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The Economic Impact of Improvements in Primary Healthcare ...€¦ · tHe eConoMiC iMPaCt oF...
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Canadian Health Services Research Foundation
The Economic Impact of Improvements in Primary Healthcare Performance
Canadian Health Services Research Foundation
TEAMInvestigators:Simone DahrougeRose Anne DevlinBill HoggGrant RussellDoug CoyleDean Fergusson
Research Associates:Thy DinhClaude HébertKarina MillMichelle PrenticeNatalie Ward
chsrf.ca
Canadian HealtH ServiCeS reSearCH Foundation
This document is available at www.chsrf.ca.
This research report is a publication of the Canadian Health Services Research Foundation. Funded through an agreement with the Government of Canada, CHSRF is an independent, not-for-profit organization that is dedicated to accelerating healthcare improvement and transformation for Canadians. The views expressed herein are those of the authors and do not necessarily represent the views of CHSRF or the Government of Canada.
ISBN 978-1-927024-43-0
The Economic Impact of Improvements in Primary Healthcare Performance © 2012, Canadian Health Services Research Foundation.
All rights reserved. This publication may be reproduced in whole or in part for non-commercial purposes only and on the condition that the original content of the publication or portion of the publication not be altered in any way without the express written permission of the CHSRF. To seek this permission, please contact [email protected].
To credit this publication please use the following credit line: “Reproduced with the permission of the Canadian Health Services Research Foundation, all rights reserved, (modify year according to the publication date).”
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TABLE OF CONTENTSPrimary healthcare ...............................................................................................................8
This report .............................................................................................................................8
The gaps in canada’s PHC performance level.....................................................................9
Technical quality of care (Figure 1) ...................................................................................10Accessibility (Figure 2) ........................................................................................................11Quality improvement initiatives (Figure 3) .....................................................................12Practice organization (Figure 4) ........................................................................................13Discussion .............................................................................................................................13
Interventions to improve quality in primary healthcare ................................................14
Quality improvement initiatives ........................................................................................14Information technology ......................................................................................................15Human resources .................................................................................................................15Discussion .............................................................................................................................16
Economic impact of improvements in PHC ....................................................................17
The link between PHC services and economics: A review of the literature ...............17The link between PHC and health (Arrow 1) ..................................................................17Macroeconomic factors and health (Arrow 2) ................................................................18Microeconomic factors and health (Arrow 3) .................................................................19Conclusions ...........................................................................................................................19
The economic impact of adding a pharmacist in a PHC practice: A systematic review ............................................................................................................20
Introduction ..........................................................................................................................20Methods .................................................................................................................................20Results ....................................................................................................................................21Discussion .............................................................................................................................23
A simulation of the impact of improvements in influenza vaccination rates ...............25
Model based simulator ........................................................................................................25Scenarios ................................................................................................................................26Data ........................................................................................................................................26Results ....................................................................................................................................27Sensitivity analysis ................................................................................................................29Conclusions ...........................................................................................................................30
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Economic impact of improvements in selected indicators .............................................31
Introduction ..........................................................................................................................31Hypertension ........................................................................................................................31Diabetes .................................................................................................................................32Cancer ....................................................................................................................................33Continuity .............................................................................................................................34Discussion .............................................................................................................................35
Recommendations and expert commentaries .................................................................36
Findings .................................................................................................................................36National coordination body ...............................................................................................36Investments in primary healthcare ....................................................................................36Investing in high quality PHC research/evaluation ........................................................37Limitations ............................................................................................................................37Conclusions ...........................................................................................................................37
APPENDICES ....................................................................................................................38
Appendix: A: Result-based logic model for PHC ............................................................38Appendix: B: OECD framework ........................................................................................39Appendix: C: Synthesis of review literature – study protocol .......................................40Appendix: D: Description of studies included in the section on interventions to improve PHC performance ...............................................................46Appendix: E: Systematic review – study protocol ...........................................................58Appendix: F: Quality assessment checklist and quality assessment results ................64Appendix: G: Flow diagram summarizing the flow of information through the different phases of the systematic review. ...............................................66Appendix: H: Included studies ...........................................................................................67Appendix: I: Elderly population projections from 2010 to 2036 ..................................71Appendix: J: Population vaccination rates for elderly population in 2007 .................71Appendix: K: Simulation results by province ..................................................................72Appendix: L: References ......................................................................................................78
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KEY MESSAGES ◥ The performance of Canada’s primary healthcare (PHC) system lags behind that of other
industrialized countries. Well-targeted investments in PHC can improve the health of individuals and populations, which can in turn have a positive impact on macro-economic indicators, such as employment rates, productivity and economic growth.
◥ There are important gaps in Canadian PHC systems that require improvement. These include accessibility of PHC services, technical quality of care, quality improvement initiatives and practice organization.
◥ Various interventions and investments have been shown to enhance the performance of PHC, improve the quality of care and produce economic savings. These include incorporating pharmacists into PHC teams, case-management strategies to enhance chronic disease management, and electronic medical records that include patient recall and provider reminders for preventive care and chronic disease management.
◥ This report presents the results of four different approaches to evaluate the economic impact of enhancements to PHC:1. A synthesis of the literature on the macro- and micro-economic effects of good health, with
specific relevance to PHC performance.2. A systematic review of the economic impact of incorporating a pharmacist into a PHC practice.3. A simulation exercise that evaluates the economic impact of improvements to influenza
immunization rates for older adults brought about by provider reminder systems in PHC.4. A literature review of reductions in burden of illness associated with four specific
enhancements to chronic disease management in PHC that produce health benefits. These include PHC improvements that result in improved blood pressure control, enhanced diabetes management, increased uptake of cancer screening and improved continuity of care.
◥ Three of the four approaches used in the report suggest that improvements to the performance of PHC in Canada would yield economic benefits. Better health outcomes have a positive impact on employment, productivity and economic growth. Simulation results indicate that increasing the influenza vaccination rate of the elderly population results in cost savings. Improved health outcomes for chronic disease management were linked to cost savings through reductions in hospitalizations, professional visits, emergency room visits and increased productivity; and higher continuity of care was associated with lower resource utilization and reduced healthcare costs. Despite literature that shows a positive health benefit of pharmacist integration in PHC, studies of the economic impact are inconclusive.
◥ There are knowledge gaps and weaknesses in the current structure of Canadian PHC systems. The creation of a National Coordination Body, additional investment to improve Canada’s PHC performance and additional investment in PHC research and evaluation is recommended.
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EXECUTIVE SUMMARYThe objective of this report is to illustrate the economic impact of improvements in PHC. Commonwealth data show that PHC services delivered in Canada are of moderate technical quality and are poorly accessible. This hinders the PHC system’s ability to provide technically adequate care to patients and negatively affects the efficiency of the entire healthcare system, because it results in a deflection of care to other sectors. Improvement in both technical quality and accessibility of PHC services could be achieved if organizational and structural support were made available to Canadian PHC practices, yet Canada has fewer quality improvement initiatives and poorer practice organization than other countries.
The use of quality improvement initiatives such as audit and feedback, and interventions aimed at optimizing practice organization through information technology (e.g., EMR-based patient-recall systems and provider reminders for processes of care, clinical decision making and drug order entry), and care delivery through multidisciplinary teams can improve the quality of care delivered. The performance of Canada’s PHC system can be enhanced through strategic national investments in these areas.
Four different approaches to evaluate the potential economic impact of enhancements to the PHC system are used. First, the macro- and micro-economic effects of good health are described and linked to PHC performance. Second, the results of a systematic review to assess the economic consequences of effective PHC intervention, adding a pharmacist to a PHC practice are presented. Third, a simulation exercise to evaluate the economic impact of improvement in influenza immunization for older adults through the use of a practice-based reminder system is carried out and the results are presented. Finally, examples from the available literature that demonstrate the potential cost consequences of four specific improvements in PHC are presented: improved blood pressure control; enhanced diabetes management; increased uptake of cancer screening; and better continuity of care.
In terms of macroeconomic effects, the literature reviewed in this study suggests that better primary care leads to better health outcomes, which themselves may lead to increased employment and increased growth and productivity.
Based on the review findings, pharmacist integration in PHC practice has the potential to be cost effective based on the estimated return on investment, especially in the control of common chronic diseases, including blood pressure control among patients with hypertension and haemoglobin levels among patients with diabetes. However, stronger evidence and better quality studies are required to draw confident conclusions.
Based on the results of a simulation exercise, an increase in the performance of PHC (as measured by increased immunization rates) would confer a significant economic benefit in cost savings associated with reduced healthcare utilization. The simulation exercise is based on the use of telephone reminder systems in PHC to increase rates of influenza vaccinations among the elderly. If an increase in the influenza vaccination rate of 2.5 percentage points for the elderly were achieved, conservative estimates suggest that healthcare costs could fall by more than $16 million, with net benefits of $8.7 million after taking the costs of affecting this increase into account. Additional benefit, not captured in the estimates may result from additional contact with a healthcare professional in order to get vaccinated, which may strengthen the patient-physician relationship and foster better continuity of care (factors that could improve care at future encounters).
The literature suggests that improvements in PHC can result in improved health outcomes for three chronic diseases (hypertension, diabetes and cancer) and through improved continuity of care. Estimates of the value of the improvement in health can be derived from estimates of the burden of disease; however, these
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estimates focus only on the potential economic gains of improving health and do not include the costs of interventions that are required to achieve these improvements. The estimates suggest substantial potential reductions in burden of illness; however, the magnitudes must be interpreted with caution because most of the available literature can be considered more advocacy than scientific in nature.
This report finds that significant gaps in Canada’s PHC performance exist, and that several PHC interventions offer the possibility of improving its current status. Three of the four approaches to measuring the value of improvements to PHC demonstrated that improvements in PHC performance would yield economic benefits. While all studies suggested a cost saving, none have adequately considered all facets of costs, and most were deemed only of moderate reporting quality.
The international comparison conducted by the Commonwealth Fund demonstrates that Canada’s performance in several indicators of the strength of its PHC sector is poor. These deficiencies create inefficiencies in care delivery. A poor PHC system reduces the effectiveness of other healthcare sectors. Strengthening PHC can significantly alleviate pressures in other parts of the healthcare system.
There are several interventions for which strong evidence of effectiveness exists. For example, the use of information technology can improve preventive care, as exemplified in the stimulation of an EMR-facilitated increase in influenza vaccination uptake described herein. It is recommended that a comprehensive and systematic review be conducted to assess the strength of the evidence supporting different strategies. Decisions about the optimal investment areas within PHC is best determined by combining information about each intervention’s effectiveness, acceptability to the user and estimated economic impact.
It is recommended that a national coordination body be established to facilitate dialogue and planning efforts across jurisdictions to improve PHC in Canada. Canada has a tremendous opportunity to learn from the natural experiment currently taking place across its jurisdictions, as well as from a better understanding of the policies, practices and organizational structure of successful PHC in OECD countries, through a similar scoping exercise to that conducted by the Commonwealth Fund Commission.
There is currently insufficient information about the economic impact of PHC investment strategies to inform further investments. Most current economic evaluations are far too narrow in scope, poorly reported and suffer from too short a time horizon. More rigorous economic evaluation (such as cost-effectiveness or cost-benefit research) that considers all costs and includes an assessment of longer-term impacts on costs and health benefits is required. Where long-term study designs are not feasible, the use of modeling (simulations) can predict long-term effects.
Canada requires an ongoing monitoring strategy that would allow continuous assessment of its performance and permit researchers to evaluate the impact of various reform strategies on the quality of care delivered, the efficiency of the system and the economic burden of PHC-sensitive illnesses. For this to be feasible, a common reporting structure of indicators, with standardized data, is required across Canadian jurisdictions. Such a strategy may be facilitated by a national coordinating body.
Because of the complex nature of PHC, the impact of an investment in PHC to achieve one endpoint is likely to have a much broader effect. The true potential impact across the entire healthcare system is likely underestimated in the report.
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PRIMARY HEALTHCAREThe last 20 years have seen an increasing recognition of the importance of primary healthcare (PHC) to population health.1-6 Countries with a greater PHC orientation have lower rates of mortality and better health outcomes.5-9 PHC also improves and sustains the healthcare system at other levels. For instance, when PHC practitioners are the gatekeepers of healthcare delivery, they can reduce unnecessary costs and the need for specialty care through improving the quality of prevention, coordination and continuity of care.4;10
Organisation for Economic Co-operation and Development (OECD) countries have made PHC their central focus for achieving healthcare reform.11 Within Canada, it is held that, in reference to efforts to strengthen PHC, “no other initiative holds as much potential for improving health and sustaining our healthcare system.”2 Recent surveys conducted by the Commonwealth Fund suggest that, compared to other developed countries, Canada’s PHC sector is poorly organized and supported, suggesting that considerable gains can be achieved through strategic investments in that sector.12-15
THIS REPORTThe objective of this report is to illustrate the economic impact of improvements in PHC. To achieve this, we begin by highlighting the current gaps in the Canadian PHC system. We then demonstrate that there are effective interventions and investments that can enhance the system’s performance. To demonstrate this, we report on selected reviews that have shown a positive effect of specific PHC interventions on the quality of care. We then apply four different approaches to evaluate the potential economic impact of enhancements to the PHC system. First, we describe the macro- and micro-economic effects of good health and link these effects to PHC performance. Second, we highlight the results of a systematic review we undertook to assess the economic consequences of another effective PHC intervention: adding a pharmacist to a PHC practice. We chose this intervention because a knowledge synthesis of published literature suggests a potential positive economic impact. Third, we report on a simulation exercise we performed to evaluate the economic impact of improvement in influenza immunization for older adults which can be achieved through the use of a practice based reminder system. Finally, we provide examples from the available literature that demonstrate the potential cost consequences of four specific improvements in PHC: improved blood pressure control, enhanced diabetes management, increased uptake of cancer screening and better continuity of care. We conclude the report with recommendations for future investment.
