Does team-based primary health care improve patients’ perception of outcomes? Evidence from the 2007–08 Canadian Survey of Experiences with Primary Health
Introduction
Primary health care (PHC) is the basic foundation upon which an efficient and effective healthcare system rests [1], [2]. In recent years, many countries have implemented team-based practice as an integral component of PHC in order to alleviate the problems of escalating costs, deteriorating quality and addressing the growing demand for healthcare driven by an aging population [3], [4]. In Canada, many jurisdictions have adopted a team-based PHC approach since year 2000 with an increased emphasis on the coordination and integration of health services [5]. These initiatives are designed “to provide most appropriate care, by the most appropriate providers, in the most appropriate settings,” to increase health promotion and disease prevention initiatives, effective management of chronic diseases, 24/7 access to essential healthcare services, and coordination with specialists and hospitals [5]. However, empirical evidence on these expected outcomes associated with team-based practices remains scant.
Theoretically speaking, a team-based primary care practice is expected to be more cost-effective than a solo practice because the team combines “cure, care and prevention” [6] and shares “the responsibility for, and the provision of, care to patients” [7]. There are several plausible mechanisms by which improved outcomes might arise in team-based practice settings. First, substitution of non-physician labor inputs [8] for physician labor inputs may allow other health professionals (e.g. nurse and physician assistant) to work with the physician(s) thereby allowing physicians to devote more time to patient care, which may lead to reduction in patient wait times [3]. It may also bring about improvements in healthcare services by allowing physicians to focus on more complex medical problems [9]. Second, cost-effectiveness may be achieved by coordinating health services for multiple treatments and assessments to deal with co-morbidities [10]. Third, team-based practice may generate scale efficiency through adopting the one-stop shop model of care where patients can receive all services in a single appointment [9]. Fourth, the team-based models might perform better than usual care settings (i.e. health services provided by solo physicians) as they enhance clinical performance through sharing of knowledge and skills [11].
Despite the theoretical appeals of team-based practice in primary care, existing empirical evidence to date is mixed at best [5]. Some studies suggest that team-based practice is positively associated with improved patient outcomes, such as increased access, improved quality of service, effective management of chronic diseases [3], [5], [11], [12], [13], [14], [15], [16], [17]. By contrast, other studies suggest a negligible impact of team-based PHC delivery on patient outcomes: limited access to physicians, compromised continuity of care, duplication of efforts, creation of barriers of disciplinary territoriality, systems inertia and organizational complexity [11], [18], [19], [20], [21], [22]. Aside from these somewhat conflicting findings, it is not clear whether these associations are causal as most studies were unable to account for selection bias associated with non-experimental data in this field of research. Without addressing this important source of confounding, comparison of outcome measures is potentially biased and hence the study results are unreliable. With the increased allocation of resources to support team-based practice initiatives in Canada and elsewhere, there is a need to produce evidence about its benefits (or lack thereof).
The main objective of this paper is to evaluate the impact of team-based PHC on available process and outcome indicators of primary care from Canadian patients’ perspective. The data for this study come from the 2007–08 Canadian Survey of Experiences with Primary Health Care, a nationally representative survey conducted by Statistics Canada. The impact of team-based PHC on several process and outcome indicators based on patients’ perception is analyzed using regression techniques and propensity score matching analysis. In addition, we account for potential selection bias due to correlation between observed variables and the treatment variable in our sensitivity analyses.
Section snippets
Literature review
Existing literature uses a variety of objective and subjective measures of outcome to evaluate the effectiveness of primary care delivery [23]. In the context of primary healthcare services, patient perceptions of outcomes (expectations or satisfaction) are often considered the relevant outcomes of interest. For example, many studies used Donabedian's (1980) model of structure, process, and outcomes [24], [25]. In this framework, a range of objective outcomes (e.g. patient functional status and
Data and methods
To analyze the impact of team-based primary healthcare delivery on patients’ perception of process and outcome indicators, we used the nationally representative individual-level data from the 2007–08 Canadian Survey of Experiences with Primary Health Care (CSEPHC) conducted by Statistics Canada. The CSEPHC provides detailed information on patient's perception of several process and outcome indicators from 11,521 respondents along with rich individual- and household-level information on
Descriptive statistics
Our data reveal that 39% of patients reported having access to a team-based PHC in Canada. Descriptive statistics for the process and outcome variables are presented in Table 2. The characteristics of CSEPHC are very similar to the Community dwelling residents (based on the estimates from 2007–08 Canadian Community Health Survey (CCHS)) with respect to gender, household income, household size, employment status and geographical region. Although the proportion of elderly is representative in the
Discussion
Although health systems in Canada and abroad increasingly rely on a team-based approach for delivery of primary healthcare services, the causal effect of this model remains largely unknown and the associations are by and large mixed [48], [49]. Although some studies do find evidence of improved access, better quality, and cost-effectiveness, these results could not be generalized as most of the studies used small pilot or observational data. The few studies that did use representative survey
Acknowledgements
Shammima Jesmin acknowledges a post-doctoral fellowship from the Schulich School of Medicine & Dentistry at the University of Western Ontario. Sisira Sarma acknowledges a MOHLTC Career Scientist Award and Amardeep Thind acknowledges a Canada Research Chair in Health Services Research. The views expressed in this paper, however, are those of the authors and do not necessarily reflect the views of any affiliated organization.
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