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Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 1
Looking backward to move forward Insights from Canadian primary healthcare reform evaluations
Jean‐Frédéric Levesque, MD, PhD
Commonwealth Department of Health and Ageing
Canberra, ACT, Australia
March 28th 2012
Looking backward to move forward Insights from Canadian primary healthcare reform evaluations
Primary healthcare (PHC) in CanadaJean‐Frédéric Levesque, MD, PhD
The Barbara Starfield Plenary Measuring the Impact of Primary care
International Primary Care Reform Conference
Brisbane, Queensland, Australia
Primary healthcare (PHC) in Canada• 13 provincial and territorial health systems• A publicly‐funded and privately‐provided medical care
• Mostly fee‐for‐service reimbursement
• Mostly privately‐funded allied health and social services• 35‐40% of health expenditure is private – below 2% for medical
• A fairly homogeneous model of practice – the solo or smallMarch 7th 2012
• A fairly homogeneous model of practice – the solo or small medical group• Absence of rostering or registration of patients
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 2
Looking backward to move forward Insights from Canadian primary healthcare reform evaluations
Primary healthcare (PHC) in CanadaJean‐Frédéric Levesque, MD, PhD
The Barbara Starfield Plenary Measuring the Impact of Primary care
International Primary Care Reform Conference
Brisbane, Queensland, Australia
Primary healthcare (PHC) in Canada• 20‐30% of patients not affiliated to a practice or doctor
• Increasing rates of orphan patients due to closing of clinics • Problems of access to primary care, mostly for younger males and children
• High rates of emergency department consultations
• Reduction of uptake of general practice as a medical
March 7th 2012
p g pspecialty
• Increasing number of patients followed by specialist for primary care
Regular doctor or regular place for medical care, countries and provinces, 2010
82 %
79 %
6 %
9 %
12 %
13 %
Ontario
Canada
79 %
83 %
85 %
88 %
94 %
95 %
72 %
12 %
13 %
4 %
3 %
3 %
4 %
12 %
9 %
4 %
11 %
8 %
16 %
Australia
New Zealand
France
Switzerland
Norway
Netherlands
Quebec
48 %
64 %
75 %
76 %
44 %
13 %
3 %
10 %
8 %
23 %
22 %
14 %
0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %
Sweden
United Kingdom
Germany
United States
Regular doctor No regular doctor but a regular place None
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 3
Emergency room visit was for a condition that could have been treated by the regular doctor, countries and provinces, 2010
49 %
46 %
51 %
54 %
Ontario
Canada
36 %
35 %
34 %
32 %
26 %
23 %
46 %
64 %
65 %
66 %
68 %
74 %
77 %
54 %
Netherlands
New Zealand
Australia
Norway
Germany
France
Quebec
49 %
42 %
41 %
39 %
51 %
58 %
59 %
61 %
0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %
United States
Switzerland
United Kingdom
Sweden
Yes No
Among respondents that had a hospital emergency room visit in the past 2 years
Waiting time (number of days) to see a specialist, countries and provinces, 2010
57.2
68.1
Ontario
Canada
34.2
27.2
20.5
14.3
13.4
82.6
United Kingdom
Netherlands
United States
Germany
Switzerland
Quebec
51.5
49.6
43.9
42.7
39.5
0 10 20 30 40 50 60 70 80 90
Sweden
Norway
France
Australia
New Zealand
Among respondents who were advised to see or decided to see a specialist in the past two years
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 4
Have been admitted to the hospital overnight in the past 2 years, countries and provinces, 2010
16 %
18 %
84 %
82 %
Ontario
Canada
20 %
20 %
19 %
16 %
12 %
8 %
20 %
80 %
80 %
81 %
84 %
88 %
92 %
80 %
Sweden
Switzerland
United States
Netherlands
United Kingdom
Germany
Quebec
24 %
22 %
22 %
21 %
76 %
78 %
78 %
79 %
0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %
France
New Zealand
Australia
Norway
Yes No
“Primary care traditionally seen as a distant observer ofa distant observer of reforms of hospital and community health centres”
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 5
Primary healthcare (PHC) reform is currently under
Looking backward to move forward Insights from Canadian primary healthcare reform evaluations
Jean‐Frédéric Levesque, MD, PhD
The Barbara Starfield Plenary Measuring the Impact of Primary care
International Primary Care Reform Conference
Brisbane, Queensland, Australia
Primary healthcare (PHC) reform is currently under way in various Canadian provinces• Recognition of the central role of primary healthcare into healthcare systems’ performance
Emerging models and policies are at various levels
March 7th 2012of implementation across jurisdictions• A natural experiment of change in PHC
Patients roster, groups, multidisciplinary, blended funding, clinical governance, quality improvement, local coordination information systems
• There has been some evaluations of these• There has been some evaluations of these reforms, few cross provincial analyses– Lack of interprovincial studies;
– Variations in designs and measurement instruments;
– Few documentation of the impact of contexts on the implementation and impact of PHC reformsimplementation and impact of PHC reforms
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 6
Looking backward Our objectivesInsights from Canadian primary healthcare reform evaluations
Jean‐Frédéric Levesque, MD, PhD
The Barbara Starfield Plenary Measuring the Impact of Primary care
International Primary Care Reform Conference
Brisbane, Queensland, Australia
Using qualitative deliberative synthesis techniques to better understand primary care reform and its impact on people,
March 7th 2012 providers, organisations and systems.Outlining the impact of context on policy
prescriptions.