The ultimate goal of healthcare improvements is to achieve better health. In many studies, the indicators used are intermediate outcomes that are known to be related to the desired health outcome. For these studies, we relied on the logic model developed by Watson et al. (Appendix A), which “links (PHC) resource inputs to activities performed, services delivered, and outcomes achieved” to relate gains in PHC performance to health gains.16 The logic model allows us to conceptually demonstrate the connection between the performance measures on which many studies report and the ultimate health outcome.
We used the conceptual framework for the OECD Healthcare Quality Indicators to guide our economic evaluation (Appendix B). This framework ties together quality of care, accessibility and costs.
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THE GAPS IN CANADA’S PHC PERFORMANCE LEVELIn recent years, concerns have emerged regarding the quality and accessibility of PHC in Canada. International and national comparisons suggest that Canada ranks below other nations and displays significant regional variability in the quality of PHC.12;15;17-19
In this section, we compare Canada to other countries across four sets of indicators. Two of these (accessibility and technical quality of care) are measures of the quality of care delivered that have been linked to better health outcomes. The other two (the presence of quality-improvement initiatives and practice organization) are indicators of practice- or system-level initiatives that are expected to support better delivery of care. These indicators are taken from the Commonwealth Fund studies evaluating PHC performance.12;15;18 While the Commonwealth Fund studies report on a large number of indicators and are commonly used to assess the quality of PHC, we felt that not all the indicators used were demonstrated to be associated with better care or health outcomes. For that reason, we chose to present a subset of indicators that we believe are robust indicators of PHC performance/outcome. We also relied on a previous Canadian Health Services Research Foundation (CHSRF) report, Quality of Healthcare in Canada: A Chartbook, to highlight differences in the PHC performance across provinces.19
Technical quality of care Commonly used indicators to measure the quality of care delivered include processes of care in the management of chronic diseases and in prevention. These are components of the PHC “Outputs” (Appendix A) and are predictive of health outcomes. Canada’s performance in these respects is relatively comparable to that of other developed countries. For example, Canadian women are as likely as those living in other OECD countries to have undergone breast and cervical cancer screening. Canada has somewhat poorer quality of diabetes management, but leads in medication review.
There is also considerable regional variation in PHC performance within Canada.19 For example, in 2007, 29% of all Canadians with diabetes had received all four recommended diabetes care processes, ranging from 21% in Newfoundland to 34% in both Alberta and British Columbia. Influenza vaccination coverage, recommended as preventive care for individuals 65 years of age and over, was 64% in Canada in 2007, but only 48% in Newfoundland and85% in Nunavut.
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Figure 1: technical quality of care – Canada’s performance in relation to other oeCd countries
0 10 20 30 40 50 60 70 80 90 100
MammogramPap Test
Cholesterol CheckBlood Pressure Monitoring
Diabetes Management
Medication Review
Hypertension
Asthma/COPD
Diabetes
% Positive Indicator
Minimum
Maximum
Canada
Mean
Legend
Tech
nica
l Qua
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of C
are
Chr
onic
Dis
ease
M
anag
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tPreventive Care
Notes: Diabetes – Practice routinely uses written guidance to treat diabetes (% yes);15 Asthma/COPD – Practice routinely uses written guidance to treat asthma or COPD (% yes);15 Hypertension – Practice routinely uses written guidance to treat hypertension (% yes);15 Medication review – How often have any of your doctors or pharmacists reviewed and discussed all medications you are using [in patients with chronic conditions]? (% often, always);18 Diabetes management – Received all four: HbA1c checked in past six months: feet examined for sores or irritations in past year; eye exam for diabetes in past year; cholesterol checked in past year [in patients with diabetes]? (% yes);18 Blood pressure – Blood pressure checked in past year [in patients with chronic conditions]? (% yes of all respondents);18 Cholesterol check – Cholesterol checked in past year [in patients with chronic conditions]? (% yes of congestive heart failure, hypertension and diabetes patients);18 Pap test – Percent of women receiving Pap test at intervals recommended in each country for age group;12 Mammogram – Percent of women receiving mammogram test at intervals recommended in each country for age group.12
AccessibilityCanadians have problems accessing PHC services. While most Canadians (92% in 2009) can identify a family physician from whom they would seek care, Canada performs poorly with regards to all other indicators of accessibility.20 Canadians have inadequate after-hours access, have difficulty getting an appointment when needed and make inappropriate use of emergency room visits. Glazier et al. estimated that the limited availability of regular family physicians led to an estimated 17,741 excess emergency department visits, and 1,932 excess hospital admissions over two years among Ontario patients with chronic conditions.21 Accessibility is an important barometer of PHC quality. Poor accessibility in the PHC system has a significant impact on the overall healthcare system efficiency and sustainability, and on patient outcome.
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Figure 2: accessibility – Canada’s PHC system performance in relation to other oeCd countries
0 10 20 30 40 50 60 70 80 90 100
No ER use for non urgentSame/ next day apt
Regular doctor
After hours access
% Positive Indicator
Minimum
Maximum
Canada
Mean
Legend
Notes: After hours – After-hours arrangement to see doctor/nurse without going to ER;15 Regular doctor – Do you have a doctor or GP you regularly see [in patients with chronic conditions]? (% yes);18 Same/next day appt – Last time you were sick or needed medical attention, how quickly can you get an appointment to see a doctor [in patients with chronic conditions]? (% same or next day appointment);18 Off-hours care – How difficult is it to get care on nights, weekends, or holidays without going to the ER [in patients with chronic conditions]? (% very or somewhat easy);18 No ER use for non urgent – Did not go to ER for a condition that could have been treated by regular doctor or source of care if available [in patients with chronic conditions] (% yes).18
Quality-improvement initiativesHealth authorities can support quality care by shaping the context within which the practices operate. For example, they can aim to optimize care delivery by providing incentives for achieving target levels of quality (e.g. pay-for-performance initiatives), direct financial or in-kind support to enhance practice organization (e.g. implementation of electronic medical records (EMRs) or introduction of non-physician healthcare providers) or a mechanism for clinicians to monitor their performance level, all of which are measures aimed at optimizing care delivery. The logic model in Appendix A demonstrates the link between context, PHC performance and health outcomes.
Because the Canadian healthcare system is administered provincially, and because Canada lacks a coordinated national strategy for PHC, the Canadian PHC landscape is a patchy arrangement of reform initiatives with no nationwide adoption of strategies. As a result, quality improvement measures vary considerably across provinces. Figure 3, below, shows that, in contrast to many other OECD countries, Canadian health authorities are less likely to monitor or reward practices for patient satisfaction or achievement of clinical targets. The Canadian Working Group for Primary Healthcare Improvement is currently drafting a national strategy for PHC that is expected to support enhancements in primary care organization and harmonization of strategies across provinces.
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Figure 3: Quality-improvement initiatives – Canada’s PHC system performance in relation to other oeCd count
0 10 20 30 40 50 60 70 80 90 100
Clinical performancePatient satisfactionClinical outcomes
Multidisiplinarity
Preventive Care
Complex needs
Clinical targets
Patient satisfaction
% Positive Indicator
Minimum
Maximum
Canada
Mean
Legend
Notes: Incentive/Support: Do you have the potential to receive or do you receive extra financial support or incentives based on any of the following? (This includes bonuses, special payments, higher fees, or reimbursements.): Patient satisfaction – High patient satisfaction ratings. (% yes);15 Clinical targets – Achieving certain clinical targets (% yes);15 Complex needs – Managing patients with chronic disease or complex needs (% yes);15 Preventive care – Enhanced preventive care activities, including patient counselling or group visits (% yes);15 Multidisciplinarity – Adding non-physician clinicians to your practice team (e.g., nurse for chronic disease management) (% yes).15
Feedback: Patient satisfaction – Does the place where you practice routinely receive and review data from surveys of patient satisfaction and experiences with care? (% yes);15 Clinical outcomes – Does the place where you practice routinely receive and review data on clinical outcomes (e.g., percent of diabetics or asthmatics with good control)? (% yes);15 Clinical performance – Are any areas of your own clinical performance reviewed against targets at least annually? (% yes).15
Practice organizationThe quality of the PHC system is also influenced by how it is organized to meet the needs of individuals and the population (depicted as “Inputs” in Appendix A). In a recent international comparison conducted by the Commonwealth Fund, Schoen ranks Canada and the United States lowest in terms of effective practice organization.13 The Commonwealth Fund studies use several indicators of organizational effectiveness. We chose to present three commonly agreed-upon important indicators: use of EMRs, information technology and multidisciplinarity.
Canada trails other countries in its adoption of information technology. In 2009, little more than one-third of Canadian family physicians reported using an EMR. In contrast, on average, four in five family physicians from the 11 surveyed countries reported having these electronic tools. Currently, approximately half of Canadian family physicians work in multidisciplinary practices, significantly fewer than in most other OECD countries. In a separate section of this report, we review the evidence supporting the use of non-physician health professionals in PHC practice.
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Figure 4: Practice organization – Canada’s PHC system performance in relation to other oeCd countries
0 10 20 30 40 50 60 70 80 90 100
Multidisciplinary team
e-information (high count=9-14)
EMR
% Positive Indicator
Minimum
Maximum
Canada
Mean
Legend
Notes: EMR – Use of EMRs in practice (% yes);15 e-information – Count of 14 functions such as electronic ordering of medications and tests, computer access to test results and medication lists, computer alerts/prompts and decision support;15 Multidisciplinary team – Practice uses non-physician staff to manage care (% yes).15
DiscussionThe Commonwealth data show that PHC services delivered in Canada (“Outputs” in Appendix A) are of moderate technical quality. Moreover, these services are poorly accessible in Canada. This hinders the PHC system’s ability to provide technically adequate care to patients and negatively affects the efficiency of the entire healthcare system, because it results in a deflection of care to other sectors. Improvement in both technical quality and accessibility of PHC services could be achieved if organizational and structural support were made available to Canadian PHC practices, yet Canada has fewer quality-improvement initiatives and poorer practice organization than other countries.
In the next section we demonstrate that addressing some of the system-level deficiencies, through better use of its resources (“Contexts” and “Inputs” in Appendix A), Canada can improve the quality of its PHC system.
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INTERVENTIONS TO IMPROVE QUALITY IN PRIMARY HEALTHCAREThis section provides published evidence demonstrating that quality-improvement initiatives and practice organization can lead to improvements in the quality of care delivered. We performed a systematic literature search for evidence on feasible and effective strategies for enhancing PHC quality. The review included publications from multiple electronic databases for the years 2000 to 2010. With one exception (financial incentives), we focused exclusively on published systematic reviews or meta-analyses to ensure that the evidence presented is robust. Because pay-for-performance incentives are increasingly being adopted as a measure of quality improvement, we report on their impact, despite the lack of currently available systematic synthesis of the literature on the subject.
Medical Subject Headings (MeSH) and keywords, such as “primary care or primary healthcare or general practice or family practice or family medicine,” were used to identify the relevant literature. We focused on studies amenable to Canadian policy intervention or practice organization. These interventions fall into three categories: quality-improvement initiatives, information technology and human resources. The quality of the reviews were assessed using the AMSTAR scale, which evaluates systematic review quality, and only those with an AMSTAR score of 4 or higher (reviews of moderate to high quality) were retained for evidence synthesis.22 The full study protocol and a description of the included studies are presented in Appendices C and D. The results of the included reviews are synthesized under each intervention category.
Quality-improvement initiativesQuality-improvement initiatives are healthcare management-level or practice-level activities used to optimize care.
Financial incentives: Our summary of the impact of financial incentives on quality care in PHC is based on individual studies, as no systematic reviews are available on this topic. Many of these studies assessed the UK Quality of Care Framework (QOF), which contains financial incentives in PHC in concert with other PHC performance-enhancement interventions.23-29 These studies and others conducted with audit and feedback30 demonstrate some improvements in the indicators for which incentives were built. Since QOF was not studied under an experimental design, however, and since the program includes more than one intervention, it is difficult to attribute improvements strictly to the financial incentives themselves.31 There are also other concerns with pay-for-performance initiatives. These may have some unintended negative consequences, such as a decrease over time in quality indicators that are not covered under the incentive program.23 By their nature, these initiatives shift the care paradigm towards a more biomedical model of healthcare, rather than holistic and patient-centred.32 Also, most financial incentives are provided to the family physician and not the entire team, potentially having a negative impact on intra-practice relationships, causing resentments and lowering motivation.33
Audit and feedback: A meta-analysis of audit and feedback studies shows that this strategy is generally effective in improving practice outcomes such as appropriate care, procedures, screening, test ordering, referrals, health promotion, preventive services, diagnostics and record keeping.34 Across the 19 studies included in the meta-analysis, audit and feedback was found to have a medium-to-large effect (Cohen’s d = 0.40, 95% confidence interval = ±0.20). Similarly, most moderate-to high-quality reviews found evidence of a small to moderate effect size on practice outcomes,29;35;36 although one review did not find sufficient evidence to determine its effectiveness.37 In other reviews of more targeted outcomes, audit and feedback was found generally effective in improving cancer screening30
and immunization uptake,38;39 as well as appropriate antibiotic prescribing.40
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Information technologyInformation technology (IT) interventions typically take place in the context of clinical practices with EMR systems. The use of these IT systems is considered a clinical activity (Appendix A). The implementation of different EMR-based IT functions has been measured in terms of their ability to affect PHC outcomes. Our review assessed the effectiveness of adopting EMR-based patient-recall systems and EMR-based provider reminders for processes of care, clinical decision making and drug order entry.
