Comparison of primary care models in the prevention of cardiovascular disease - a cross sectional study.
BACKGROUND
Primary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models.


METHODS
This is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practice's adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models.


RESULTS
The percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management.


CONCLUSIONS
This study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice.


BACKGROUND
ClinicalTrials.gov: NCT00574808.
CT Lamont Primary Health Care Research Centre, Élisabeth Bruyère Research Institute, Ottawa, Ontario, K1N 5C8, Canada. cliddy@bruyere.org
Clare
C
Liddy
Jatinderpreet
J
Singh
William
W
Hogg
Simone
S
Dahrouge
Monica
M
Taljaard
D002204:Capitation Fee; D002318:Cardiovascular Diseases / Q000191:economics / Q000453:epidemiology / Q000517:prevention & control*; D003151:Community Health Centers / Q000191:economics* / Q000458:organization & administration / Q000592:standards; D015897:Comorbidity; D003430:Cross-Sectional Studies; D055317:Evidence-Based Practice / Q000191:economics / Q000706:statistics & numerical data*; D018588:Fee-for-Service Plans; D019983:Guideline Adherence / Q000191:economics / Q000706:statistics & numerical data; D006801:Humans; D008485:Medical Audit; D018803:Models, Economic; D017146:Models, Organizational; D009864:Ontario / Q000453:epidemiology; D011320:Primary Health Care / Q000145:classification / Q000191:economics* / Q000592:standards; D012051:Reimbursement Mechanisms / Q000145:classification / Q000191:economics* / Q000706:statistics & numerical data