A policy analyses of PHC reforms in ten provinces and three territories
• Examines primary health care reform efforts in Canada duringreform efforts in Canada during the last decade drawing on:– descriptive information from
published and grey literature
– and from a series of semi‐structured interviews with informed observers of PHC in CanadaCanada
(Hutchison, Levesque, Strumpf, Coyle 2011)
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 7
A deliberative synthesis of PHC reforms evaluations in five provinces
• Examines the impact of models and factors facilitating reform through:g g– Case studies of provincial reforms
– Deliberative synthesis involving reform evaluations researchers as well as decision‐makers
(Levesque, Burge, Haggerty, Hogg, Katz, Pineault, Wong 2012)
Various quantitative and qualitative evaluations
• Primary care reform evaluation in Nova Scotia (Burge and Lawson)( g )
• Studies of Family Medicine Groups implementation in Quebec (Haggerty, Pineault, Lamarche, Beaulieu, Levesque)
• Comparison of primary care models in Ontario (Hogg, Russell, Dharouge, Green)
• Assessment of chronic care in fourAssessment of chronic care in four intervention practices in Manitoba (Katz)
• Evaluation of primary care experiences in British Columbia (Wong and Watson)
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 8
Four measurement perspectives
1. Capturing contextual influences
2. Measuring the nature of reform efforts
3. Understanding the levers of reform
4. Evaluating impact of reforms
1. Capturing contextual influences
• A felt urgency for changef h hl h d ’ d f– Performance reports highlighting Canada’s deficits
– A tired and de‐motivated workforce
• A history of separate community health centres and primary care providers– Multi‐disciplinarity is outside of primary care and doctors have resisted working inside a community orientation
• A supportive socio‐political context– Recognition that primary care must be supported
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 9
“ A strong desire for change has been observed i i Ph i i i th iin many provinces. Physicians are seeing their workloads increase because of the shortage of human resources relative to the increased complexity of clinical cases. Many are now more receptive to changes.”
Satisfaction with practicing medicine, countries and provinces, 2009
24 %
21 %
53 %
55 %
23 %
24 %
Ontario
Canada
19 %
22 %
28 %
31 %
35 %
35 %
13 %
59 %
67 %
54 %
50 %
54 %
55 %
60 %
23 %
11 %
18 %
20 %
11 %
10 %
27 %
Italy
Netherlands
United Kingdom
Sweden
New Zealand
Norway
Québec
5 %
8 %
12 %
14 %
33 %
69 %
36 %
48 %
62 %
23 %
52 %
38 %
0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %
Germany
France
Australia
United States
Very satisfied Satisfied Somewhat dissatisfied/Very dissatisfied
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 10
Leaving medical practice within the next 5 years, countries and provinces, 2009
18 %
20 %
7 %
7 %
75 %
73 %
Ontario
Canada
14 %
16 %
17 %
17 %
18 %
29 %
19 %
7 %
15 %
3 %
8 %
4 %
28 %
4 %
80 %
70 %
80 %
75 %
78 %
43 %
78 %
Netherlands
United States
Italy
France
Germany
Sweden
Québec
7 %
9 %
11 %
13 %
15 %
13 %
4 %
12 %
78 %
78 %
85 %
75 %
0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %
New Zealand
Australia
Norway
United Kingdom
Yes, retiring Yes, leaving for other reasons No
Other health care providers in the practice, countries and provinces, 2009
55 %
55 %
45 %
45 %
Ontario
Canada
79 %
88 %
89 %
91 %
98 %
98 %
65 %
21 %
12 %
11 %
9 %
35 %
Germany
Australia
New Zealand
Netherlands
United Kingdom
Sweden
Québec
11 %
54 %
63 %
74 %
89 %
46 %
37 %
26 %
0 % 10 % 20 % 30 % 40 % 50 % 60 % 70 % 80 % 90 % 100 %
France
Italy
United States
Norway
Yes No
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 11
“ If the policy environment has historically b t l t d i dbeen neutral towards primary care and professionals generally opposed to the redesign of their practice, it is clear that the current socio‐political context has changed throughout the country.”