There is high-quality evidence from systematic reviews supporting the adoption of patient-recall systems for enhancing preventive care. Patient-recall systems improve immunization rates, both for influenza and other vaccine targets.41;42 These systems are also effective in improving levels of colon cancer,42 cervical cancer,42;43 and breast cancer screening,42;44 and in increasing the proportion of hypertensive patients who attended follow-up, which in two small trials led to improved blood pressure control.45
Standard reminder prompts to PHC practitioners are generally effective across many processes of care and outcomes,46 showing at least a moderate effect on processes such as prescription of vaccinations, tests and medication;45 administration of cancer screening; and adherence to recommended guidelines for chronic disease management.35;47
Provider reminders in the form of clinical decision support systems and/or computerized physician order entry were found to be effective in many areas of medication management,48 resulting in improved drug choices for outpatients,49;50 increased appropriate use and drug safety51;52 and reduced adverse drug events.53
Human resourcesPrimary care in Canada has traditionally been delivered by family physicians working in small, office-based practices. In many provinces, however, recent policy changes have encouraged a move to a multidisciplinary model of care. A number of reviews, including many systematic reviews, as well as one meta-analysis, have shown that nurses play an important role in PHC. They participate in patient education/management and facilitate compliance,54-58 improve the management of patients with major depression55;59 and improve clinical outcomes.60;61
The involvement of a pharmacist in a family practice has been associated with improved medication adherence, appropriate prescribing and disease-appropriate outcomes.60 In a few studies, higher survival among patients was documented in pharmacist-led interventions in PHC.62 Pharmacists can play a role in improving diabetes by increasing medication adherence, promoting patient education, and improving patient-healthcare provider communication.63 Pharmacist-led interventions in PHC have also been found effective in controlling blood pressure among hypertensive patients56 and improving prescribing of antidepressants for older patients.56;64-67
The implementation of collaborative care delivered by a multidisciplinary team has been associated with improvements in mental health and preventive care.56;67-69 However, there is little evidence that such improvements are sustainable or responsive to the degree of collaboration.42;66;68;69 Assigning a case manager has been identified as one of the key elements in improving clinical outcomes, even for complex interventions.19;30;35;61;63;70-72 Positive results were associated with case management when it was provided by nurses as well as many different types of PHC providers.61 One study found favourable effects on processes of care and patient outcomes when combining a multidisciplinary team with both case management and patient education.56
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DiscussionThis section demonstrates that effective system-level quality-improvement initiatives and interventions aimed at optimizing practice organization can improve the quality of care delivered. Given that these are two areas in which Canada is deficient, we suggest that the performance of Canada’s PHC system can be enhanced through strategic national investments.
The purpose of this exercise was to demonstrate the evidence base for effective interventions. We did not attempt to identify all effective interventions. For that reason, with one exception, the evidence garnered in this section was restricted to systematic reviews or meta-analyses. We recognize that limiting the scope of the work that way will have inevitably resulted in overlooked effective interventions for which no systematic reviews exist. For example, there is considerable evidence that access greatly affects patient outcomes, but this evidence is not presented as these studies have not been synthesized.73-76
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ECONOMIC IMPACT OF IMPROVEMENTS IN PHC In this section, we use four approaches to demonstrate the economic effect of PHC improvements. First, we synthesize the literature on the relationship between health and economics, with a focus on PHC. Second, we present the results of our systematic review designed to assess the economic consequences of adding a pharmacist to a PHC practice; a strategy that has been demonstrated to improve chronic disease management. Third, we report on a simulation exercise that we performed to evaluate the economic impact of enhancing influenza immunization in older adults. Finally, using published work, we work through a few examples that demonstrate how improvements in PHC can lead to cost savings.
The link between PHC services and economics: a review of the literatureThis section demonstrates that improvements in PHC can enhance the health and welfare of individuals. The literature suggests links between socioeconomic factors and health as well as employment and health. It shows that better health has positive effects on employment, thus improving the economic wellbeing of individuals and families. Increased health can also promote growth and productivity, which would lead to improved population health measures.The OECD framework (Appendix B) highlights the importance, among other things, of socio-economic conditions and environment on the health of individuals and populations. We synthesize these links between PHC, health and economic factors in Figure 5. While most of the literature linking health to economics refers to either measures of individual health from self-assessed health surveys, or measures of population health, typically derived from self-reported health, it is reasonable to link PHC to this literature via its impact on these measures of health as demonstrated in the logic model (Appendix A). Although there is a dearth of literature relating the economic impact of a well-functioning PHC system to the broader healthcare system, we argue that a number of the benefits from PHC lead naturally to a better-functioning overall healthcare system.
Figure 5: linking PHC to economics
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The link between PHC and health (arrow 1) There is strong support for a link between PHC and better health. One study found that people receiving good PHC (as characterized by accessibility, comprehensiveness, coordination, continuity and accountability) are 10-15% more likely to report being in good health in comparison to those receiving poorer PHC.77 Another study looked at the contribution of PHC to mortality in OECD countries.6 The study differentiated between three different measures of mortality: all-cause, all-cause premature and case-specific premature death from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease and heart disease. For all three levels, there is strong evidence that better PHC care is associated with lower mortality. Even when controlling for important macro-economic influences (GDP per capita, number of physicians per 1,000 population, percent of elderly
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in the population) and for micro-level effects (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption), the relationship between PHC and health is positive and significant. Similarly, another study showed that the effect of adding one PHC physician per population of 10,000 people in the US is associated with an average improvement of 5.3% across a number of population based measures of health such as all-cause mortality, heart disease mortality, stroke mortality, infant mortality, low birth weight, life expectancy, and self-reported health.4
When discussing how to improve the performance of PHC, it is useful to distinguish between performance gains arising from increases (or decreases) in the inputs into the system (the extensive margin) – the most important being that of the number of family physicians – and those derived from the improved use of a given amount of inputs (the intensive margin). A number of papers have looked carefully at the intensive margin performance of family physicians. Some have looked at how measures such as patient-visits per week respond to changes in how physicians are remunerated,78;79 while others have focused on how different ways of organizing PHC can influence the quality of services or care provided.80-82
On the extensive margin, the literature suggests a strong link between family physician supply and health and the performance of the overall healthcare system. U.S. studies have shown larger family physician supply relative to population size to be associated with lower hospitalization for conditions that are ambulatory care sensitive,83 lower obesity,84 better self-reported health,85 earlier detection of cancer86 and better quality of care.87 Higher density of family physicians is also associated with reduced healthcare utilization, including hospital admissions, emergency department visits and surgeries.88
Canadian studies point in the same direction. Using random samples of the Ontario Cancer Registry, one study demonstrated that higher physician density is associated with earlier breast cancer detection and better survival outcomes.89 Using the Canadian National Population Health Survey, another showed that a higher supply of family physicians is associated with better health, whereas more specialists is associated with worse health.90
Overall, it seems clear that both quantity and quality of services matter for population health and for the functioning of the healthcare system in general. In a review of the literature, Starfield et al. conclude that “… primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care.”4 p.457
Macro-economic factors and health (arrow 2)The most important link from macro-economics to health is via employment. Better employment means better financial resources for the family and, therefore, a healthier life.91 Unemployment is also associated with poorer health.92;93
More interesting, however, is the link between health and economic growth. The economic literature often uses life expectancy and mortality rate as measures of health. Growth is usually measured as the growth in gross domestic product (GDP), GDP per capita, or GDP per worker.
One study examined the link between improvements in life expectancy and growth by summarizing many important papers.94 The review paper suggests that an improvement of five years in life expectancy would add to the GDP growth rate somewhere between 0 and 0.58 – with only one of the 13 papers summarized suggesting that the growth impact is zero.95-97 98-102 For instance, if the growth rate were, say, 3%, an increase of five years in life expectancy could increase this rate to as
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much as 3.58%. There is, thus, the potential to have a significant impact on the economy derived from improvements in life expectancy. While the literature is not all in support of this link, population based studies suggest that that better health leads to GDP growth.103 Improvements in the performance of PHC lead to better health, which in turn leads to macro-economic growth.
Micro-economic factors and health (arrow 3)The link between socioeconomic status and health is generally recognized by economists – what is less clear, however, is the direction of causation. There is evidence showing that the socio-economic status of a household affects the health of its children.104-106 The inverse direction is also demonstrated, i.e. the health of the family impacts its socioeconomic status. A Canadian study demonstrated that females providing care to a family member in poor health (on average 4.6 hours weekly) worked 2.1 fewer hours weekly, which represents 6% of a normal working week, thus reducing the household potential for income.107 Improvements in the performance of PHC leads to better health, a higher earning capacity, and lower economic burden.
ConclusionsOverall, there is reason to believe that better primary care leads to better health outcomes, which themselves may lead to increased employment and increased growth and productivity. The literature underlying Figure 5 suggests that investments in PHC can have a direct impact on health and hence an indirect effect on employment and growth.
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THE ECONOMIC IMPACT OF ADDING A PHARMACIST IN A PHC PRACTICE: A SYSTEMATIC REVIEWIntroductionEconomic evaluations can help inform health resource-allocation choices by comparing costs and consequences of interventions. In an earlier section we reported several interventions that have been shown to improve the quality of PHC. Of these, the integration of a pharmacist in a primary-care practice showed especially encouraging improvements in care delivery and in health benefits. For example, one randomized controlled trial reported that the intervention had increased the number of patients reaching goal blood pressure by 32%.108 We therefore chose to evaluate the economic consequences of adding a pharmacist to a primary healthcare practice as one example of the economic impact of improvement in PHC performance.
We undertook a systematic review of the evidence on the trade-offs between intervention costs, health benefits and direct and indirect cost savings of broad-scale implementation of pharmacist integration in PHC practices. We undertook a systematic review of the literature from the past 20 years on the health and economic impact of pharmacist integration in PHC practices.
MethodA systematic review was conducted of health economic studies published between 1990 and 2010 that evaluated the impact of multidisciplinary PHC teams on costs of any kind as well as health or clinical outcomes, and/or performance indicators. The full study protocol is found in Appendix E.
Search strategy: Studies were identified from databases (Cochrane Library/National Health Services Economic Evaluation Database, Medline and EconLit) using strict search criteria, and the grey literature (relevant websites and bibliographic references from relevant reviews). The citations in these articles were also reviewed to identify new relevant articles.
Eligibility criteria: Studies were included if they assessed the costs and health consequences of pharmacist integration in PHC practice.
Selection of studies: Identified studies were screened by two reviewers for eligibility using the inclusion and exclusion criteria outlined in the protocol in Appendix E.
Quality assessment: At least two reviewers were involved in the quality assessment of eligible studies by using the CHEC list (Appendix F) that assesses the quality of health economic evaluations based on a set of evaluation criteria.109 We retained studies with moderate-to-high quality (met more than 50% of the quality criteria).
Data abstraction: Two reviewers abstracted data from the retained studies using an established data extraction sheet capturing study design, population, time horizon, method used to measure costs and other health outcomes and the main results of the study, as well as any other comments that the reviewers found important in the overall assessment.
Analysis: The systematic review focused on the health economic impact of the addition of a pharmacist in a family practice. Due to the heterogeneity of approaches and outcomes, the results could not be combined to provide an overall estimate. The results are reported in narrative form. A flow diagram summarizing the flow of information through the different phases of the review is found in Appendix G.
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ResultsDescriptions of the included studies can be found in Appendix H. A total of 1,787 articles were identified using broad search criteria to capture articles on the economic impact of multidisciplinary PHC teams, of which 249 related to a pharmacist intervention. After the first screen, 33 articles were identified according to article title and abstract, as potentially relevant articles. The 33 eligible articles were assessed for methodological quality and eight were retained because they were evaluated as being of moderate-to-high quality.
The majority of included studies assessed the costs and benefits of pharmacist integration in PHC in improving medication usage. Six studies involved an intervention where the pharmacist had direct contact with the patients, such as face-to-face consultation,110-115 and two involved an intervention whereby the pharmacist provided advice and recommendations to physicians after reviewing patient health records only.116;117
Three studies evaluated pharmacist integration in PHC in the control of blood pressure among hypertensive patients:
◥ In the study by Borenstein et al., the intervention group experienced a greater decrease in systolic blood pressure compared to the control group (usual care) by an average of 11 mmHg, and at a reduced cost. However, only drug costs and provider visit costs were assessed.115 This is a significant impact because a decrease in 10 mm Hg in the systolic blood pressure and 5 mmHg in the diastolic blood pressure reduces the risk of stroke by 38% and heart failure by 50%.19 The intervention achieved an estimated cost savings of $27.94 per mmHg decrease (USD) over one-year. Cost savings were attributable to lower average provider use (and therefore costs) in the intervention group compared to the usual care group (average cost of $160 vs. $195, p=0.04). Drug costs increased in the intervention group, but not statistically significantly (average monthly drug cost of $11.31 vs. $4.25, p=0.12). The study did not consider the cost of the pharmacist or cost consequences of better-controlled blood pressure such as hospitalization.
◥ Isetts et al.’s report focused on individuals with elevated blood pressure and cholesterol.111 One year after involving the pharmacist in their care, significant improvements in hypertension and cholesterol management compared to pre-intervention were observed, as well as a return on investment of $12.15 per $1 in intervention costs. Cost savings were attributable to decreased expenditures post-intervention by 57.9% for facilities (work and office space, including rent and utilities) and a decrease by 11.1% for professional claims. In contrast, drug costs increased by approximately 19.7%. The difference in total expenditures was found to be statistically significant (p<0.001).
◥ Forstrom et al. examined changes in medication use only, but did not report on clinical or health outcomes directly related to hypertension.116 They found that the average daily drug cost was significantly greater in the intervention group compared with the control group at baseline, but that over a six-month period the average daily drug cost decreased in the intervention group while it increased in the control group. By the end of the study (six months) the difference in drug cost was no longer significant. The average daily drug cost in the intervention group was reduced by 5.6 cents per patient day (16.8%) over the study period.
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Two studies evaluated pharmacist integration in PHC in the control of haemoglobin A1C (HbA1C) levels in diabetic patients:
◥ Monte et al. found that 50% of patients had improvements in their HbA1C at six months, and the new levels were maintained relatively constantly until the end of the one-year study period.113 There was a significant decrease in costs associated with the intervention in terms of direct medical, and prescription costs by the end of the one-year period. It was not clear to which direct medical costs or cardiovascular outcomes the authors were referring.
