Hospitalizations for ambulatory care sensitive conditions across primary care models in Ontario, Canada

The study analyzes the relationship between the risk of a hospitalization for an ambulatory care sensitive condition (ACSC), and the primary care payment and the organizational model used by the patient (fee-for-service, enhanced fee-for-service, blended capitation, blended capitation with interdisciplinary teams).The study used linked patient-level health administrative databases and census data housed at the Institute for Clinical Evaluative Sciences in Ontario. Since the province provides universal health care, the data capture all patients in Ontario, Canada's most populous province, with about 13 million inhabitants. All Ontario patients diagnosed with an ACSC prior to April 1, 2012, who had at least one visit with a physician between April 1, 2012, and March 31. 2013, were included in the study (n=1,710,310). Each patient was assigned to the primary care model of his/her physician. The different models were categorized as Fee-forService (FFS), enhanced-FFS, blended capitation, and interdisciplinary team. A logistic regression was used to model the risk of having an ACSC hospitalization during the one-year observation period. Adjustments were made for patient characteristics (age, sex, health status, and socio-economic status) and for the geographic location of the practice. Using patients belonging to FFS models as the reference group, the risk of an ACSC hospitalization was higher for patients belonging to the blended-capitation model using interdisciplinary teams (Adjusted Odds Ratio [AOR] = 1.06, 95% confidence interval [CI] = 1.00-1.12) and lower for enhancedFFS (AOR = 0.78, CI= 0.74-0.82) and blended capitation patients (AOR = 0.91, CI= 0.86-0.96). Using patients with hypertension as the reference group, the odds of an ACSC hospitalization were much higher for patients with any other ACSC and increased with patients' morbidity. The risk was lower for patients of higher socio-economic status (AOR=0.63, CI=0.60-0.67) in the highest neighborhood income quintile

Feedback GAP : study protocol for a cluster-randomized trial of goal setting and action plans to increase the effectiveness of audit and feedback interventions in primary care

Peer reviewedPublisher PD

Did changing primary care delivery models change performance? A population based study using health administrative data

<p>Abstract</p> <p>Background</p> <p>Primary care reform in Ontario, Canada started with the introduction of new enrollment models, the two largest of which are Family Health Networks (FHNs), a capitation-based model, and Family Health Groups (FHGs), a blended fee-for-service model. The purpose of this study was to evaluate differences in performance between FHNs and FHGs and to compare performance before and after physicians joined these new primary care groups.</p> <p>Methods</p> <p>This study used Ontario administrative claims data to compare performance measures in FHGs and FHNs. The study population included physicians who belonged to a FHN or FHG for at least two years. Patients were included in the analyses if they enrolled with a physician in the two years after the physician joined a FHN or FHG, and also if they saw the physician in a two year period prior to the physician joining a FHN or FHG. Performance was derived from the administrative data, and included measures of preventive screening for cancer (breast, cervical, colorectal) and chronic disease management (diabetes, heart failure, asthma).</p> <p>Results</p> <p>Performance measures did not vary consistently between models. In some cases, performance approached current benchmarks (Pap smears, mammograms). In other cases it was improving in relation to previous measures (colorectal cancer screening). There were no changes in screening for cervical cancer or breast cancer after joining either a FHN or FHG. Colorectal cancer screening increased in both FHNs and FHGs. After enrolling in either a FHG or a FHN, prescribing performance measures for diabetes care improved. However, annual eye examinations decreased for younger people with diabetes after joining a FHG or FHN. There were no changes in performance measures for heart failure management or asthma care after enrolling in either a FHG or FHN.</p> <p>Conclusions</p> <p>Some improvements in preventive screening and diabetes management which were seen amongst people after they enrolled may be attributed to incentive payments offered to physicians within FHGs and FHNs. However, these primary care delivery models need to be compared with other delivery models and fee for service practices in order to describe more specifically what aspects of model delivery and incentives affect care.</p

Understanding end-user support for health information technology: a theoretical framework

