelihood of a polygenic explanation of their increased LDL-C. CONCLUSIONS: A 6-SNP LDL-C score consistently distinguishes FH/M- patients from healthy individuals. The hypercholesterolemia in 88% of mutation-negative patients is likely to have a polygenic basis

Refinement of variant selection for the LDL cholesterol genetic risk score in the diagnosis of the polygenic form of clinical familial hypercholesterolemia and replication in samples from 6 countries

Background: Familial hypercholesterolemia (FH) is an autosomal-dominant disorder caused by mutations in 1 of 3 genes. In the60%of patients who are mutation negative, we have recently shown that the clinical phenotype can be associated with an accumulation of common small-effect LDL cholesterol (LDL-C)-raising alleles by use of a 12-single nucleotide polymorphism (12-SNP) score. The aims of the study were to improve the selection of SNPs and replicate the results in additional samples.Methods: We used ROC curves to determine the optimum number of LDL-C SNPs. For replication analysis, we genotyped patients with a clinical diagnosis of FH from 6 countries for 6 LDL-C-associated alleles. We compared the weighted SNP score among patients with no confirmed mutation (FH/M-), those with amutation(FH/M-), and controls from aUK population sample (WHII).Results: Increasing the number of SNPs to 33 did not improve the ability of the score to discriminate between FH/M-and controls, whereas sequential removal of SNPs with smaller effects/lower frequency showed that a weighted score of 6 SNPs performed as well as the 12-SNP score. Metaanalysis of the weighted 6-SNP score, on the basis of polymorphisms in CELSR2 (cadherin, EGF LAG 7-pass G-type receptor 2), APOB (apolipoprotein B), ABCG5/8 [ATP-binding cassette, sub-family G (WHITE), member 5/8], LDLR (low density lipoprotein receptor), and APOE (apolipoprotein E) loci, in the independent FH/M-cohorts showed a consistently higher score in comparison to the WHII population (P95% likelihood of a polygenic explanation of their increased LDL-C.Conclusions: A 6-SNP LDL-C score consistently distinguishes FH/M-patients from healthy individuals. The hypercholesterolemia in 88% of mutation-negative patients is likely to have a polygenic basis