1. Comprehensiveness in Primary Care: Results from the Comparison of Models of Primary Care (COMPC) Study C.T. LAMONT PRIMARY HEALTH CARE RESEARCH CENTRE Russell G, Hogg WE, Tuna M, Dahrouge S, Gebremichael G, Geneau R,

2. Objectives Background on primary care comprehensiveness and primary care reform in Canada Compare comprehensiveness in 4 primary care delivery models Explore facilitators of comprehensiveness

3. Comprehensiveness in primary care “Care that is able to meet the broad range of a patient’s or client’s health needs...” “the type and range of services that primary care providers have the capacity to offer to patients” “The type and range of services delivered by primary health care providers.” »(adapted from Starfield 1998)

4. William Osler A physician should have no higher ambition than to become an all-round family doctor, whose business in life is to know disease and to know how to treat it.

5. A decline in comprehensiveness? Reductions in practices offering –Whole person care (Safran 2003) –Home visits and office procedures (Chan 2002) –Preventive services (Stange, 2000) –Comprehensive primary care for minority groups (Stevens 2003)

6. Reform and models of care delivery in Ontario Primary care reform aims to provide better access to comprehensive, around-the- clock health care to people in their own communities... http://www.health.gov.on.ca/transformation/hresults.html

7. Research questions 1.Do models of primary care delivery differ in offering comprehensive primary care? 2.If so, what organizational factors explain the difference?

8. Design Cross sectional mixed methods study Set in Ontario 2005-2006 Sample of 137 Primary care practices in four models of primary care delivery

9. Ontario’s models of primary care Fee for Service Family Health Network Health Service Organization Community Health Centre Physician remuneration FFSBlendedCapitationSalary Patient rostersNoYes No Group practiceOptionalMandatory 24/7 AccessOptionalMandatory Funding for other primary care providers NoneSome Significant

10. Ontario’s models of primary care Fee for Service Family Health Network Health Service Organisation Community Health Centre Physician remuneration FFSBlendedCapitationSalary Patient rostersNoYes No Group practiceOptionalMandatory 24/7 AccessOptionalMandatory Funding for other primary care providers NoneSome Significant

11. Sample Aimed for 40 practices sites/model) –Random sample of FFS practices (150) –Predefined lists for FHN (104), HSO (69) and CHC (51) Within the models –Primary care providers working at these practices and practice patients ≥ 18 years.

12. Data collection 4 sources Bilingual, patient, practitioner and practice surveys (PCAT based) + Chart audit + Administrative data. + Qualitative interviews

13. Practice survey 3 sections description of the practice environment. PCAT measures of comprehensiveness, community orientation and cultural competency. Economic and governance information (team structure, sources of income, salaries and costs.)

14. Assessing comprehensiveness “Does your practice offer the following services? (PCAT) Women’s health –Antenatal care, PAP smear, Preparation and delivery (off site) of babies, family planning Counselling –Nutrition, Alcohol/drug abuse, mental health problems Procedural –Suturing, Allergy shots, wart treatment, splinting for a sprained ankle, removal of an ingrown toenail Diagnostic –Sigmoidoscopy, ECG, Spirometry

15. Analysis method 1) Unadjusted comprehensiveness scores by model 2) ANOVA to compare these scores 3) Multiple linear regressions to –adjust for socio-demographic confounders. (Question 1) –evaluate the impact of organizational characteristics on overall comprehensiveness. (Question 2)

16. Results

17. Recruitment

18. Demographics (Practices)

19. Demographics (Patients) CHC patients were younger, sicker and more likely to be female. FFS and CHCs saw more immigrants (30% cf 16%) than other models

20. Research questions 1.Do models of primary care delivery differ in offering comprehensive primary care? 2.If so, what organizational factors explain the difference?

21. Comprehensiveness % of basket of services offered FFS FHN blended HSO capitated CHC salaried ANOVA Women’s health 79818082 NS Counseling56605978* <0.05 Procedures70666883* <0.05 Diagnostic32392545 NS Overall62636174* <0.05

22. Comprehensiveness % of services provided per practice FFS FHN blended HSO capitated CHC salaried ANOVA Women’s health 79818082 NS Counseling56605978* <0.05 Procedures70666883* <0.05 Diagnostic32392545 NS Overall62636174* <0.05

23. Question 1 Models comprehensiveness

24. Question 2 Other predictors of comprehensiveness

25. Question 2 Explaining comprehensiveness NS: Model % females, #NPs, presence of nurses, patient health, booking time,

26. Limitations Ontario based, cross-sectional, self report. FFS representativeness ‘what is comprehensiveness?’ Subscales varied BUT large size, numerous measures

27. Messages Community Health Centre model linked with higher reported comprehensiveness Comprehensive primary care increases with rurality, proximity to a hospital, the number of FPs, and whether the practice has other health professionals. ….context seems to be important

28. McWhinney and comprehensiveness We must not say: I will care for you as long as you don't get too complicated, or as long as you don’t get AIDS, or become an alcoholic, or become housebound, or as long as you are not dying. Nor should we say, ‘I will care for you, but I only do psychotherapy, or palliative care, or addiction medicine.’ These are all splendid vocations, but they are not general practice.