title: The impact of primary care reform on health system performance in Canada: a systematic review.
abstract: We aimed to synthesize the evidence of a causal effect and draw inferences about whether Canadian primary care reforms improved health system performance based on measures of health service utilization, processes of care, and physician productivity.
  
  
  
  We searched the Embase, PubMed and Web of Science databases for records from 2000 to September 2015. We based our risk of bias assessment on the Grading of Recommendations Assessment, Development and Evaluation guidelines. Full-text studies were synthesized and organized according to the three outcome categories: health service utilization, processes of care, and physician costs and productivity.
  
  
  
  We found moderate quality evidence that team-based models of care led to reductions in emergency department use, but the evidence was mixed for hospital admissions. We also found low quality evidence that team-based models, blended capitation models and pay-for-performance incentives led to small and sometimes non-significant improvements in processes of care. Studies examining new payment models on physician costs and productivity were of high methodological quality and provided a coherent body of evidence assessing enhanced fee-for-service and blended capitation payment models.
  
  
  
  A small number of studies suggested that team-based models contributed to reductions in emergency department use in Quebec and Alberta. Regarding processes of diabetes care, studies found higher rates of testing for blood glucose levels, retinopathy and cholesterol in Alberta's team-based primary care model and in practices eligible for pay-for-performance incentives in Ontario. However pay-for-performance in Ontario was found to have null to moderate effects on other prevention and screening activities. Although blended capitation payment in Ontario contributed to decreases in the number of services delivered and patients seen per day, the number of enrolled patients and number of days worked in a year was similar to that of enhanced fee-for-service practices.
authors.affiliation: Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, QC, Canada. renee.carter@mail.mcgill.ca.
authors.forename: Renee
authors.initials: R
authors.lastname: Carter
authors.affiliation: Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, QC, Canada.
authors.forename: Bruno
authors.initials: B
authors.lastname: Riverin
authors.affiliation: Bureau of Health Information, Level 11 Sage Building, 67 Albert Avenue, Chatswood, NSW, Australia.|Center for Primary Health Care and Equity, University of New South Wales, Level 3, AGSM Building, Sydney, Australia.
authors.forename: Jean-Frédéric
authors.initials: JF
authors.lastname: Levesque
authors.affiliation: Institute for Health and Social Policy, McGill University, 1130 Pine Avenue West, Montreal, QC, Canada.
authors.forename: Geneviève
authors.initials: G
authors.lastname: Gariepy
authors.affiliation: Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 1020 Pine Avenue West, Montreal, QC, Canada.|Department of Sociology, McGill University, 855 Sherbrooke Street West, Montreal, QC, Canada.
authors.forename: Amélie
authors.initials: A
authors.lastname: Quesnel-Vallée
mesh_terms: D002170:Canada; D003920:Diabetes Mellitus / Q000628:therapy; D004632:Emergency Medical Services / Q000706:statistics & numerical data; D018166:Health Care Reform; D006296:Health Services / Q000706:statistics & numerical data*; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D010348:Patient Care Team; D011320:Primary Health Care / Q000458:organization & administration*; D012051:Reimbursement Mechanisms
keywords: Canada; Payment models; Primary care reform; Team-based practice