◥ Ragucci et al. reported similar results. In that study, moderate improvement in HbA1C levels were observed in approximately 40% of intervention patients.114 They reported an estimated cost-avoidance of $59,040 for the year based on an estimated cost avoidance of $685–950 per year of mean total healthcare costs for every 1% reduction in HbA1C.
One study by Ramalho et al. examined the impact of medication therapy management (MTM) by pharmacists in PHC, over a 10-year period, on various clinical outcomes, economic impacts, and patient satisfaction for a variety of chronic diseases including, but not limited to, hypertension, hyperlipidaemia, diabetes and osteoporosis.110 They found that 80% of drug-therapy problems identified in the MTM program were resolved at study close. They also found an improvement for 55% of the conditions, 23% were unchanged, while 22% worsened during MTM services. The MTM program generated a cost savings of approximately $86.45 per encounter, with an average cost of $67.00 per MTM visit in last three months of 2008. The pharmacist-led intervention achieved an estimated cost savings to the health system over the 10-year period of $2,913,850 and the total cost of the intervention for the same period was estimated at $2,258,302. The estimated cost savings included medical services avoided, including office visits, long-term care stays and hospitalizations, as well as avoidance of lost work time. The overall return on investment was estimated at $1.29 per $1 in intervention costs, where cost savings were attributable to reduction in office visits, laboratory services, urgent care visits and emergency room visits, as well as lost work time avoided due to the intervention.
The studies by Malone et al. and Sellors et al. did not address the impact of pharmacist integration on any specific disease, but reported broadly on only either costs and/or some other outcome, such as quality of life or patient satisfaction:112;117
◥ Malone et al. looked at the impact of clinical pharmacist consultation with patients in PHC on medication usage, quality of life and patient satisfaction among patients at high risk for drug-related problems. Taking into account the cost of the pharmacist intervention, the overall healthcare expenditures, which included clinic costs, drug costs, laboratory costs and costs of hospitalizations, were not statistically significantly different in the intervention compared to the control group (p=0.06). Mean increases from baseline for the intervention group compared to the control group were $1,020 and $1,313, respectively. There was also no statistically significant difference in the health-related quality of life or patient satisfaction between the groups.
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◥ Sellors et al. examined the impact of pharmacist integration in PHC within the context of a randomized controlled trial on process outcomes, including number of drug-related problems and proportion of recommendations implemented by the physician for an elderly population, as well as costs related to drug use.117 After five months, the patients in the intervention group were taking a mean 0.4 extra medication units (prescription and over the counter) compared to the control group (p=0.50). There was also no significant difference in the use of healthcare resources or in costs between the intervention group and the control group. The total daily medication costs for the intervention group was $5.01 vs. $4.82 for the control group (p=0.72). Costs to the Ontario Drug Benefit Program were also similar with $3.57 for the intervention group compared to $3.76 for the control group (p=0.78). Including the cost of the pharmacist intervention and only drug-related hospital stays, the mean cost of healthcare resources per senior in the intervention group was $1,281.27 versus $1,299.37 per senior in the control group. In terms of recommendation implementation, physicians fully implemented 46.4% of recommendations and partially implemented 9.3% of recommendations.
DisscussionThis systematic review synthesizes the existing health economic evidence surrounding one PHC intervention with the potential to improve PHC performance in Canada. Pharmacist integration has been shown to be effective in improving a number of clinical health outcomes. Unfortunately, this review could not make conclusions as to the economic impact of implementing a pharmacist in PHC due to the paucity of high-quality economic studies. Future investments should be made in high quality health economic research in this area that addresses the limitations of the current literature
Table 2 in Appendix F highlights the proportion of studies that meet each quality criteria evaluated in this review. More than half the studies (61%) did not measure costs appropriately. Studies often failed to describe the study population adequately (42%), select adequate horizons (39%), and measure outcomes appropriately (39%). Future investments should be made in high-quality health economic research in this area that addresses the limitations of the current literature.
Two studies looked specifically at return on investment, which may be considered a type of cost minimization analysis, where cost savings could be accrued from avoidance of healthcare use such as emergency room visits or hospitalizations.110;111 Other studies did not compare any corresponding clinical or health benefits to costs of the intervention when there was potential to report on these measures.110;111;116 Many studies were flawed in design, including lack of an adequate control group and short time horizons. Many also lacked transparency on methods used, the sources of data and how they were measured and analyzed, making it difficult to discern the validity and reliability of results. No study provided an actual incremental cost-effectiveness ratio. The return on investment studies by Isetts et al. and Ramalho et al. reported cost savings attributable to an intervention involving the integration of a pharmacist to a PHC practice in the context of direct, face-to-face consultation with patients.110;111 However, the lack of direct comparison of costs to health benefits in these studies impedes the ability to determine the actual cost-effectiveness of the intervention.
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All included studies were of short time horizon. All but one study used a time horizon of one year or less. The use of intermediate health outcomes that can be captured within that time frame, such as blood pressure (mmHg) for hypertension, is considered a weak effectiveness measure in health economic evaluation. Stronger measures are clinical outcomes such as cardiovascular events. While these are understandably difficult to measure because of time horizons, no study attempted to model these outcomes. Longer study time horizons, such as life-time projection, are preferred as they can provide better estimates of costs and health or clinical benefits that change over time.
Only one article attempted to address uncertainty through a sensitivity analysis around particular cost parameters.112 In addition, most studies were unclear on their conceptual and decision-making context. It was also difficult to classify study design and to interpret study results due to lack of clarity in results reporting. The limitations of the included studies previously mentioned are common methodological flaws in economic evaluations, which Drummond and Sculpher have previously discussed.118
Based on the review findings, pharmacist integration in PHC practice has the potential to be cost effective based on the estimated return on investment, especially in the control of common chronic diseases, including blood pressure control among patients with hypertension and HbA1C levels among diabetics. However, stronger evidence and better quality studies are required to draw confident conclusions. The tradeoffs between costs and health benefits are unsatisfactorily addressed in the current literature. Although the intervention is considered effective, the question “what is the health economic impact of pharmacist integration in PHC practice?” cannot be answered by the current literature, nor can the question “is pharmacist integration in PHC practice cost-effective?” In order to answer these questions, investments need to be made in research with a focus on improving the body of high-quality health economic evidence. New evidence should employ more rigorous methods, taking into account long-term costs and direct clinical and health outcomes, as well as improved reporting to allow for evidence synthesis. Healthcare system-level decisions can be more confidently made when studies can provide results on the overall and long-term cost effectiveness of interventions in terms of, for example, costs per life years gained or cost per quality-adjusted life years gained. For example, one such study could employ a mathematical modeling approach using the reviewed studies’ intermediate outcomes and costs to project long-term health economic impact, similar to the exercise in the next section of this report.
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A SIMULATION OF THE IMPACT OF IMPROVEMENTS IN INFLUENZA VACCINATION RATESWe conducted a simulation of the potential costs and benefits associated with an improvement in PHC performance by assessing the likely impact of increasing the rate of influenza vaccinations in the elderly population, brought about by a reminder system in the family physicians’ offices that is part of an EMR system.45 Uncertainty in the impact is addressed by providing different population/vaccination rate scenarios.
The benefits associated with an increase in vaccination rates are considered to be the cost savings arising from the reduction in services required by individuals with influenza-like conditions. The costs associated with increasing vaccination rates can be classified as direct and indirect. Direct costs include the cost of the vaccine and its administration and the costs of any incentive schemes in place to encourage vaccinations. Indirect costs refer to those associated with the implementation and usage of EMR systems in all Canadian family physician offices.
Model-based simulatorFor this model, we used a custom-designed program running on Stata©. This model is based on a simple one-period Markov chain process developed using the average likelihood of developing influenza-like symptoms, which may, in turn, trigger three events: a family physician visit, an Emergency Department (ED) visit, and/or hospitalization.119 First, the simulation hypothesizes a population of one million elderly people. The results from this simulated population are then adjusted to represent the elderly population numbers in different regions/time periods. Our population is assigned a vaccination status following a binomial distribution with a probability equal to the vaccination rate under study. For example, to simulate a population vaccinated at 64%, we use a binomial with p=0.64 where p is the probability that vaccination occurred. Second, the simulation program evaluates the probability that one of three events – family physician visit, ED visit or hospitalization – occurs. The assigned probability for each event uses a random sampling process based on a normal distribution whose mean is equal to the probability of the event occurring. These means are extracted from a review of the medical literature on influenza as explained in the data section of this report. After the Markov chain process is carried out on the population (i.e. run one million times), the simulation performs summaries of the events and calculates the costs associated with the adverse events. Finally, we ran the model over again with various incremental gains in vaccination rates in order to ascertain the possible savings associated with improving vaccinations among the elderly population.
ScenariosWe used four scenarios based on vaccination target rates of 66.5%, 69%, 74%, and 80%, representing an increase of 2.5, 5, 10 and 16 percentage points over the actual rate of 64%.19 We derived these values by stratifying the data from Jacobson and Silagyi (2005) to reflect low, medium and high effectiveness of the recall systems for the elderly.41 The 80% scenario represents an increase in the vaccination rate in all jurisdictions (except Nunavut) and hence could be considered as the highest achievable rate in Canadian provinces. We ran each scenario as a separate simulation.
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DataPopulation: For the population, we downloaded population estimates from Statistics Canada.120 Statistics Canada also provides different projections to evaluate future population demographics (Appendix I). While they use many different population trends, we focus on the medium population growth scenario (M4 – increase based on 2001 to 2006 trends scenario) for our simulation. This scenario gives the population by age group on a yearly basis from 2010 to 2016, then by five years up to 2036. For our simulation, we find particularly interesting the projections for 2031 as during that year the seniors’ population peaks.
Influenza-specific statistics: The percentage of the population 65 and older vaccinated in Canada was taken from Leatherman and Sutherland (2010).19 We use the statistical mean at the provincial level and a weighted average for Canada. Currently, 64% of Canadians 65 and older are vaccinated, based on data gathered for year 2007. Appendix J presents the detailed data for all provinces.
Treatment events: Information was gathered on the vaccine effectiveness from different sources. Gross et al. found that individuals are about 50% less likely to develop an influenza-like illness (ILI) if vaccinated.121 We created three scenarios based on a lower bound, or “worse case” of 28%, an average value of 50% and an upper bound (or “best case”) of a 65% decrease in the likelihood of developing ILI.
Information on the likelihood that an ILI will result in three events – a visit to a family physician, an emergency department or a hospitalization – is found in a Canadian study by Kwong et al. (2008).119
However, the analysis in Kwong et al. is population-wide and does not distinguish between individuals who were vaccinated and those who were not. Thus, for the purposes of our simulation, we needed to calculate the probability of one of these three events occurring for the vaccinated group and for the non-vaccinated group separately. To do this, we start with noting that Kwong et al. finds that 7.492% of the elderly population (irrespective of vaccination status) will visit a family physician for influenza-like illnesses in a given year, 3.396% will visit an emergency department and 2.604% will be hospitalized. We know that 64% of the elderly population is vaccinated. Thus: 0.64*(probability of going to a family physician visit if vaccinated) + 0.36*(probability of going to a family physician visit if not vaccinated) = 0.07492. If we take the 35% number, (i.e. the likelihood of contracting an ILI is reduced by 35% if vaccinated), then we know that the probability of going to a family physician visit if vaccinated is (1 - 0.35) times the probability of going to a family physician if not vaccinated. So, letting x=the probability of going to a family physician if not vaccinated, we need to solve the following expression: 0.64*(0.65x) + 0.36x = 0.07492. In this case, x = 0.09655 or 9.655% and the probability of going to a family physician if vaccinated is 0.06276 or 6.276% (or 35% lower than the non-vaccinated case), corresponding to the highlighted numbers in table 1. We did this calculation for a 28%, 35%, 50% and 65% reduction in the likelihood of contracting an ILI if vaccinated.
table 1 – Calculated effectiveness rates for vaccinated (v) and non-vaccinated (nv) by event
28% 50% 60%
Event V NV V NV V NVGP Visit 0.06572 0.09128 0.05509 0.11018 0.04490 0.12829ED Visit 0.02979 0.04138 0.02497 0.04994 0.02035 0.05815Hosp 0.02284 0.03173 0.01915 0.03830 0.01561 0.04459
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To help visualize what we have just described, Figure 6 presents the results from our simple algorithm based on 64% of the elderly population being vaccinated. The percentages at the end of each tree represent the probability that the particular event occurs (assumed to be 50%121) depending on whether the elderly person is vaccinated.
Vaccination costs: The direct cost included in our simulation is the actual cost of the vaccine and its administration to the patient and the cost associated with any bonus paid to the family physician office. The cost of the vaccine was taken from Sander et al. (2010) and is $7.50.122 Administering costs were found in the Family Health Organization Agreement (2007). In the context of influenza vaccinations, two scenarios are possible. In the first scenario, the patient receives the flu shot when coming for a family physician visit concerning another matter. In this case, the cost for the shot would be $8.15 (intervention G538). In the second scenario, the patient comes solely for the flu shot, which incurs a cost of $17.85 (intervention G539). More research is required to know the percentage of individuals who fall into these two cases, but a conservative estimate would be 25% and 75% respectively. We use this estimation in our simulation. The indirect costs associated with the different events, which include the administration costs of visits to clinics and hospitals were taken from Sander et al. (2010).122 It is important to clarify that these costs are lower bound values and the actual cost could be higher. For example, the $35 cost associated with a family physician visit only captures the actual consultation and does not include costs for any additional treatments such as x-rays or blood tests.
