1. Performance Measurement and Rural Primary Care: A scoping review
Murphy, P., Burge, F., Wong, S.T.
Contact:
Background
Efforts to improve primary care (PC) rely on measuring and reporting performance to support decision-making. Comprehensive performance measurement systems need to account for diverse stakeholder groups, including rural residents and health care providers. The purpose of this study is to establish the features of PC that should be measured and reported in a rural versus a non-rural context.
Methods
A literature search was conducted via: PubMed, CINAHL, Scopus, grey literature (e.g. Google), and hand searching relevant journals.
Inclusion criteria for articles:
Compares rural with non-rural aspects of primary care
Written in the English language
Published between 2003 and 2017
Discusses practice characteristics, physician scope of practice or practice patterns, and/or patient patterns of health care use
Pertains to one of four pillars of quality PC as defined by the CFPC’s Patient’s Medical Home model (Fig. 1): accessibility, continuity, comprehensiveness, or electronic health records. These pillars were chosen as they focused the scope of the project and emerged as key elements during the initial literature search.
Exclusion criteria for articles:
Inverse of inclusion criteria
Focuses on specific patient populations, health concerns or health outcomes, and/or patient/physician preferences or experiences with primary care
Results
Twenty-six studies were identified for analysis for this scoping review (See Fig. 2). Key findings are summarized in Table 1.
Access: physicians in rural communities divide their time between hospital and clinic-based practice.
Comprehensiveness: increasing rurality is associated with an increase in PC providers’ scope of practice.
EMR use: practice size as well as level of rurality, can predict functionality and adoption of EMR systems.
Continuity: Rurality is associated with a lower reported level of continuity.
Conclusions
The 26 identified studies describe differences between rural and non-rural PC that should be considered in the design of performance measurement systems.
Further research in this area needs to be conducted e.g. implications on other PMH pillars, patient and provider perspectives, and equivalent definitions of rurality.
Acknowledgements
Richard Payzant Ward Travel Fund
This work is funded by:
Figure 1. Patient’s Medical Home Pillars
Figure 2. Flow diagram of included articles
Patient Centred-Care
Personal Family Physician
Team-Based Care
Timely-Access
Comprehensive Care
Continuity of Care
Electronic Medical Records
Education, Training and Research
Evaluation and CQI
Internal and External Supports
Studies identified through database searching
(n=7,413)
Studies identified through grey literature search and hand-search of remaining studies’ references
(n=5)
Studies excluded based on title/abstract screening
(n=7,341) 
Studies assessed for eligibility
(n=79)
Studies excluded after full- text review
(n=53)
Studies included in final scoping review
(n=26)
4 key pillars emerged during the initial search and were used to focus the scope
Table 1. Key findings
Select Aspects of PHC
Considerations for Performance Measurement in a Rural Context
Access
There was a marked increase in the use of specialist services among urban residents and a greater likelihood of receiving care from allied health professionals, nursing, and community health centres among rural residents.
A greater number of rural residents than urban described receiving care from an emergency department (ED).
Most patients attending rural EDs or urgent care centres have primary care providers, but among urban patients attending an ED, this finding is reversed (i.e. urban patients in the ED are less likely to have a primary care provider).
The most urban and most rural residents were the least likely to have a primary care provider.
Comprehensiveness
Increasing rurality is associated with an increase in primary care physicians’ scope of practice; geography is the main driver behind an individual physician’s scope of practice.
EMR use
Rural-urban differences in EMR use were explained away by adjusting for practice size and type, and rates of use were roughly similar.
Continuity
Practice factors associated with lower reported patient continuity included rural setting, a higher number of physicians in the practice, employing nurses as part of the practice staff, weekend appointments, and 24 hours or less per week of on-call services.
MEASURING AND IMPROVING THE PERFORMANCE OF PRIMARY HEALTH CARE IN CANADA