Several factors may influence chronic disease management in family medicine. For example, practices located in rural regions are challenged by less availability and access to technology or specialty care to help diagnose or monitor some conditions. For chronic diseases, this may affect some aspects of patient care such as echocardiogram and spirometry testing and ophthalmologic assessment. Physician knowledge, experience or comfort in managing chronic disease may influence medical therapy that their patients receive, such as medications. Practice structures can facilitate chronic disease management through processes such as interdisciplinary care. Physician remuneration models and pay for performance incentives may improve benchmark levels of chronic disease performance measures.
The results for the HF and DM prescribing indicators are similar to those measured in other studies conducted in Canada [11, 18, 19]. Benchmark prescribing levels for HF patients are usually based on patients discharged from hospital and do not include HF patients diagnosed and managed outside of the hospital setting . Quality of care for DM management has focused on clinical targets and less so on providing specific prescribing benchmarks . Nevertheless, the prescribing levels for HF and DM patients in this study approach some evidence based targets. While the HF and DM prescribing indicators did not significantly differ from patients belonging to a FHG versus a FHN, some prescribing indicators did differ slightly (of around 5%) by region in Ontario. However, further work which would control for potential confounders such as socioeconomic status and comorbidity still needs to be done to confirm these comparisons.
Since 2002, several clinical evidence-based guidelines have been disseminated to primary care practitioners for DM management [21, 22]. In this analysis, after patients enrolled in either a FHG or FHN model, improvements were seen in the prescribing of metformin, angiotensin converting enzyme inhibitor (ACEI) and antilipid medications. This may be a result of incentive payments for DM care. It may also reflect the success in knowledge translation of evidence based care for DM. Interestingly, while the prescribing of antihypertensive medications had not reached benchmark levels, we did not see a significant change after patients enrolled in either FHGs or FHNs.
In this analysis, there were no significant changes in ACEI prescribing for HF patients after they enrolled in either a FHG or FHN model. The HF management incentives for FHGs and FHNs were introduced in 2008, after the study time frame. Although evidence-based guidelines have been developed by the Canadian Cardiology Association for the management of HF patients, their dissemination into primary care practice has been limited . Rather than concluding a lack of affect of primary care delivery models affecting HF management, our study may point to a lack of knowledge translation of the current HF recommendations into primary care. Follow up work, after the HF management incentives were implemented, may better demonstrate any potential impact they may have in the care of HF patients.
More striking gender and age differences were found. We found lower echocardiogram use and ACEI prescribing for women newly diagnosed with HF and lower ophthalmology use for DM patients less than 64 years of age. For several reasons, women receive fewer cardiovascular investigations than men [23, 24]. As of November 1 2004, funding for routine eye examinations by either an optometrist or physician for patients between 20 and 64 years of age was no longer covered under the publically funded health insurance plan. However, patients of all ages with stipulated medical conditions, such as DM are still eligible for an annual eye examination. It may be that younger DM patients and their FPs are unaware of this coverage and this may be one reason for poorer referrals for younger DM patients.
There were no improvements in our performance measures for asthma care and no asthma management incentives exist for either model. While asthma guidelines exist for FPs, the emphasis on evidence-based clinical care often focuses on the medications prescribed for people with asthma and less so on health administrative data indicators such as spirometry testing and emergency room use as used in this study . Further analysis should include an examination of medication use by people with asthma.
While the proportion or women getting mammography or pap smear testing was higher amongst those belonging to a FHN versus a FHG, the differences were not large. The capitation remuneration payment for FPs participating in FHN models may account for this slight improvement. In Ontario, benchmark mammography and pap smear testing levels are generally set at 75% for screen eligible women . In this study, both mammography and pap smear testing met or approached these levels, regardless of the physician remuneration structure or practice location. However, secular trends in Ontario for mammography and pap smear testing prior to the introduction of these new primary care models were already approaching benchmark levels . Although the proportion of the study patients receiving colorectal screening is still low, it did improve significantly after patients joined either a FHG and FHN, and in comparison to similar provincial results released in 2006 . No differences were seen in colorectal screening between FHGs and FHNs. In March 2008, after the time frame of this study, a new Cancer Care Ontario colorectal screening program was launched, which included more financial incentives to improve colorectal screening benchmarks . Further comparison with primary care models which do not have incentive payments may expand the understanding of the impact of these initiatives on colorectal cancer screening rates. In England, an examination of 18 general practices found that financial incentives introduced to improve quality of care for "incentivized" conditions and non-"incentivized" conditions did not demonstrate any quality improvement . Similarly another study, based in the UK, found that the quality of care for asthma, diabetes and coronary artery disease was improving before the introduction of 2004 pay for performance incentives. However, it did conclude there was a modest acceleration in quality improvement for diabetes and asthma after 2004 . Another British study, which examined preventive prescribing indicators and the health gains related to potential payments (including incentive payments), found no relationship between pay and health gain across the prescribing interventions examined .
A retrospective review of a US Medicare community health centre population which used administrative data to measure performance did not find evidence of clinically significant change with financial incentives for preventive care performance . Another US study of 35 Kaiser Permanente facilities found the removal of financial incentives was associated with decreased DM retinopathy screening and cervical cancer screening .
A systematic review of studies examining pay for performance confirms that the results of pay for performance range from extremely positive to disappointing . Among the recommendations made to ensure success with the selection of pay for performance incentives are the selection and definition of pay for performance targets on the basis of baseline room for improvement. This may be the situation for breast cancer and cervical cancer screening activity in Ontario. Prior to the introduction of FHGs and FHNs, these screening rates were approaching 75% . Colorectal cancer screening rates were extremely low prior to the introduction of FHNs and FHG, and therefore incentive payments, along with other provincial strategies, may have contributed to the improvements seen in screening rates.
There are several limitations to our study. First, this study was limited to enrolled patients, and as the numbers continue to rise as more patients enroll in FHGs, FHNs and other models further research would be warranted. In some cases, the period of time over which the indicator was measured was insufficient. For example, a two and half year window for determining mammography screening may be more appropriate than two years. Using administrative data alone poses challenges in assessing quality of care. For example, getting a prescription for a medication is not the same as actually taking it. And finally tracking FP care is challenging in Canada, as FPs may participate in more than one type or primary care model.