2. Measuring the nature of reform efforts
• Model‐based reformsOntario and Québec implementing a variety of practice– Ontario and Québec implementing a variety of practice models (organisational types)
– Some efforts at modifying reimbursement models
• Principle‐based reforms– Nova Scotia and British Columbia investing in quality improvement initiatives (best practice)
• System integration– Alberta, British Columbia and Québec implementing coordination organisations (networks and divisions)
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 12
(Hutchison, Levesque, Strumpf, Coyle 2011)
(Hutchison, Levesque, Strumpf, Coyle 2011)
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 13
(Hutchison, Levesque, Strumpf, Coyle 2011)
(Hutchison, Levesque, Strumpf, Coyle 2011)
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 14
Family medicine groups
F il h l h
Local integrated health networks
Cooperative clinics
Primary care divisionsLocal health centres
Family health teamsPrimary care networks
Community health centres
Solo providers
Cooperative clinics
Walk‐in clinics
Group practices
Network clinic
Family health groups
Community health centres
Health services organisations
Local department of general practice
Quality improvement initiative
3. Understanding the levers of reform
• Coercive policies and incentives– Provincial governments have been the main driversg
• Legislation supported expanded roles for other professionals• Best practice characteristics parts of contractual agreements
– Funding of reform is crucial• Too little thwarts efforts and demoralizes• Too much proves overwhelming and unsustainable
• Normative influences– There was a few case of active lobbying by professionaly g y p– Support and engagement of professional leaders was essential
• Mimetic influence– Presence of champion and an incremental process
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 15
“ Few changes have been imposed on providers d it i di f i tiand it is more a discourse of incentives or
demonstrations that is currently seen in many provinces. In many cases, the need to treat physicians as partners in reforms was identified as the key to success.”
“ ...in every province, the presence of certain h i i id hchampions among primary care providers has been crucial and they have often acted as role models for other physicians in order to generate the necessary uptake for new models or initiatives to grow.”
