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CBPHC Common Indicator Project
Sabrina Wong, RN, PhD
Professor, University of British Columbia
CBPHC Indicator Working Group Chair
February 2015
1
Questions being addressed by Indicators Working Group
• What are the attributes of: (a) community based primary health care (CBPHC) innovations that address adult and child populations? (b) alternative models of chronic disease prevention and management in CBPHC on patient and system outcomes (e.g., health outcomes, cost, access, equity)?
• What structures (e.g. governance, financing, etc.) and context influence the cost, implementation, delivery, scale-up and impact of PHC models of care?
• What underlying methods, theories, or frameworks can be used to advance the science of comparative research?
2
Agreed upon Dimensions
• Access (accommodation)• Comprehensiveness (primary health care support
for self-management of chronic conditions, scope of services
• Coordination (team functioning, system integration, information continuity, management continuity)
• Effectiveness (self-efficacy, patient empowerment, patient centeredness, health and well-being, EQ5D-5L)
• Equity (horizontal and vertical)
3
Summary of Agreed upon Dimensions and Related
IndicatorsDimension/sub-dimension
• Access (difficulty getting access, accommodation)
• Comprehensiveness (PHC support for self-management of chronic conditions, scope of services)
• Coordination (team functioning, system integration, information continuity, management continuity)
Indicator (CIHI and other)• Difficulties accessing
routine or ongoing PHC• PHC support for self-
management of chronic conditions; Scope of PHC services
• HC Team Effectiveness Score; Collaborative Care with other health care organizations
4
Summary of Agreed upon Dimensions and Related
Indicators (2)
Dimension/sub-dimension• Effectiveness (self-efficacy,
patient empowerment, patient centredness, global health)
• Equity (horizontal-equality, vertical)
Indicator (CIHI and other)• ACSC hospitalization
rate, ED visits for asthmas; using patient reported impacts and outcomes of care
• No CIHI indicators in CIHI PHC Update report; using pt. reported impacts and outcomes of care
• Work in this area completed by researchers in Canada
5
Coverage by common indicator
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• Teams validated on ability to report on access, comprehensiveness, effectiveness, coordination, cost, equity and multimorbidity using the recommended common indicator and common measure/instrument
Data sources
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Source TeamsQualitative interviews 12
Patient surveys 10Administrative data 9
Provider/practice surveys 7Cost data 7
Organization survey 5
Work to date
• Agreement on: research questions, common dimensions of CBPHC, common indicators, common measures and data sources
• Completed reviews of sampling, dimensions, indicators, and measures across teams
• Working on mapping individual team’s work to expanded chronic care model; asking teams to develop their logic model
9
Coverage by common indicator*For “all teams” column, data was interpreted for the 2 non-validated teams.
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Domain Indicator
Access *Difficulties accessing routine or ongoing PHC
Comprehensiveness *PHC support for self-management of chronic conditions
Comprehensiveness *Scope of PHC services
Coordination *PHC team effectiveness score
Coordination *Collaborative care with other healthcare organizations
Effectiveness ACSC hospitalization rateEffectiveness PROM: Functional healthEffectiveness Self-efficacy for managing chronic diseaseEffectiveness Patient empowerment
Cost Direct (utilization) + indirect costs (e.g., out-of-pocket)
Equity N/AMultimorbidity N/A
Next Steps
• Overarching logic model• Analytic plan for common
dimensions of CBPHC• Case study protocol
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Access: Difficulties accessing routine or ongoing PHC
13
• 9/10 teams teams reported “Yes”Team Comments
Grunfeld (Yes) • In RCT
Haggerty (Yes) • N/AKaczorowski (Yes) • Patient survey within RCT
Katz (Yes) • With First Nations Regional Health SurveyLiddy (Yes) • Patient survey in nurse practitioner-led clinicsPloeg (Yes) • RCT 1 & RCT 2: In planned participant
questionnaireStewart & Fortin (Yes) • Can include in patient self-reported questionnaire,
but do not expect changesWong (Yes) • With questions recommended to 12 teamsYoung (Yes) • Secondary analysis of existing CCHS data;
question will be similar to the patient survey.
Comprehensiveness: PHC support for self-management of chronic conditions
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• 10/10 teams reported “Yes”Team Comments
Grunfeld (Yes) • In RCT
Haggerty (Yes) • N/AHarris (Yes) • Could incorporate into the Readiness Tool provider survey
and modify for relevance to indigenous populations.• Could also use Clinical readiness tool or report qualitatively
from clinical and community teams.