Figure 6: algorithm tree for determining the probability of an influenza-like illness-related event in the elderly, assuming a 50% vaccination effectiveness rate
ElderlyPopulation
Not Vaccinated(36%)
Vaccinated(64%)
GP Visit (5.509%)
ED Visit (2.497%)
Hospitalization (1.915%)
GP Visit (11.018%)
ED Visit (4.994%)
Hospitalization (3.830%)
EMR system and reminder: The actual cost of the installation of an EMR system and its maintenance is not accounted for in our simulation. The main reason is that these systems include many more functions than a reminder system for vaccinations. Given that an EMR system is in place, the marginal cost associated with reminding elderly patients to have a vaccination is likely to be very small. Because evidence shows that phone call-based reminder systems perform better than other forms of reminders such as mailings,41 we estimate the cost for a staff member to call patients under the indirect costs.
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ResultsBenefits: In this section, we present the simulation results for the year 2010 for Canada assuming 50% effectiveness. The individual province results for the projected years 2010 and 2031 are presented in Appendix K.
table 2: reductions in the number of adverse events and the dollar savings associated with these reductions for 2010 by target vaccination rate
target vaccination rate
Events 66.5% 69.0% 74.0% 80.0%
Number of Adverse Events (Reductions)
GP 6,591 13,209 26,333 42,559ED 2,811 5,848 11,913 19,298
Hosp. 2,201 4,696 9,130 14,722
Cost Savings (Dollars)
GP $230,716 $462,259 $921,648 $1,489,550
ED $618,478 $1,286,656 $2,620,882 $4,245,488Hosp. $14,123,431 $30,138,489 $58,596,134 $94,491,255
Total Cost Saved $14,972,625 $31,887,404 $62,138,664 $100,226,293
The top half of Table 2 presents the reduction in the number of adverse events arising from an increase in the vaccination rate from the actual rate of 64% to the indicated rate in the column. For example, the first column shows the reduction in the number of family physician (GP) visits, ED visits and hospitalizations resulting from a 2.5 percentage point increase in the vaccination rate from 64% to 66.5%. The simulation indicates that the resulting decrease in GP visits would be 6,591. The second section, called Costs Savings, represents the reduction in costs associated with the decrease in adverse events (a measure of the “benefits” associated with the decrease in adverse events): the 2.5% vaccination rate increase would thus result in a savings of $230,716 from the reduction in GP visits. The bottom row represents the total cost saved from increasing the vaccination rate by 2.5, 5, 10 and 16 percentage points. According to our simulation, a 2.5 percentage point increase in the vaccination rate of the elderly will result in a savings of almost $15 million. This savings increases to more than $100 million should the vaccination rate increase to 80%.
Direct costs: Table 3 presents estimates of the increase in direct costs associated with the given increase in the vaccination rate. For example, if we increased the vaccination rate from 64% to 66.5%, the cost for the additional vaccines required would be $958,532 and its administration would be $1,859,792 for a total cost of $2,818,324.
table 3: direct costs associated with increasing the vaccination rate
targeted vaccination rate
66.5% 69.0% 74.0% 80.0%Vaccination Cost $958,532 $1,917,063 $3,834,126 $6,134,602
Visit Cost $1,859,792 $3,719,585 $7,439,169 $11,902,670Total Direct Cost $2,818,324 $5,636,648 $11,273,295 $18,037,272
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Indirect Costs (Patient reminder): We used an hourly wage rate of $20 for a staff member calling patients with reminders. Assuming that 20 calls could be made per hour, and assuming that these calls go out to the entire elderly population, this would then result in an indirect cost of $4,822,800.
Benefits minus costs: Table 4 presents the net benefits resulting from our simulation with a vaccination effective rate of 50%.
table 4: net benefit calculations by target vaccination rate for 2010 and 2031 (projected)
target vaccination rate
Year 2010 population profile 66.5% 69.0% 74.0% 80.0%Benefit $16,357,073 $31,744,056 $63,626,889 $101,247,194Direct Cost $2,818,324 $5,636,648 $11,273,295 $18,037,272Benefit before EMR Cost $13,538,749 $26,107,408 $52,353,594 $83,209,922
Patient Reminder Cost $4,822,800 $4,822,800 $4,822,800 $4,822,800Net Benefit $8,715,949 $21,283,608 $47,530,794 $78,387,122
target vaccination rate
Year 2031 popuation profile 66.5% 69.0% 74.0% 80.0%Benefit $32,596,116 $63,259,058 $126,794,665 $201,763,817Direct Cost $5,616,312 $11,232,623 $22,465,245 $35,944,392Benefit before EMR Cost $26,979,804 $52,026,435 $104,329,420 $165,819,425Patient Reminder Cost $9,610,800 $9,610,800 $9,610,800 $9,610,800Net Benefit $17,369,004 $42,415,635 $94,718,620 $156,208,625
The net benefit of increasing the vaccinated population from 64% to 66.5% (a 2.5 percentage point increase) using a reminder system would result in a potential savings of about $8.7 million. By the year 2031 all of the “baby boomer” part of the population will have reached 65 years of age or older. We can use the projected population for the year 2031 to estimate what the potential benefits may be of increasing the elderly vaccination rate with the projected demographics at that time. These figures are presented in the bottom half of table 4. Using the 2031 demographics, the potential savings from increasing the vaccination rate of the elderly population would range from more than $17 million to more than $156 million, depending on the vaccination rate achieved.
Sesitivity analysisThe largest uncertainty in this simulation exercise is the vaccine effectiveness rate. We thus performed a sensitivity analysis. We used the confidence interval of 28%–65%, from Gross et al. (1995), and ran two different scenarios: one for the “worse case” of a very low vaccination effectiveness rate of 28% and one for the “best case” of 65%.121 Table 5 presents these results. With the worse-case scenario, increasing the vaccination rate of the elderly by 2.5 percentage points would not be cost effective as it results in a net loss of about $200,000. However, if we were to push up the vaccination rate to 69% of the elderly population, then the net benefits would be more than $4 million, even with the very low vaccination effectiveness rate of 28%. Of course, if the effectiveness rate were high (i.e. 65%), then the net benefits of even a modest increase in the vaccination rate of the elderly would be large – more than $15 million for a 2.5 percentage point increase.
Canadian HealtH ServiCeS reSearCH Foundation 30
table 5: net benefit calculations using best- and worst-case scenarios regarding vaccination effectiveness (costs in $millions)
target vaccination rate
Year 2010 Population profile 66.5% 69.0% 74.0% 80.0%Effectiveness 28% 65% 28% 65% 28% 65% 28% 65%Benefit $7.4 $22.9 $14.7 $49.1 $29.4 $94.8 $46.9 $151.7Direct Cost $2.8 $2.8 $5.6 $5.6 $11.3 $11.3 $18.0 $18.0Gross Benefit $4.6 $20.1 $9.1 $43.5 $18.1 $83.5 $28.9 $133.7EMR Cost $4.8 $4.8 $4.8 $4.8 $4.8 $4.8 $4.8 $4.8Net Benefit $-0.2 $15.3 $4.3 $38.7 $13.3 $78.7 $24.1 $128.9
target vaccination rate
Year 2031 Population profile 66.5% 69.0% 74.0% 80.0%Effectiveness 28% 65% 28% 65% 28% 65% 28% 65%Benefit $14.8 $45.6 $29.3 $97.8 $58.7 $189.0 $93.4 $302.4Direct Cost $5.6 $5.6 $11.2 $11..2 $22.5 $22.5 $36.0 $36.0Gross Benefit $9.2 $40.0 $18.1 $86.6 $36.2 $167.5 $57.4 $266.4EMR Cost $9.6 $9.6 $9.6 $9.6 $9.6 $9.6 $9.6 $9.6Net Benefit $-0.4 $30.4 $8.5 $77.0 $26.6 $157.9 $47.8 $256.8
ConclusionsIf an increase in the influenza vaccination rate of 2.5 percentage points for the elderly were achieved, our analysis indicates that healthcare costs could fall by more than $16 million. Once the costs of effecting this increase were taken into account, net benefits are still $8.7 million. In most scenarios, several millions of dollars can be saved annually by reducing the need to treat elderly people with ILIs. One way to bring about increases in influenza vaccinations would be through the use of telephone reminder systems. Investments in such systems at the PHC level may make a lot of economic sense and certainly bear further investigation.
The estimates derived in this section do not take into account the benefits that may arise from additional contact with a healthcare professional in order to get vaccinated. An additional visit to a PHC physician may strengthen the patient-physician relationship and foster better continuity of care, factors that could improve care at future encounters.
The strength of the simulation approach is that it provides estimates of the potential impact of an increase in immunization rates of the targeted population. The main weakness of this approach is that it is based on average outcomes for the targeted population, as well as average costs and benefits. We have tried to be conservative in our estimates and have provided ranges based on best- and worst-case scenarios with respect to vaccination effectiveness.
This simulation exercise clearly demonstrates that an increase in the performance of PHC (as measured by increased immunization rates) would confer a significant economic benefit in cost savings associated with reduced healthcare utilization.
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 31
ECONOMIC IMPACT OF IMPROVEMENTS IN SELECTED INDICATORSIntroduction
This section uses the existing literature to demonstrate the link between primary healthcare improvements and economic benefits. It is important to note that the discussion focuses on the potential economic gains of improving health and does not include the costs of interventions that are required to achieve these improvements. We represent the economic impact of improvements in a set of health conditions using an economic burden of illness approach, and one indicator of service delivery, continuity of care. For the health outcomes, we chose to focus on three common chronic conditions where the potential for improvement in care has been clearly established in the section “Interventions to improve quality in PHC,” focusing on hypertension, diabetes and cancer.
Hypertension is a serious risk factor for many other health problems, such as stroke or myocardial infarction.123 As a result of the associated risk of these events, the economic burden of hypertension is very large,124 as poor blood pressure control extends its hazards to these other health conditions. Type 2 diabetes is another prevalent disease in Canada. The economic burden of Type 2 diabetes could be reduced through the implementation of preventive interventions and improved management of diabetic patients.125 The high costs of treating various cancers can be reduced through early screening and detection. Cancer screening can result in cost minimization by shifting the stage at diagnosis to an earlier stage which incurs lower treatment costs compared to later stage cancer and confers better health outcomes.126 Improvements in the management of hypertension, diabetes and cancer have potential to reduce mortality, improve life expectancy, thereby improving productivity, which can, in turn, provide further economic benefits. This section reviews the estimated impact of these conditions based on available literature, and how improvements in the quality of care can produce economic benefits. Unfortunately, there is a lack of independent evidence, so that the estimates provided here may not be fully accurate.
Continuity of care, also referred to as relational continuity or longitudinality is defined as “a therapeutic relationship between a patient and one or more clinicians that spans various health care events and results in accumulated knowledge of the patient and care consistent with the patient’s needs.”127
Continuity of care is improved by accessing care from the same provider, good patient-provider communication and, ultimately, better knowledge of the patient.
HyptertensionThe Conference Board of Canada estimates the 2005 total costs for cardiovascular disease to be more than $20 billion, nearly half of which is from income loss due to premature mortality.128 Hypertension is a leading cause of cardiovascular disease (as well as stroke and renal disease129). It has been estimated that the prevalence of hypertension in Canada increased by approximately 60% from 1995 to 2005.129 Approximately six million adult Canadians have been diagnosed with hypertension in 2007, a number expected to grow to 7.3 million in 2012.130 Because age increases the risk of hypertension, an aging population means that nearly 10 million individuals will be living with hypertension by 2030.
Currently, one-third of adult Canadians diagnosed with hypertension have uncontrolled blood pressure levels, which worsens the risks of hypertension.124 Blood pressure control can be effectively improved through PHC interventions. For instance, a Cochrane systematic review by Glynn et al. showed that reminder systems for blood pressure monitoring can improve the odds of blood pressure control (OR=1.85, 95% CI: 1.37 – 2.44), potentially improving control from 66% to 78%.71Another meta-analysis by Carter et al. found that integrating pharmacists in PHC clinics improves systolic blood pressure control in hypertensive patients (OR=2.17, 95% CI: 1.75 – 2.68), potentially improving control from 66% to 81%.63
Canadian HealtH ServiCeS reSearCH Foundation 32
Uncontrolled hypertension leads to significant resource use and is a significant economic burden. In 2004–05, the total acute care inpatient costs in Canada for hypertensive-related conditions was an estimated $74 million.131 Patients with uncontrolled blood pressure have follow-up office visits with a family physician about 13 days earlier than patients with controlled blood pressure.132 In 2004, the cost of heart failure was estimated to be $425 million in Canada, 50% of which is attributable to poor blood pressure control.131;133 According to a study by Moffatt et al., the total costs attributable to hypertension among Albertans in 2005 were estimated at $125.5 million.134 Direct and indirect costs were estimated using the Public Health Agency of Canada’s Economic Burden of Illness Report 2000. A more recent study by Anis et al. estimated that the current total health expenditures in Canada related to hypertension were $3,459 million (CAD 2006 dollars).135 The total direct costs (expenditures on hospital care, physician services, services provided by other health professionals, drugs, health research and other healthcare) were extracted from the National Health Expenditure Database (NHEX) projections for 2006. Indirect costs included morbidity costs due to long-term and short-term disability.
The potential cost minimization associated with improved blood pressure control in PHC is substantial. Controlling blood pressure can also improve life expectancy. For instance, a 10 mmHg reduction in systolic blood pressure can reduce all-cause mortality by 26% and extend life by at least 17 years.136;137 Using a population-based simulation approach, one study estimated the cost consequences of a 2 mmHg reduction in systolic blood pressure to result in a savings of more than $38 million through reduction in risk of stroke and myocardial infarction.138 A pharmacist intervention that has the potential to reduce blood pressure by 10 mmHg can therefore result in savings of more than $190 million via stroke and myocardial infarction prevention alone.
