High and Sustained Participation in a Multi-year Voluntary Performance Measurement Initiative Among Primary Care Teams

Document Type : Original Article

Authors

1 Department of Family Medicine, Queens University, Kingston, ON, Canada

2 Alliance for Healthier Communities, North York, ON, Canada

3 Department of Medicine, Western University, London, ON, Canada

Abstract

Background
The province of Ontario, Canada has made major investments in interdisciplinary primary care teams. There is interest in both demonstrating and improving the quality of care they provide. Challenges include lack of consensus on the definition of quality and evidence that the process of measuring quality can be counter-productive to actually achieving it. This study describes how primary care teams in Ontario voluntarily measured quality at the team level.
 
Methods
Data for this 4-year observational study came from electronic medical records (EMRs), patient surveys and administrative reports. Descriptive statistics were calculated for individual measures (eg, access, preventive interventions) and composite indicators of quality and healthcare system costs. Repeated measures identified patient and practice characteristics related to quality and cost outcomes.
 
Results
Teams participated in an average of 5 of 8 possible iterations of the reporting process. There was variation between teams. For example, cervical cancer screening rates ranged from 21 to 86% of eligible patients. Rural teams had significantly better performance on some indicators (eg, continuity) and worse on others (eg, cancer screening). There were some statistical but small changes in performance over time.
 
Conclusion
High, sustained voluntary participation suggests that the initiative served a need for the primary care teams involved. The absence of robust data standards suggests that these standards were not crucial to achieve participation. The constant level of performance might mean that measurement has not yet led to improvement or that measures used might not accurately reflect improvement. The data reinforce the need to consider differences between rural and urban settings. They also suggest that further analysis is needed to identify characteristics that teams can change to improve the quality of care their patients experience. The study describes a practical, sustainable real-world approach to performance measurement in primary care that was attractive to interdisciplinary teams.