Kaczorowski (Yes) • Patient survey within RCT
Katz (Yes) • N/A
Liddy (Yes) • Patient survey and similar questions for patient centred medical home survey
Ploeg (Yes) • RCT 1 & RCT 2: In planned participant questionnaire
Stewart & Fortin (Yes) • Could incorporate into baseline, but maybe not beyondWong (Yes) • N/A
Young (Yes) • Could incorporate within planned provider survey
Comprehensiveness: Scope of PHC services
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• 6/10 teams reported “Yes,” 1 reported “Maybe”Team Comments
Haggerty (Yes) • N/AHarris (Yes) • Could incorporate into the Readiness Tool
provider survey and modify for relevance to indigenous populations.
Katz (Yes) • N/ALiddy (Maybe) • Will use patient-centred medical home org.
survey, but willing to adapt or change if necessary.
Ploeg (Yes) • RCT 1 & RCT 2: In practice questionnaireWong (Yes) • N/AYoung (Yes) • Based on existing information
Coordination: PHC team effectiveness score
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• 9/10 teams reported “Yes,” 1 reported “Maybe”Team Comments
Grunfeld (Maybe) • Maybe in RCT: May want to include an oncology-specific scale.
Haggerty (Yes) • Patient survey only. Information Continuity scaleHarris (Yes) • Could incorporate into the Readiness Tool provider
survey and modify for relevance to indigenous populations.
Kaczorowski (Yes) • Patient survey within RCT
Katz (Yes) • N/A
Liddy (Yes) • In patient survey
Ploeg (Yes) • RCT 1 & RCT 2: TCI 19 items; in practice questionnaire
Stewart & Fortin (Yes) • Can add the information continuity sub-scale to our patient questionnaire.
Wong (Yes) • N/A
Young (Yes) • Modified CIHI survey for own provider survey
Coordination: Collaborative care with other healthcare organizations
17
• 8/10 teams reported “Yes”Team Comments
Harris (Yes) • Could incorporate into the Readiness Tool provider survey and modify for relevance to indigenous populations.
Haggerty (Yes) • Patient survey and organizational surveyKaczorowski (Yes) • Patient survey within RCT
Katz (Yes) • N/ALiddy (Yes) • Incorporated into patient survey
Ploeg (Yes) • RCT 1 & RCT 2: In practice questionnaire
Stewart & Fortin (Yes)
• Not part of survey, but can incorporate within in-depth provider interviews)
Wong (Yes) • N/A
Effectiveness: ACSC hospitalization rate
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• 5/10 teams reported “Yes,” 1 reported “Maybe”
Team Comments
Grunfeld (Maybe) • RCT: Depends on conditions; will be measuring ED & hospitalizations associated w/chemotherapy toxicity.
• Admin data: Likely yes, possibly in a few provinces
Haggerty (Yes) • Expect to use admin data, but in QC
Katz (Yes) • Using an adapted version to be shared with the group.
Liddy (Yes) • Y for NL & ON cohort studies; TBC for ON
Stewart & Fortin (Yes) • N/A
Wong (Yes) • N/A
Effectiveness: Functional Health (VR-12)
19
• 6/10 teams reported “Yes”Team Comments
Grunfeld (Yes) • RCT
Haggerty (Yes) • N/A
Kaczorowski (Yes) • Incorporated into patient survey within RCT
Katz (Yes) • Likely in conjunction with CIHI patient planned survey; see if this has been validated with First Nations
Liddy (Yes) • Through patient survey
Wong (Yes) • N/A
Ploeg (No) • Using SF-12
Stewart & Fortin (No) • EQ-5D and SF-12 (could include PROMIS)
Effectiveness: Self-efficacy for managing chronic disease
20
• 7/10 teams reported “Yes”Team Comments
Grunfeld (Yes) • RCT: Likely if it passes face validity
Haggerty (Yes) • N/A
Kaczorowski (Yes) • Incorporated into patient survey within RCT
Liddy (Yes) • Through patient survey
Ploeg (Yes) • RCT 1 & RCT 2: In participant questionnaire
Stewart & Fortin (Yes) • SE-MCD; can add Patient activation questions
Wong (Yes) • N/A
Effectiveness: Patient empowerment
21
• 5/10 teams reported “Yes”Team Comments
Grunfeld (Yes) • RCT: If there is a breast cancer specific tool, would need to use that. Don't believe there is one.
Kaczorowski (Yes) • Incorporated into patient survey within RCT
Liddy (Yes) • Could be incorporated, but concerned about response burden
Stewart & Fortin (Yes) • N/A
Wong (Yes) • N/A
Cost: direct (utilization) + indirect costs (e.g. out-of-pocket) (will use EQ5D-5L)
22
• 7/10 teams reported “Yes,” 1 reported “Maybe”Team Comments
Grunfeld (Yes) • Admin data if we link to admin data - from societal perspective, therefore need patient costs, but may need a cancer-specific one
• Collecting encounters during diagnostic, treatment and survivorship phase, and then cost out cancer services (possibly only ON)
Haggerty (Maybe) • “Probably” will use
Katz (Yes) • With admin data; but in First Nations communities, would really only have hospitalization data because other access is not captured.