DiabetesThe prevalence of diabetes mellitus in Canada increased by 69% from 1995 to 2005, with the 2005 prevalence estimate exceeding the World Health Organization’s projected global rate for 2030.139 Diabetes is considered one of the most expensive medical conditions in terms of acute care inpatient costs, estimated at $284 million in Canada in 2005.131
Moffatt et al. reported an estimated $161.5 million attributable to Type 2 diabetes in Alberta alone in 2005.134 Current total health expenditures in Canada related to Type 2 diabetes are estimated at $1.4 billion (CAD 2006 dollars).135
Hemoglobin A1C (HbA1C) is an indicator of glucose control in patients with diabetes.140 A variety of PHC interventions have been shown to improve HbA1C levels among diabetic patients. For example, multidisciplinary PHC teams with case management and patient education can effectively reduce HbA1C. These interventions can improve HbA1C
control by 1.5%, a relative improvement of 15%, as well as reduce the number of hospital admissions.61;141 A study by Grimshaw et al. showed that continuity of care in diabetes has the potential to improve HbA1C by as much as 2.1%.35
Uncontrolled diabetes can also have a substantial impact on resource use, including hospitalizations from a variety of health problems, including ischemic heart disease, heart attack, heart failure, chronic kidney disease, stroke and lower limb amputations.142 It has been estimated that diabetic patients aged 20-49 visit family physicians two times more and specialists three to four times more than the general population.142
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CancerIn 2010 there were an estimated 173,800 new cases of cancer and 76,000 deaths due to cancer in Canada.126 Screening has been shown to improve survival for a number of cancers, including breast, cervical and colorectal cancer.19 There are few peer-reviewed estimates of the impact of cancer in Canada, although the Canadian Cancer Society estimates 1,026,700 potential years of life lost (PYLL) as a result of cancer in 2004, representing 32% of the PYLL resulting from all causes of death.143 One study estimated current total health expenditures in Canada related to post-menopausal breast cancer and colorectal cancer at $351.1 million and $978.8 million (CAD 2006 dollars), respectively.135 The Public Health Agency of Canada estimates the economic burden of malignant neoplasms at upwards of $20 billion in 2000, the great majority of which is due to morbidity and mortality.144
Screening can improve cancer survival by detecting cancers at an earlier stage, when treatment is usually more effective. Between 1992 and 2004, mortality rates in Canada fell by approximately 25% and the number of years of life lost to breast cancer decreased by about 29%, in part due to increased screening uptake and improvements in treatment.19 A recent study found that mammography screening resulted in a relative risk reduction in breast cancer mortality by 10% compared to no screening.145 A Swedish study found that cervical cancer screening with Pap smear resulted in a 53% reduction in cervical cancer mortality (95% CI: 23–72%).146 In Canada, biennial colorectal cancer screening with fecal occult blood testing (FOBT) of 67% of the population aged 50-74 in the year 2000 resulted in an estimated 10-year colorectal cancer mortality reduction of 16.7%.147 Colorectal cancer screening was reported to contribute 194–203 life-years gained, depending on the screening tool, per 1,000 persons screened.148 The effects of cervical cancer screening were estimated at 640–1,110 life years gained for every 1,000,000 women in the general population, which corresponds to 5 and 40 Pap smear tests over an individual’s lifetime.149
PHC interventions have been shown to improve cancer screening uptake. One review reported that provider assessment and feedback interventions are effective in increasing screening rates for certain cancers by about 13%.30 These interventions were found to increase the uptake of breast cancer screening (mammography) by 3%–21%, cervical cancer screening (Pap test) by 4%–30%, and colorectal cancer screening (FOBT) by 4%–30%. Another review also found improvements in screening attributable to various organizational and practice-level interventions in PHC.42 For instance, it found that organizational change could improve cervical and colorectal cancer screening by an odds ratio of 3.03 (95% CI 2.56-3.58) and 17.6 (95% CI 12.3-25.2), respectively. Financial incentives for patient care were found to improve mammography and cervical cancer screening by odds ratio of 2.74 (95% CI 1.78-4.24) and 2.82 (95% CI 2.35-3.38), respectively. Patient reminder systems and provider education were found to improve colorectal screening uptake by an odds ratio of 2.75 (95% CI 1.90-3.97) and 3.01 (95% CI 1.98-4.56), respectively. Collaboration and teamwork were found to improve cervical and colorectal cancer screening uptake by an odds ratio of 5.55 (95% CI 4.54-6.80) and 9.21 (5.46-15.5), for cervical and colorectal cancer, respectively.42
Improvements in cancer screening can affect costs at the healthcare-system and societal levels. It has been reported that screening 1,000 women every year for breast cancer, starting at age 40 and continuing until age 84, would result in 177 to 227 life-years gained compared with no screening.150 Increases in cancer screening uptake can result in significant economic gains achieved from reduced healthcare utilization and prolonged life.
Canadian HealtH ServiCeS reSearCH Foundation 34
ContinuityContinuity of care is often measured as the proportion of visits to the usual provider relative to all primary care visits. Taking into account socio-demographic factors and severity of health conditions, a higher proportion of visits to the usual provider (compared to the low continuity group) is associated with a lower risk of hospitalization for any cause, in the general population (odds ratio (OR) (95% confidence interval (CI)) of 0.75 (0.66, 0.87) in one study151 and 0.48 (0.45-0.51) in another.152 It is also associated with a lower risk of avoidable hospitalization in individuals of all age groups (for people aged 19-64: OR 0.41 (0.35, 0.48)), children with diabetes (OR 0.14 (0.03-0.67))153 and elderly people with diabetes (rate ratio 0.82 (0.69, 0.97).154
A higher proportion of visits to the usual provider is also associated with a lower risk of emergency room visit in all individuals (OR 0.82 (0.70, 0.95)),155 and a lower risk of making multiple emergency room visits in all individuals (OR 0.65 (0.56, 0.76)).155 One study randomly assigned individuals to high versus low continuity of care, and found that those randomized to better continuity had fewer hospital admissions (20% vs. 39%) and shorter duration of hospital stay (15.5 vs. 25.5 days).156
A systematic review of continuity of care found 20 studies addressing its impact on resource utilization, only one of which found no association. In total, the studies assessed 41 resource variables, 35 of which were lower in higher continuity contexts.157
Findings from Canadian studies are in keeping with these studies. Controlling for socio-demographic and health conditions, having low continuity of care is associated with a much greater risk of making emergency room visits in end-of-life cancer patients (relative risk 3.93 (3.57, 4.34))158 and in individuals aged 65 and over (relative risk 1.46 (1.44, 1.48).159 A higher continuity of care score is linked to a lower risk of avoidable hospitalization in older adults (OR 0.67 (0.51, 0.90)),160 a lower risk of making an emergency room visit in individuals 15 years and older (OR 0.90 (0.87, 0.92)), and a lower risk of making three or more such visits (OR 0.78 (0.73, 0.83)).161
Three studies quantified the costs associated with different levels of continuity. One U.S. study found that African or Latino Americans with low provider continuity (as measured by usual provider continuity score) incurred significantly higher healthcare costs ($3,565/year) compared to those with high continuity ($2,279/year). These costs were largely driven by hospital costs.162 That study is flawed in that it did not account for differences in patients characteristics between the two groups. Another U.S. study assessed continuity by asking individuals 65 years and older how long they had been seeing their usual provider and categorized their answers into five groups ranging from less than one year to more than 10 years. Adjusting for potential confounders, the study found that, compared to individuals with the shorter relationship, those with the longest relationship had lower hospital costs ($496 ($81, $910)), and lower medical costs (e.g. outpatient visits, tests) ($317 ($117, $516)).163
A dose-response relationship across length of relationship categories was observed. The third study assessing costs is a Canadian study by Hollander et al. that evaluated the extent to which the patients used the same practice (rather than same provider) for their visits. That study found a dose-response relationship between the extent of attachment to a practice and the costs of hospital and medical services for patients with diabetes. For example, among the high resource users (Resource Utilization Band of 5), the hospitalization cost was $16,988 and $5,909 for those with lowest and highest continuity levels. Similarly, for individuals with congestive heart failure with high resource use, the hospitalization cost was $21,293 and $7,507 for those with lowest and highest continuity levels.72
These studies suggest that improvement in the continuity of primary care services can result in considerable cost savings in various sectors of the healthcare system.
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DiscussionThis section uses an economic burden of illness approach by compiling evidence from the literature to report on the potential economic impact of improvements in health for common chronic diseases in Canada. We focus on hypertension, diabetes and cancer, for which there is evidence that improvements can be made through PHC interventions. Due to the paucity of available evidence, some of the data relating the current costs of illness was derived from literature that may be considered more advocacy than scientific. Non-governmental organizations often use research to help define their advocacy positions and to provide additional arguments to support their advocacy activities, which may result in biased methodology and results.164 For that reason, some of the projections about gains may not be accurate. Despite these limitations, this section demonstrates a clear potential for economic gains with improvements in PHC performance.
This section only considered the impact of improvements in PHC and did not consider the cost of interventions required to achieve these gains. PHC interventions can offer high economic value from the health service payers’ perspective when the value of health system resources avoided exceeds the value of resources required to implement the intervention.165 It has also been suggested that through aggregation of micro-economic contributions, including labour productivity, labour supply, education and savings and investment, a healthier population may generate greater rates of macro-economic growth than would a less healthy population.166;167
This section also provides strong evidence of the economic benefit of high continuity of care in family practice. Better continuity allows a better knowledge of the patient, produces more appropriate care and results in significantly lower healthcare costs. It is necessary to note that much of the available literature has been published in the form of cost-of-illness studies and by disease-focused organizations and could contain some biases toward such matters. A study by Larg and Moss suggests there are often inconsistencies in the way in which cost of illness studies are conducted and there is a lack of transparency in reporting.168 These limitations have impeded the interpretation of study results and have, therefore, limited their usefulness.
Canadian HealtH ServiCeS reSearCH Foundation 36
RECOMMENDATIONS AND EXPERT COMMENTARIESFindingsThis report finds that significant gaps in Canada’s PHC performance exist, and that several PHC interventions offer the possibility of improving its current status. We used four strategies to assess the economic impact of improvements in PHC. Three of these, the macro- and micro-economic effects of good health derived from PHC performance, the vaccination simulation exercise and the cost consequences of four specific improvements in PHC based on currently published literature, demonstrated that improvements in PHC’s performance would yield economic benefits. The systematic review on the economic impact of integrating a pharmacist into practice was inconclusive. While all studies suggested a cost saving, none have adequately considered all facets of costs, and most were deemed only of moderate reporting quality.
In the course of producing this report, we identified gaps in knowledge and weaknesses in the current structure of the Canadian PHC system. These are discussed below.
National coordination bodyThere is inadequate inter-jurisdictional dialogue and coordination of effort on the direction of PHC investments in Canada, largely because in Canada, the healthcare system is governed at the provincial level. Canada’s systems for delivering primary care services vary substantially, providing ample opportunities for cross-jurisdictional learning. The Canadian PHC sector needs a national coordination body to facilitate this dialogue and planning efforts across jurisdictions. We recommend that a national coordination body be established. We recommend that the national body be responsible for facilitating the following activities in order to inform investments in PHC:
◥ Conduct a scoping exercise to understand the variability in PHC structure across Canada and assess the strengths, weaknesses, barriers and facilitators of the various PHC reform strategies.
◥ Conduct a systematic review of the scientific literature and jurisdictional reports to assess the effectiveness of various potential investments in PHC and assess the transferability of these finding to the Canadian context.
◥ Coordinate a cross-jurisdictional dialogue of the findings and facilitate the discussion of investments in PHC appropriate for the various jurisdictions.
◥ Identify gaps in knowledge, develop a research agenda for Canada and coordinate research efforts to address these gaps.
Investments in primary healthcareThe international comparison conducted by the Commonwealth Fund demonstrates that Canada’s performance in several indicators of the strength of its PHC sector is poor. These deficiencies create inefficiencies in care delivery. Canada’s performance on accessibility, for instance, is dismal. The quality of PHC significantly influences outcomes and, as such, will have a significant impact on other healthcare sectors. A poor PHC system reduces the effectiveness of other healthcare sectors. Strengthening primary care can significantly alleviate pressures in other parts of the healthcare system.
This report demonstrated that there are several interventions for which strong evidence of effectiveness exists. For example, the use of information technology can improve preventive care, as exemplified in our stimulation of an EMR-facilitated increase in influenza vaccination uptake. It was not the purpose of this report to perform a comprehensive assessment of potential strategies for PHC, only to demonstrate that
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 37
effective interventions exist that can address the current deficiencies and evaluate their economic impacts. To guide future investments, we recommend that a comprehensive and systematic review be conducted to assess the strength of the evidence supporting different strategies. Decisions about the optimal investment areas within primary care is best determined by combining information about each intervention’s effectiveness, acceptability to the user and estimated economic impact.
Investing in high-quality PHC research/evaluationThere is currently insufficient information about the estimated economic impact of PHC investment strategies to inform further investments. Most current economic evaluations are far too narrow in scope, poorly reported and suffer from too short a time horizon. More rigorous economic evaluation (such as cost-effectiveness or cost-benefit research) that considers all costs and includes an assessment of longer-term impacts on costs and health benefits is required. Where long-term study designs are not feasible, the use of modeling (simulations) can predict long-term effects.Canada requires an ongoing monitoring strategy that would allow continuous assessment of its performance and permit researchers to evaluate the impact of various reform strategies on the quality of care delivered, the efficiency of the system and the economic burden of primary care-sensitive illnesses. For this to be feasible, a common reporting structure of indicators, with standardized data, is required across Canadian jurisdictions. Such a strategy can be facilitated by a National Coordination Body.
In addition, Canada has a tremendous opportunity to learn from the natural experiment currently in place across its jurisdictions, as well as from a better understanding of the policies, practices and organizational structure of successful PHC in OECD countries, through a similar scoping exercise to that conducted last year by the Commonwealth Fund Commission in its report “The Path to a High Performance U.S. Health System – A 2020 Vision and the Policies to Pave the Way.”169
LimitationsWhile this report largely demonstrates that investing in PHC would reap economic benefits, it did not aim to address which interventions would yield the best economic value. We have shown that many effective interventions exist but, with the exception of the systematic review of the pharmacist integration we performed, we did not assess the economic viability of the different interventions.