Keywords


  1. Hutchison B, Glazier R. Ontario's primary care reforms have transformed the local care landscape, but a plan is needed for ongoing improvement. Health Aff (Millwood). 2013;32(4):695-703. doi:10.1377/hlthaff.2012.1087
  2. Jesmin S, Thind A, Sarma S. Does team-based primary health care improve patients' perception of outcomes? evidence from the 2007-08 Canadian Survey of Experiences with Primary Health. Health Policy. 2012;105(1):71-83. doi:10.1016/j.healthpol.2012.01.008
  3. Kiran T, Glazier RH, Campitelli MA, Calzavara A, Stukel TA. Relation between primary care physician supply and diabetes care and outcomes: a cross-sectional study. CMAJ Open. 2016;4(1):E80-87. doi:10.9778/cmajo.20150065
  4. Glazier RH. Reflections of the quality of primary care in Canada and Israel. Isr J Health Policy Res. 2018;7(1):46. doi:10.1186/s13584-018-0243-y
  5. Canadian Institute for Health Information (CIHI). How Canada Compares: Results from the Commonwealth Fund 2015 International Health Policy Survey of Primary Care Physicians. Ottawa, Ontario: CIHI; 2016.
  6. Petch J, Tepper J. The Next Challenges for Primary Care in Ontario. Healthy Debate; 2012. https://healthydebate.ca/2012/10/topic/community-long-term-care/the-next-challenges-for-primary-care-in-ontario. Accessed Aug 4, 2019.
  7. Grant K. Ontario’s Curious Shift Away from Family Health Teams. The Globe and Mail. February 15, 2015.
  8. Auditor General of Ontario. Chapter 3 section 3.06: Funding Alternatives for Family Physicians. Auditor General of Ontario; 2011.
  9. Kiran T, O'Brien P. Challenge of same-day access in primary care. Can Fam Physician. 2015;61(5):399-400.
  10. Premji K, Ryan BL, Hogg WE, Wodchis WP. Patients' perceptions of access to primary care: analysis of the QUALICOPC patient experiences survey. Can Fam Physician. 2018;64(3):212-220.
  11. Deber R, Schwartz R. What's measured is not necessarily what matters: a cautionary story from public health. Healthc Policy. 2016;12(2):52-64.
  12. Veillard J, Denny K, Tipper B, et al. Using performance measurement and monitoring for performance improvement. In: Managing a Canadian Healthcare Strategy. Kingston: The Monieson Centre for Business Research in Healthcare; 2015.
  13. Smith PC. Performance management in British health care: will it deliver? Health Aff (Millwood). 2002;21(3):103-115. doi:10.1377/hlthaff.21.3.103
  14. Rogan L, Boaden R. Understanding performance management in primary care. Int J Health Care Qual Assur. 2017;30(1):4-15. doi:10.1108/ijhcqa-10-2015-0128
  15. Haj-Ali W, Hutchison B. Establishing a primary care performance measurement framework for Ontario. Healthc Policy. 2017;12(3):66-79.
  16. Berwick DM. Measuring physicians' quality and performance: adrift on Lake Wobegon. JAMA. 2009;302(22):2485-2486. doi:10.1001/jama.2009.1801
  17. Propper C, Wilson D. The use and usefulness of performance measures in the public sector. Oxford Rev Econ Policy. 2003;19(2):250-267. doi:10.1093/oxrep/19.2.250
  18. Sheldon TA. The healthcare quality measurement industry: time to slow the juggernaut? Qual Saf Health Care. 2005;14(1):3-4. doi:10.1136/qshc.2004.013185
  19. Adair C, Simpson L, Birdsell J, et al. Performance Measurement Systems in Health and Mental Health Services: Models, Practices and Effectiveness. A State of the Science Review. Edmonton, Alberta: Alberta Heritage Foundation for Medical Research; 2003.
  20. Eggleton K, Liaw W, Bazemore A. Impact of gaps in merit-based incentive payment system measures on marginalized populations. Ann Fam Med. 2017;15(3):255-257. doi:10.1370/afm.2075
  21. Goddard M, Davies HT, Dawson D, Mannion R, McInnes F. Clinical performance measurement: part 2--avoiding the pitfalls. J R Soc Med. 2002;95(11):549-551. doi:10.1258/jrsm.95.11.549
  22. Starfield B, Powe NR, Weiner JR, et al. Costs vs quality in different types of primary care settings. JAMA. 1994;272(24):1903-1908. doi:10.1001/jama.1994.03520240031037
  23. Stange KC, Ferrer RL. The paradox of primary care. Ann Fam Med. 2009;7(4):293-299. doi:10.1370/afm.1023
  24. Rosen AK, Reid R, Broemeling AM, Rakovski CC. Applying a risk-adjustment framework to primary care: can we improve on existing measures? Ann Fam Med. 2003;1(1):44-51. doi:10.1370/afm.6
  25. Starfield B. New paradigms for quality in primary care. Br J Gen Pract. 2001;51(465):303-309.
  26. Starfield B. Primary Care: Balancing Health Needs, Services, and Technology. New York, NY: Oxford University Press; 1998.
  27. Talbot C. Performance management. In: Ferlie E, Lynn LE Jr, Pollitt C, eds. The Oxford Handbook of Public Management. New York, NY: Oxford University Press; 2005:491-517.
  28. Smith PC. Performance management: the clinician's tale. Health Econ Policy Law. 2015;10(3):357-360. doi:10.1017/s1744133114000474
  29. Langley GJ, Moen R, Nolan KM, Nolan TW, Norman CL, Provos LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd ed. Hoboken, NJ: Jossey-Bass; 2009.
  30. Berwick DM. A primer on leading the improvement of systems. BMJ. 1996;312(7031):619-622. doi:10.1136/bmj.312.7031.619
  31. Institute of Medicine (IOM). Community-Oriented Primary Care: A Practical Assessment. The Committee Report. Washington, DC: National Academies Press (US); 1984.
  32. 32. Health Quality Ontario. MyPractice: Primary Care. https://www.hqontario.ca/Quality-Improvement/Guides-Tools-and-Practice-Reports/primary-care.    Accessed August 12, 2019.
  33. Dalkey NC. The Delphi Method: An Experimental Study of Group Opinion. Santa Monica: Rand Corp; 1969.
  34. World Health Organization, Regional Office for South-East Asia. Training Module on Development of Health Workforce Strategic Plans. New Delhi, India: WHO Regional Office for South-East Asia; 2011.
  35. Bloom FJ, Graf T, Anderer T, Stewart WF. Redesign of a diabetes system of care using an all-or-none diabetes bundle to build teamwork and improve intermediate outcomes. Diabetes Spectr. 2010;23(3):165-169. doi:10.2337/diaspect.23.3.165
  36. Mulder C, Sunderji N. Balancing patient priorities for technical and interactional aspects of care in a measure of primary care quality. Prim Health Care Res Dev. 2019;20:e85. doi:10.1017/s1463423619000392
  37. SPSS [computer program]. Version 24. Armonk, NY: IBM Corp; 2016.
  38. Baker R, Grol R. Measuring the quality of primary medical care. In: Jones R, Britten N, Culpepper L, Gass D, Mant D, eds. Oxford Textbook of Primary Medical Care. Vol 1. New York: Oxford University Press Inc; 2005:464-469.
  39. Deming WE. The New Economics for Industry, Government, Education. 2nd ed. Cambridge, USA: The MIT Press; 2000.
  40. Cennamo C, Berrone P, Gomez-Mejia LR. Does stakeholder management have a dark side? J Bus Ethics. 2009;89(4):491-507. doi:10.1007/s10551-008-0012-x
  41. van de Ven AH, Poole MS. Explaining development and change in organizations. Acad Manage Rev. 1995;20(3):510-540. doi:10.2307/258786
  42. Weinhold I, Gurtner S. Rural - urban differences in determinants of patient satisfaction with primary care. Soc Sci Med. 2018;212:76-85. doi:10.1016/j.socscimed.2018.06.019
  43. Green M, Gozdyra P, Frymire E, Glazier R. Geographic Variation in the Supply and Distribution of Comprehensive Primary Care Physicians in Ontario, 2014/15. Toronto: Institute for Clinical Evaluative Sciences; 2017.
  44. Scholle SH, Roski J, Adams JL, et al. Benchmarking physician performance: reliability of individual and composite measures. Am J Manag Care. 2008;14(12):833-838.
Volume 11, Issue 4
April 2022
Pages 514-520
  • Receive Date: 13 October 2019
  • Revise Date: 22 September 2020
  • Accept Date: 23 September 2020
  • First Publish Date: 19 October 2020