Background Support is often considered an important factor for successful implementation and realising the benefits of health information technology (HIT); however, there is a dearth of research on support and theoretical frameworks to characterise it. Objective To develop and present a comprehensive, holistic, framework for characterising enduser support that can be applied to various settings and types of information systems. Method Scoping review of the medical informatics and information systems literature. Results A theoretical framework of end-user support is presented. It includes the following facets: support source, location of support, support activities, and perceived characteristics of support and support personnel. Conclusion The proposed framework may be a useful tool for describing and characterising enduser support for HIT. it may also be used by decision makers and implementation leaders for planning purposes

End-user support for a primary care electronic medical record: a qualitative case study of a vendor’s perspective

Background In primary care settings, users often rely on vendors to provide support for health information technology (HIT). Yet, little is known about the vendors’ perspectives on the support they provide, how support personnel perceive their roles, the challenges they face and the ways they deal with them.Objective To provide in-depth insight into an electronic-medical record (EMR) vendor’s perspective on end-user support.Methods As part of a larger case study research, we conducted nine semi-structured interviews with help desk staff, trainers and service managers of an EMR vendor, and observed two training sessions of a new client.Results With a growing client base, the vendor faced challenges of support staff shortage and high variance in users’ technical knowledge. Additionally, users sometimes needed assistance with infrastructure, and not just software problems. These challenges sometimes hindered the provision of timely support and required supporters to possess good interpersonal skills and adapt to diverse client population.Conclusion This study highlights the complexity of providing end-user support for HIT. With increased adoption, other vendors are likely to face similar challenges. To deal with these issues, supporters need not only strong technical knowledge of the systems, but also good interpersonal communication skills. Some responsibilities may be delegated to super-users. Users may find it useful to hire local IT staff, at least on an on-call basis, to provide assistance with infrastructure problems, which are not supported by the software vendor. Vendors may consider expanding their service packages to cover these elements

Using a data entry clerk to improve data quality in primary care electronic medical records: a pilot study

Background The quality of electronic medical record (EMR) data is known to be problematic; research on improving these data is needed. Objective The primary objective was to explore the impact of using a data entry clerk to improve data quality in primary care EMRs. The secondary objective was to evaluate the feasibility of implementing this intervention. Methods We used a before and after design for this pilot study. The participants were 13 community based family physicians and four allied health professionals in Toronto, Canada. Using queries programmed by a data manager, a data clerk was tasked with re-entering EMR information as coded or structured data for chronic obstructive pulmonary disease (COPD), smoking, specialist designations and interprofessional encounter headers. We measured data quality before and three to six months after the intervention. We evaluated feasibility by measuring acceptability to clinicians and workload for the clerk. Results After the intervention, coded COPD entries increased by 38% (P = 0.0001, 95% CI 23 to 51%); identifiable data on smoking categories increased by 27% (P = 0.0001, 95% CI 26 to 29%); referrals with specialist designations increased by 20% (P = 0.0001, 95% CI 16 to 22%); and identifiable interprofessional headers increased by 10% (P = 0.45, 95 CI _3 to 23%). Overall, the interventionwas rated as being at least moderately useful and moderately usable. The data entry clerk spent 127 hours restructuring data for 11 729 patients. Conclusions Utilising a data manager for queries and a data clerk to re-enter data led to improvements in EMR data quality. Clinicians found this approach to be acceptable

First operational BRDF, albedo nadir reflectance products from MODIS

With the launch of NASA’s Terra satellite and the MODerate Resolution Imaging Spectroradiometer (MODIS), operational Bidirectional Reflectance Distribution Function (BRDF) and albedo products are now being made available to the scientific community. The MODIS BRDF/Albedo algorithm makes use of a semiempirical kernel-driven bidirectional reflectance model and multidate, multispectral data to provide global 1-km gridded and tiled products of the land surface every 16 days. These products include directional hemispherical albedo (black-sky albedo), bihemispherical albedo (white-sky albedo), Nadir BRDF-Adjusted surface Reflectances (NBAR), model parameters describing the BRDF, and extensive quality assurance information. The algorithm has been consistently producing albedo and NBAR for the public since July 2000. Initial evaluations indicate a stable BRDF/Albedo Product, where, for example, the spatial and temporal progression of phenological characteristics is easily detected in the NBAR and albedo results. These early beta and provisional products auger well for the routine production of stable MODIS-derived BRDF parameters, nadir reflectances, and albedos for use by the global observation and modeling communities