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 16
4.Impacts of reforms
• Most benefits of the reforms so far seem to have occurred with regards to: occurred with regards to: – patients’ affiliation with a usual source of care, – some benefits on the experience of care of patients, – higher workforce satisfaction
• Emerging evidence of the impact of new models on prevention and management of chronic diseases:– recognition of the value of oldermodels, such as CHCs, on
complex patients care– limited evidence of impact on quality of life and health
outcomes
5
6
General practice assessment survey scores by subdimensions across organisational types at baseline
2
3
4
0
1
Accessibility Reception Continuity Communication Nursing
Solo provider Private group practice Family medicine group/network clinic Local community health centre/Family medicine unit
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 17
(Commissaire à la santé et au bien‐être 2011)
(Commissaire à la santé et au bien‐être 2011)
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 18
Overall view of the health care system, Canada’s respondents (practice), 2009
29%
35%
67%
58%
3%
7%
Group practice
Solo practice
etting
32%
36%
34%
33%
34%
37%
39%
37%
64%
60%
64%
65%
59%
60%
58%
64%
4%
3%
3%
3%
7%
3%
3%
No
Yes
5 and more
2 to less than 5
Less than 2
Hospital / Other
Local com. health centre
Family medicine group
etwork of
practices
FTE doctors
Practice se
Improvement of the quality of medical care, Canada’s respondents (practice), 2009
6 %
21 %
%
46 %
33 %
33 %
G ti
Solo practice
g
33%
34%
31%
38%
62%
63%
65%
59%
5%
3%
4%
3%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
No
Yes
No
Yes
Other
providers
Electronic
records
N p
Works pretty well Fundamental changes are needed Need to be completely rebuilt
21 %
16 %
17 %
21 %
17 %
15 %
21 %
16 %
51 %
51 %
51 %
48 %
53 %
54 %
50 %
51 %
28 %
33 %
32 %
31 %
30 %
31 %
30 %
33 %
Yes
5 and more
2 to less than 5
Less than 2
Hospital / Other
Local com. health centre
Family medicine group
Group practice
ork of
tices
FTE doctors
Practice settin
Disease burden across types
SoloPrivate group
Family medicine group /
Local community
health centre / SpecialistSolo
Average elderly population
Better perceived health status
practice
Low elderly population
Better perceived health status
group / Network clinic
Average elderly population
Worse perceived health status
health centre / Family medicine
unit
High elderly population
Worse perceived health status
Specialist
Average elderly population
Worse perceived health status
Lower multimorbidity
Low home‐care reception
Lower multimorbidity
Low home‐care reception
Average multimorbidity
Average home‐care reception
High multimorbidity
High home‐care reception
High multimorbidity
High home‐care reception
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 19
(Provost et al. 2010)
P15. Asked how chronic condition affects life
P16. Contacted after a visit
P17. Encouraged to attend community programs
P18. Referred to health educator or counselor
P19. Explain visits with other doctors
P20. Asked about visits with other doctors
ng /
Follow‐up /
Coordination
Reported reception of chronic illness care, PACIC (n =776)
P6 Shown how what I did influenced my condition
P7. Asked to talk about goals in caring for condition
P8. Helped to set specific goals to improve eating and exercise
P9. Given a copy of treatment plan
P10. Encouraged to go to a specific group or class
P11. Asked questions about health habits
P12. Doctor or nurse thought about values, beliefs and traditions
P13. Helped to make a treatment plan
P14. Helped to plan ahead in hard times
gn
Goal Setting
Problem‐solvin
Contextual
Counselling
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
P1. Asked for my ideas when we made a treatment plan
P2. Given choices about treatment to think about
P3. Asked to talk about medicines problems
P4. Given a written list of things to improve my health
P5. Satisfied that my care was well organized
P6. Shown how what I did influenced my condition
Patient
Activation
Delivery
System Desig
/ Decision
Support
None of the time A little of the time Some of the Time Most of the time Always
v2
Slide 38
v2 J'ai noté "agrandir le stackbar...vous vous souvenez de quoi il s'agissait?"vlemieux, 28/04/2010
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 20
30
40
50
Average percentage gap with mean scores of PACIC subdimensions across organisational types (12 months)
‐10
0
10
20
‐30
‐20
Solo provider Private group practice Family medicine group/Network clinic
Local community health centre/Family medicine
unit
Specialist
Patient Activation Delivery System Design / Decision Support Goal Setting Problem‐solving / Contextual Counselling Follow‐up / Coordination
(Levesque et al. 2012)
Local community health t
Percentage of severe patients followed by specialists for their chronic illness (typology)
Group practice
Family medicine groups
centers
0 10 20 30 40 50 60 70 80 90 100
Solo provider
(Levesque et al. 2012)
Professor Jean‐Frédéric Levesque Wed 28 March 20123pm – 4pm
Presented byThe Australian Primary Health Care Research Institute, ANUaphcri.anu.edu.au 21
Looking forward
• Canadian provinces and territories are experiencing an acceleration of primary careexperiencing an acceleration of primary care reforms
• Understanding their diversity and the levers that facilitate their implementation will help us better guide the continuation of reforms
• Change is happening where synergies betweenChange is happening where synergies between policy and professional leadership align
• It is starting to translate into population level impacts
Acknowledgements
Brian Hutchison
Erin Strumpf
Raynald Pineault
Bill Hogg
Jeannie Haggerty
Alan Katz
Fred Burge
Sabrina Wong
Dominique Grimard
And all the Forum participants