Because of the complex nature of PHC, the impact of an investment in PHC to achieve one endpoint is likely to have a much broader effect. For example, achieving higher vaccination rates involves a contact with the family practice and could have additional benefits such as improving continuity and the patient-provider relationship. Similarly, the integration of a pharmacist focused on addressing hypertension is likely to have a broader reach than merely improving patient blood pressure control. Medication reviews are likely to identify other areas of deficiency and the presence of the pharmacist in the practice can be expected to result in acquired knowledge among other practitioners. The broad-reaching impact of PHC is well illustrated by the multifactorial effect of enhanced continuity. However, because most research relied on for this report focused on specific outcomes, the resulting discussion follows a reductionist approach. The true potential impact across the entire healthcare system is likely underestimated in the report.
ConclusionsThe economic burden of illnesses which are sensitive to the quality of primary care is great. Canada’s PHC system performance lags behind that of other industrialized countries. Well-targeted investments in PHC can achieve considerable benefits. Better data on the economic impact of individual investments are required to make informed decisions about the direction of future investments.
Canadian HealtH ServiCeS reSearCH Foundation 38
APP
END
IX A
: RES
ULT
-BA
SED
LO
GIC
MO
DEL
FO
R P
HC
Soc
ial,
cultu
ral,
polit
ical
, pol
icy,
legi
slat
ive/
regu
lato
ry, e
cono
mic
and
phy
sica
l con
text
s,po
pula
tion
char
acte
ristic
s an
d pu
blic
par
ticip
atio
n.
PH
C p
rodu
cts
and
serv
ices
: vol
ume,
type
(e.g
. ref
erra
l, pr
even
tion,
cur
ativ
e, p
allia
tive)
and
qua
litie
s (i.
e. re
spon
sive
, co
mpr
ehen
sive
, con
tinui
ty, c
oord
inat
ion,
inte
rper
sona
l com
mun
icat
ion
and
tech
nica
l effe
ctiv
enes
s)
Fisc
al re
sour
ces
Incr
ease
d K
now
ledg
e ab
out
heal
th a
nd h
ealth
car
eam
oung
the
popu
latio
n
Red
uced
risk
, dur
atio
nan
d ef
fect
s of
acu
te a
ndep
isod
ic h
ealth
con
ditio
ns
Mat
eria
l res
ourc
esH
ealth
hum
an re
sour
ces
Pol
icy
and
gove
rnan
ce-l
evel
act
iviti
tes
and
deci
sion
s
Hea
lth c
are
man
agem
ent l
evel
act
iviti
es a
nd d
ecis
ions
Clin
ical
act
iviti
es a
nd d
ecis
ions
Sus
tain
able
hea
lthca
re s
yste
mIm
prov
e an
d/or
mai
ntai
n fu
ctio
ning
resi
lienc
e an
d he
alth
for i
ndiv
idua
ls
Cont
exts
and
exte
rnal
fact
ors
Cont
exts
Inpu
ts
Act
iviti
es(e
nabl
e P
HC
deliv
ery)
Out
puts
(pro
duct
s an
dse
rvic
es)
Inte
rmed
iate
(dire
ct)
outc
omes
Inte
rmed
iate
(indi
rect
)ou
tcom
es
Fina
lou
tcom
es
Red
uced
risk
and
ef
fect
s of
con
tinui
nghe
alth
con
ditio
ns
Impr
oved
leve
l and
dis
trib
utio
nof
pop
ulat
ion
heal
th a
nd w
elln
ess
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 39
APPENDIX B: OECD FRAMEWORK
Health Status How Healthy are the citizens of the oeCd member countries?
Health Conditions Human Function and Quality of Life
Life Expectancy and Well-being
Mortality
non-Healthcare deterninants of Health are the non-healthcare factors that also determine health as well as how healthcare is used changing across and within oeCd member countries?
Healthcare System Perfomance How does the healthcare system perform? What is the level of care across the range of patient needs?
What does this performance cost?
Dimensions of Healthcare Performance
Healthcare Needs
eFFiCienCY
(MaCro- and MiCro-eConoMiC eFFiCienCY)
HealtH SYSteM deSiGn and ConteXt
What are the important design and contextual aspects that may be specific to each health system and which may be useful for interpreting the quality of it’s healthcare?
Other country-related determinants of performance (e.g capacity, societal values/ preferences, policy)
Health System Delivery Features
eQu
itY
Staying Healthy
Getting Better
Living with illness or disability
Coping with end of life
AccessibilitySafetyEffectiveness Responsiveness/ Patient-
centeredness
AccessQuality Cost/Expenditure
Physical Environment
Socio-economic Conditions & Environment
Perssonal or Host Resources
Health Behaviours and Lifestyle
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APPENDIX C: SYNTHESIS OF REVIEW LITERATURE – STUDY PROTOCOLProject title: Economic analysis of the consequences of achieving a high-quality primary healthcare system in Canada
Study title: Assessing and Projecting the Health Impact of Improvements in PHC Performance – A Synthesis of the Review Literature
1. 0 IntroductionBackground
There is now good evidence demonstrating the substantive contributions of PHC services to health and equity of health within populations.4 Concerns remain, however, that changes at the system level have not kept pace with available evidence. It has been suggested that health services researchers internationally should more closely examine the impact that PHC has on health services, patients, providers, and the system as a whole.170 The development and performance of the Canadian primary healthcare (PHC) sector have lagged in comparison to other wealthy industrialized countries,13;14 despite the $800 million investment made by Health Canada between 2000 and 2006 through the Primary Health Care Transition Fund (PHCTF)171 to support reform initiatives within the provinces and territories. Sixty-eight projects and project envelopes were resourced through the PHCTF, but more work is needed to disseminate the knowledge arising from these initiatives and to bring a national focus to primary healthcare in Canada, particularly with respect to defining priorities for research and stimulating evidence-informed policy and practice that will strengthen the healthcare system and improve the health of Canadians. In her recent commentary on the state of PHC in Canada, Barbara Starfield noted that “Canada seems to have stalled in its commitment to strengthening PHC. One reason for this lack of movement may be the poor investment in PHC research and evaluation. In this regard, Canada is probably at least 10 years behind.”172
An analysis of the health and economic consequences of closing the gap in access and quality between evidence-based practice and current PHC performance will provide a better understanding of the opportunities for improvement in Canada. CHSRF recently commissioned two reports173;174
that examined important elements of primary healthcare related to improving quality and research capacity. In Mapping the Future of Primary Healthcare Research in Canada the authors presented case studies of system-level structures that support and sustain PHC research and practice change.174
Initiatives in the UK and Australia provide examples that could be considered for application in Canada to enhance the profile of and system-level support for PHC research and reform in policy and practice. Recently CHSRF funded the project “Economic analysis of the consequences of achieving a high-quality primary healthcare system in Canada,” of which one component was to assess the current evidence of how PHC performance can be enhanced.
objectives
The objective of this project component (deliverable #3) is to identify review studies that have demonstrated that PHC performance can be enhanced and summarize the evidence in a qualitative synthesis format.
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Hypothesis
From our experience, we anticipate that the examples will be provided from the following six areas where sufficient evidence exists to allow conclusions to be made: accessibility, relational continuity, prevention/screening, immunization, diabetes, and/or cardiovascular disease. We anticipate covering multidisciplinary collaboration in primary-care practices, remuneration strategies, including capitation and pay-for-performance initiatives, and the organization of primary-care practices, including the use of information technology.
2.0 Key questions1. What is the evidence that PHC performance can be enhanced?2. What is the evidence on the effectiveness of specific PHC interventions or improvements?
3.0 Method 3.1 Study designA literature review and synthesis will be used to answer the project key questions.
include:
◥ Published reviews, systematic reviews or meta-analyses ◥ Published articles in English or French ◥ Work published between 2000 and 2010 ◥ Studies with content relating to interventions that are amenable to policy intervention or practice
organization and/or focused on a common condition
exclude:
◥ Non-review articles ◥ Content not related to quality (e.g. provider satisfaction) ◥ Studies that cannot be generalizable to the Canadian setting ◥ Studies that are not focused on general practice (i.e. special population) ◥ Interventions focused on a rare condition
3.2 Searching for the evidence: Literature search strategies for identification of relevant studies to answer the key questions
ovid
OVID Medline and OVID Healthstar will be used to search for published literature to identify relevant articles pertaining to categories identified in the inclusion and exclusion criteria.
Search terms used included: “primary care or family practice or general practice or family medicine or family physician or primary healthcare” in Title, Abstract or Key words.
Limits used for the search were: Full articles, English language and Publication year 2000–Current.
The initial OVID search produced a total of 6,842 articles.
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Cochrane library
Potentially relevant reviews were identified in the Cochrane Library including CENTRAL Cochrane Central Register of Controlled Trials.
Search terms used included: “primary care or primary healthcare or general practice or family practice or family medicine” in Title, Abstract or Key words.
The Cochrane Library search produced a total of 455 articles.
Health technology assessment (Hta) database
Potentially relevant reviews were identified in the Health Technology Assessment (HTA) Database, produced by the Centre for Reviews and Dissemination (CRD).
Search terms used included: “primary care or primary healthcare or general practice or family practice or family medicine” in Title, Abstract or Key words.
Studies that were recorded as being “Brief record” or “Project record” did not contain data and were excluded.
The HTA database search produced a total of 802 articles.
database of abstracts of reviews of effectives (dare)
Potentially relevant reviews were identified in the Database of Abstracts of Reviews of Effectives (DARE), produced by the Centre for Reviews and Dissemination (CRD).
Search terms used included: “primary care or primary healthcare or general practice or family practice or family medicine” in Title, Abstract or Key words.
The DARE search produced a total of 218 articles.
nHS economic evaluation database (nHSeed)
Potentially relevant reviews were identified in the NHS Economic Evaluation Database (NHSEED).
Search terms used included: “primary care or primary healthcare or general practice or family practice or family medicine” in Title, Abstract or Key words.
The NHSEED search produced a total of 150 articles.
Campbell library
Potentially relevant reviews were identified in the Campbell Library.
Search terms used included: “primary care or primary healthcare or general practice or family practice or family medicine” in Title, Abstract or Key words.
The Campbell Library search produced a total of 7 articles.
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3.3 ScreeningIn total, 8,474 articles were identified in the preliminary databases search. The article screening process further assessed via scan of article title and abstract, relevance based on both general inclusion and exclusion criteria outlined in section 3.1 as well as specific inclusion and exclusion criteria relating to specific conditions/outcomes/populations or interventions of interest.
Articles will be screened by one reviewer (SD). Articles identified as being potentially relevant after the screening process will be retrieved and coded by a different reviewer (KM or MP). Newest versions available for each article will be retrieved.
Database-specific exclusions included the HTA database, where some studies that were recorded as a “Brief record” or “Project record” did not contain data and were excluded right away. Also the NHSEED had many articles that were not reviews. The reviewer SD used the “find” function to locate the word “review” to identify potential reviews to screen.
The following table outlines specific inclusion and exclusion criteria used in the screening process.
Condition/outCoMe/PoPulation
Include ExcludeObesity Complementart medicineDiabetes Breast FeedingCardiac condition Children and adolescentsDepression Specific cardiac condition (e.g. left ventricular dysfunction)
Primary vs secondary care Drinking/ addictionsFrequent attenders STD (e.g. Chlamydia and HIV)Physical activity AsthmaDrug prescription AutismPrevention (Breast cancer) Abuse
Healthcare workersBladderProstateCancer managementScreening for rare condition (e.g. oral cancer, micro-albuminuria, ocular hypertension)Vulnerable populationPrenatal careEating disordersDementiaDeveloping countriesDentalcare
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intervention
Include ExcludeAudit and feedback (knowledge transfer) Communication/patient-centered/family-centered careElectronic tools Alternative and complementary interventionsMultidisciplinarity/NP/managed care/midwife TelemedicineSelf care/management PharmacotherapyConsultation lengthDifferent models of care (e.g. after hours)Continuity of care
3.4 Data abstraction and data managementData extraction of included studies will be undertaken by one reviewer (KM/MP/TD) and checked by a second reviewer (SD). A data extraction form (Excel workbook) will be used to record information on relevant key information that can be used for the synthesis.
The data abstraction form includes the following headings: Author and Year, Title, Source, Search Method, Document Type and Notes.
3.5 Quality assessmentWe seek to identify and include only those reviews that meet a minimum standard of quality as a systematic review. This required that the review had to have used and described adequate methods to search for, appraise and describe included studies. Narrative reviews, in which the inclusion of studies may have been subject to a high level of bias, would be included as low quality. The quality of each review identified will be assessed within the following domains:
◥ description of study selection and inclusion criteria ◥ comparability of included studies ◥ assessment of publication bias ◥ assessment of heterogeneity ◥ generalizability to the Canadian context
Review articles that were screened into the data abstraction phase will be reviewed for quality of the reporting and methods using the AMSTAR checklist (‘assessment of multiple systematic reviews) (Shea et al. 2007) and Cochrane Handbook for Systematic Reviews of Interventions.175 Review articles that were deemed “moderate quality” or “high quality” will be included.
Currently, there exists a paucity of systematic reviews of incentives as a quality-improvement initiative in PHC. In order to provide a more complete picture of this intervention, data from the few identified review articles was supplemented by evidence from primary studies. These studies were not assessed for quality.
Evidence summaries will be created for each intervention based on the evidence from the review studies included. Evidence summaries can be produced in a similar format as those produced by the Ontario Health Research Institute – Knowledge to Action group.176
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4.0 Results reporting4.1 Identified studiesThe identified studies were maintained in a database using Microsoft Excel. Studies were categorized according to interventions, target outcomes and quality scores. Those reviews that did not target policy-relevant outcomes or had low quality scores were separated into a list of excluded studies.
