title: Managing chronic disease in ontario primary care: the impact of organizational factors.
abstract: OBJECTIVE
  New approaches to chronic disease management emphasize the need to improve the delivery of primary care services to meet the needs of chronically ill patients. This study (1) assessed whether chronic disease management differed among 4 models of primary health care delivery and (2) identified which practice organizational factors were independently associated with high-quality care.
  
  
  METHODS
  We undertook a cross-sectional survey with nested qualitative case studies (2 practices per model) in 137 randomly selected primary care practices from 4 delivery models in Ontario Canada: fee for service, capitation, blended payment, and community health centers (CHCs). Practice and clinician surveys were based on the Primary Care Assessment Tool. A chart audit assessed evidence-based care delivery for patients with diabetes, congestive heart failure, and coronary artery disease. Intermediate outcomes were calculated for patients with diabetes and hypertension. Multiple linear regression identified those organizational factors independently associated with chronic disease management.
  
  
  RESULTS
  Chronic disease management was superior in CHCs. Clinicians in CHCs found it easier than those in the other models to promote high-quality care through longer consultations and interprofessional collaboration. Across the whole sample and independent of model, high-quality chronic disease management was associated with the presence of a nurse-practitioner. It was also associated with lower patient-family physician ratios and when practices had 4 or fewer full-time-equivalent family physicians.
  
  
  CONCLUSIONS
  The study adds to the literature supporting the value of nurse-practitioners within primary care teams and validates the contributions of Ontario's CHCs. Our observation that quality of care decreased in larger, busier practices suggests that moves toward larger practices and greater patient-physician ratios may have unanticipated negative effects on processes of care quality.
authors: C.T. Lamont Primary Health Care Research Centre, Elisabeth Bruyère Research Institute, Ottawa, Ontario, Canada. grussell@bruyere.org
authors: Grant M
authors: GM
authors: Russell
authors: Simone
authors: S
authors: Dahrouge
authors: William
authors: W
authors: Hogg
authors: Robert
authors: R
authors: Geneau
authors: Laura
authors: L
authors: Muldoon
authors: Meltem
authors: M
authors: Tuna
mesh_terms: D002908:Chronic Disease / Q000628:therapy*; D003430:Cross-Sectional Studies; D019468:Disease Management; D055317:Evidence-Based Practice; D005260:Female; D006801:Humans; D016014:Linear Models; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D017146:Models, Organizational; D009722:Nurse Practitioners; D009864:Ontario; D010348:Patient Care Team / Q000458:organization & administration; D011320:Primary Health Care / Q000379:methods / Q000458:organization & administration*; D011787:Quality of Health Care; D000078329:Workforce