Liddy (Yes) • For NL & ON cohorts & possibly MB
Ploeg (Yes) • RCT 1 & RCT 2: In participant questionnaireStewart & Fortin (Yes) • Plan to use admin data
Wong (Yes) • N/A
Young (Yes) • Economic evaluation of patient transportation
Equity
23
• 10/10 teams reported “Yes”Team Comments
Grunfeld (Yes) • RCT: 6-digit postal code
Haggerty (Yes) • Economic, immigrant/refugee status (specific ethnicities); aboriginal; age (young adult and elderly); rurality; residential stabiltiy; mental health
Harris (Yes) • Not using admin data, but from chart data can do sex/gender, age, geography in terms of province and degree of rural/remoteness.
Kaczorowski (Yes) • N/A
Katz (Yes) • Yes for some of the basic equity measuresLiddy (Yes) • Yes for nurse practioner clinics (age, sex, gender, postal code,
health ins #).• Maybe in admin cohort studies through equity of access to care.
Will have health ins # but might not have postal code.Ploeg (Yes) • N/A
Stewart & Fortin (Yes) • Will use gender, age and the Grunfeld questionnaireWong (Yes) • N/AYoung (Yes) • Existing databases on health status, determinants and utilization
for Ab vs non-Ab and North vs South.
Multimorbidity
24
Team Comments
Grunfeld (Maybe) • RCT: Not sure if linking to admin data; otherwise, will embed within patient questionnaire (may use Martin's if relevant to population)
• Admin data: Jon Hopkins ADGsHaggerty (Yes) • N/A
Harris (Yes) • Will capture most items from chart data but will not do a survey or admin data.
Katz (Maybe) • Not sure about asking directly about the chronic conditions, and about others like TB, HIV, other mental health issues beyond depression & anxiety.
Liddy (Maybe) • Potential for NP study in patient questions (should HIV be added to increase comparability?).
• Will capture through admin data for cohorts.Ploeg (Yes) • In patient questionnaire for RCT 1 & RCT 2
Stewart & Fortin (Yes) • N/A
• 4/10 teams reported “Yes,” 3 reported “Maybe”
Data sources possibilities 1
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*Audas 1. Administrative data (including cost), 2. Statistics Canada surveys, 3. Patient/family/provider interviews
Grunfeld 1. Admin, lab, registry data, 2. Focus groups and interviews with patients and service providers
Harris 1. National Community Profile survey 2. Community readiness tool (repeated measures), 3. Clinical readiness tool (repeated measures), 4. T2DM registry/surveillance data (chart audit), 5. Participant observation and interviews, 6. cost data
Kaczorowski 1. Patient questionnaires (CANRISK) in pharmacy, 2. Admin data, 3. Focus groups & key informant interviews, 4. ChAMP database, patient EMRs, and patient surveys
Katz 1. CIHI patient, provider, organization surveys, 2. administrative data (for ACSC hosp.), 3. qualitative case studies (sharing circles and focus groups), 4. service provider/administrator/manager interviews
Asterisk denotes teams that have not been validatedBold texts denotes methods related to the common indicators
Data sources possibilities 2
26
Haggerty 1. International and national surveys (CMWF, QUALICOPC, CCHS), 2. interviews and focus groups with key stakeholders, 3. admin data, 4. patient and organizational questionnaires (EQ-5D, access measures, unmet need, quality care), 5. costs of implementation of intervention model
Liddy 1. Admin, lab, registry, chart/clinical, HIV cohort data (including HRQoL like SF-36 for ON), 2. CIHI organizational survey, 3. semi-structured interviews with PM stakeholders, 4. cost (billing data, ON case costing initiative)
Ploeg 1. Admin and population survey data (CCHS), 2. Semi-structured interviews with patients, family members, service providers, 3. family caregiver survey data (e.g., HRQoL, self efficacy, etc.), 4. Health and Social Services Inventory for utilization & cost data
Data sources possibilities 3
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Stewart & Fortin 1. In-depth interviews with patients, providers, informal caregivers, decision makers regarding context, 2. admin data, 3. patient survey data, 4. cost data (admin data + CIHI Resource Intensity Weights)
*Wodchis 1. QUALICOPC data from ON, QC, NZ at regional level, 2. organization, provider and patient survey and key informant interview data
Wong 1. Modified CIHI patient, provider, organization surveys, 2. admin data, 3. clinical data (EMRs or chart), 3. case study data from interviews and focus groups on context
Young 1. key informant interviews, 2. health centre and patient records & coroners' reports, 3. EMRs, 4. cost data