4.2 Data synthesisTables will be used to present included studies and their findings in a systematic and clear format. A ‘Summary of findings’ table provides key information concerning the quality of evidence, and the sum of available effectiveness data on all important outcomes for a given comparison. This table can help inform the main results of the synthesis of reviews, which, in turn, will help address the project objectives and key questions and provide key recommendations on priorities for PHC system improvement in terms identifying specific interventions to enhance the PHC system.
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APPENDIX D: DESCRIPTION OF STUDIES INCLUDED IN THE SECTION ON “INTERVENTIONS TO IMPROVE PHC PERFORMANCE”Quality assurance - incentives
Authors, Year Title Article Type Effects Quality Score
Campbell et al., 2007
Quality of primary care in England with the introduction of pay-for-performance
Primary Study Primary Study Pay-for-performance schemes have been mostly found to be effective in improving practice level quality scores in the area of care they reward.
CHD: ~+11.5% ; Diabetes: ~+15.6%; Asthma: ~+19.9%;
N/A
Campbell et al., 2009
Effects of Pay-for-performance on the Quality of Primary Care in England
Primary Study Pay-for-performance schemes have been mostly found to be effective in improving clinical quality scores in disease-specific processes:
(Asthma: +0.83% on clinical quality score; Diabetes: + 2.83% on clinical quality score);
Health outcomes not related to the incentives decrease over time and those that were rewarded reached a peak shortly after being implemented.
N/A
Campbell et al., 2008
The Experience of Pay-for-performance in English Family Practice: A Qualitative Study
Primary Study (Qualitative)
It is difficult to attribute improvements in clinical outcomes to incentives. The tendency away from collaborative care and towards delegation causes physicians to lose skills in the areas they have reassigned to others
N/A
Checkland et al., 2008
Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract
Primary study (Qualitative)
Quality and Outcomes Framework (QOF) was implemented and impacts were assessed by collecting qualitative information on the viewpoints of practitioners and staff. The quality of care in pay-for-performance shifts towards a biomedical model of healthcare and away from a holistic model. GP respondents generally failed to consider the overall experience of a patient attending the practice and were more concerned with the measurable (within QOF) outcomes as definable entities of “what went wrong” in their offices.
N/A
Doran and Roland, 2010
Lessons from Major Initiatives to Improve Primary Care in the United Kingdom
Commentary The U.K.’s comprehensive physician practice incentive program improved physician morale, helped address a shortage of FPs, and improved chronic disease care. But the longer-term effects on the physician–patient relationship cannot yet be assessed.
N/A
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Gravelle et al., 2007
Doctor Behaviour Under a Pay-for-performance Contract: Evidence from the Quality and Outcomes Framework
Primary Study Pay-for-performance may have led to above trend increases in quality. Ninety-one percent of practices achieved above quality thresholds.
N/A
Lee et al., 2009
Linking families and facilities for care at birth: What works to avert intrapartum-related deaths?
Systematic Review
Pay-for-performance schemes have been mostly found to be effective in improving the area of care they reward Institutionalized births: +41%Primary care centre births: +4%
6
Naccarella et al, 2009
Final report: Narrative Literature Review on Incentives for Primary Healthcare Team Services Provision: Learning and Working Together in Primary Healthcare
Narrative Review
Pay-for-performance schemes have been mostly found to be effective in improving the area of care they reward, but reinforce hierarchies, therefore disempowering nurses.
3
Oluwatowoju et al., 2010
Organisation and Delivery of Care- Improvements in glycaemic control and cholesterol concentrations associated with the Quality and Outcomes Framework: a regional 2-year audit of diabetes care in the UK
Primary Study Pay-for-performance schemes have been mostly found to be effective in improving the area of care they reward: Glycemic control: +12.4% of patients
Achieving HbA1c and cholesterol targets: +13.5% of patients.
N/A
Petersen L, 2006
Does Pay-for-Performance Improve the Quality of Healthcare?
Review Provider group-level incentive resulted in a statistically significant improvement in the measure of quality of care in two studies. In five other studies the financial incentive had a partial effect. One study found a small improvement in rates of cervical cancer screening between the intervention and comparison groups after the quality incentive program (difference, 3.6%; P=0.02). Improvements in mammography screening rates and hemoglobin A1c testing were not statistically significant.
8
Sabatino et al., 2008
Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers systematic reviews of provider assessment and feedback and provider incentives
Systematic Review
Financial incentives may be effective when coupled with audit and feedback interventions. There is insufficient evidence to determine the effectiveness of provider incentives in increasing screening for breast, cervical or colorectal cancers. Evidence is insufficient because of too few qualifying studies and inconsistent results.
4
Schatz et al., 2008
Does pay-for-performance influence the quality of care?
Systematic Review
Pay-for-performance programs that reward physician groups or individual physicians can improve markers of quality, but not always. Of the studies included, even when studies suggest positive effects, the designs often do not permit assurance that the effects are due to the incentives compared with other factors.
4
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Strong et al., 2009
The UK Quality and Outcomes Framework pay-for-performance scheme and spirometry: rewarding quality or just quantity? A cross-sectional study in Rotherham, UK
Primary Study Pay-for-performance may only increase the quantity and not the quality of care provided.
There was an approximately 95 % mean achievement for COPD indicators.
N/A
Sturam et al., 2007
Pharmaceutical policies: effects of financial incentives for prescribers
Systematic Review
Due to methodological limitations, overall the evidence is weak. It supports the conclusion that drug budgets can decrease prescribed drug volume and drug expenditure. Results on healthcare utilization and quality of care were inconclusive. Approximately 10% difference between fundholders and non-fundholders in terms of increase in prescribing costs.
9
Quality assurance - Feedback
Authors Title Article Type Effects Quality Score
Jamtvedt et al. 2006
Audit and feedback: effects on professional practice and healthcare outcomes.
Review A&F had a small effect on professional practice outcomes: median adjusted risk difference: 4% (-16 to 32%)
8
Grimshaw et al. 2004
Audit and feedback: effects on professional practice and healthcare outcomes.
Review A&F had a medium effect on professional practice outcomes: median risk difference: 7% (1.3-16%)
7
Hysong 2009 Meta-analysis audit and feedback features impact effectiveness on care quality.
Meta-analysis A&F was generally effective in improving professional practice outcomes.
5
Marinopoulos et al. 2007
Effectiveness of continuing medical education.
Review Insufficient evidence for the effect of A&F on professional practice outcomes.
7
Baskerville 2010
Systematic Review of Practice Facilitation and Evaluation of a Chronic Illness Care Managment Tailored Outreach Facilitation Intervention for Rural Primary Care Physicians.
Systematic Review
EOV had a medium effect on professional practice outcomes: odds ratio: 0.54 (0.43-0.65).
10
Shaw et al. 2005
Tailored interventions to overcome identified barriers to change: effects on professional practice and healthcare outcomes.
Review EOV was generally effective in improving professional practice outcomes.
7
Qureshi et al. 2002
A systematic review of educational outreach visits for a non-prescribing interventions in general practice.
Systematic Review
EOV was generally effective in improving professional practice outcomes.
7
O’Brien et al. 2007
Educational outreach visits: effects on professional practice and healthcare outcomes.
Review Insufficient evidence for the effect of EOV on professsssional practice outcomes.
8
Forsetlund et al. 2009
Continuing education meetings and workshops: effects on professional practice and healthcare outcomes.
Review Insufficient evidence for the effect of EOV on professsssional practice outcomes.
8
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Thomas et al. 2000
Guidelines in professions allied to medicine.
Review Insufficient evidence for the effect of EOV on professsssional practice outcomes.
8
Légaré et al. 2010
Interventions for improving the adoption of shared decision making by healthcare professionals.
Review Insufficient evidence for the effect of EOV on professsssional practice outcomes.
9
Faulkner et al. 2003
A systematic review of the effect of primary care-based service innovations on quality and patterns of referral to specialist secondary care.
Systematic Review
Insufficient evidence to draw any conclusions regarding the effects of A&F on interprofessional collaboration.
8
Akbari et al. 2008
Interventions to improve outpatient referrals from primary care to secondary care.
Review Insufficient evidence to draw any conclusions regarding the effects of A&F on interprofessional collaboration.
7
Zwarenstein et al. 2008
Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes.
Review Insufficient evidence to draw any conclusions regarding the effects of EOV on interprofessional collaboration.
7
Smolders et al. 2008
Knowledge transfer and improvement of primary and ambulatory care for patients with anxiety.
Review Insufficient evidence to draw any conclusions regarding the effects of EOV on interprofessional collaboration or on managing anxiety.
7
Sabatino et al. 2008
Task Force on Community Preventive Services. Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers systematic reviews of provider assessment and feedback and provider incentives.
Systematic Review
A&F is generally effective for improving cancer screening.
4
Bordley et al. 2000
The effect of audit and feedback on immunization delivery.
Review A&F is generally effective for immunization rates.
5
Ryman et al. 2008
The effect of audit and feedback on immunization delivery.
Review A&F is generally effective for immunization rates.
5
Safdar and Abad 2008
Educational interventions for prevention of healthcare-associated infection: a systematic review.
Systematic Review
Insufficient evidence for the effect of A&F on reducing infections.
5
Glynn et al. 2010
Interventions used to improve control of blood pressure in patients with hypertension.
Review Insufficient evidence for the effect of A&F on managing hypertension.
10
Flodgren et al. 2010
Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people.
Review Insufficient evidence for the effect of A&F on managing obesity.
8
Renders et al. 2000 (Published as up to date in 2009)
Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings.
Review Insufficient evidence for the effect of A&F on managing diabetes.
7
Guldberg et al. 2009
The effect of feedback to general practitioners on quality of care for people with type 2 diabetes.
Review Insufficient evidence for the effect of A&F on managing diabetes.
4
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Gilbody et al. 2003
Educational and organisational interventions to improve the management of depression in primary care.A systematic review.
Systematic Review
EOV is generally effective for managing depression medication.
6
Arnold and Straus 2005
Interventions to improve antibiotic prescribing practices in ambulatory care.
Review EOV has small effect on improving appropriate antibiotic prescription (5.1% (-6.5 to 9.5%).
A&F has a small effect (5.8% (-0.4-14.5%) on improving antibiotic prescription.
7
Steinmann et al. 2006
Improving antibiotic selection: a systematic review and quantitative analysis of quality improvement strategies.
Systematic Review
EOV is generally effective for improving antibiotic prescription
Insufficient evidence for the effectiveness of A&F for improving appropriate antibiotic prescription.
5
Bennett and Glasziou 2003
Computerised reminders and feedback in medication management: a systematic review of randomized controlled trials.
Systematic Review
A&F was generally effective for improving appropriate prescriptions of medication: Risk Difference: 2% (0-8%).
4
Chaudhry et al. 2006
Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care.
Systematic Review
Insufficient evidence for the effectiveness of A&F in improving appropriate prescription of medication.
4
Figueiras et al. 2001
Effectiveness of educational interventions on the improvement of drug prescription in primary care: a critical literature review.
Review Insufficient evidence for the effectiveness of A&F in improving appropriate prescription of medication.
4
information technology - Patient recall
Authors Title Article Type Effects Quality Score
Jacobson Vann and Szilagyi 2005
Patient reminder and recall systems to improve immunization rates.
Review Improved immunization rates: Influenza: absolute risk difference (ARD) = 12 more people out of 100 (95% CI: 6, 18); all other vaccines: ARD = 18 more people out of 100 (95% CI: 4, 33).
10
Stone and Morton 2002
Interventions that increase use of adult immunization and cancer screening services: a meta-analysis.
Meta-analysis Improved immunization rates:All vaccines: Odds Ratio (OR) = 2.52 (95% CI: 2.24, 2.82)Improved cancer screening:Colon cancer: adjusted OR= 2.75 (1.90–3.97) Cervical cytology: adjusted OR= 1.74 (1.58–1.92) Mammography: adjusted OR = 2.31 (1.97–2.70)
9
Forbes et al. 2002
Interventions targeted at women to encourage the uptake of cervical screening.
Review Improved cancer screening:Cervical cytology: generally effective.
10
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Bonfill Cosp et al. 2001
Strategies for increasing the participation of women in community breast cancer screening.
Review Improved cancer screening:Mammography: letter of invitation (OR 1.66, 95% CI 1.43 to 1.92); letter of invitation plus phone call (OR 2.53, 95% CI 2.02 to 3.18); phone call (OR 1.94, 95% CI 1.70 to 2.23.
9
Glynn et al. 2010
Interventions used to improve control of blood pressure in patients with hypertension.
Review Improved proportion of hypertensive patients who attended follow-up.In two small trials also led to improved blood pressure control, odds ratio favouring intervention 0.54 (95% CI 0.41 to 0.73).
10
Renders et al. 2000 (Published as up to date in 2009)
Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings.
Review Improved follow-up in diabetic patients. 7
information technology - Provider reminders
Authors Title Article Type Effects Quality Score
Shojania et al. 2009
The effects of on-screen, point of care computer reminders on processes and outcomes of care.
Review Small effects on clinical processes and outcomes:-prescription of vaccinations (3.8%, IQR: 0.5 to 6.6%)-test ordering (3.8%, IQR: 0.4 to 16.3%) -all measure of medication ordering (6.2%, IQR: 3.0% to 28.0%).Median improvement across all process measures (5.6% (IQR: 2.0% to 19.2%)) with a process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes.Intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%); systolic blood pressure (-1 mm Hg; (IQR: 2.3 mmHg reduction to 2.0 mmHg increase)).
8
Grimshaw et al. 2004
Effectiveness and efficiency of guideline dissemination and implementation strategies.
Review Medium effects on adherence to guidelines (cancer screening, blood pressure monitoring, diabetes care, immunizations, etc.): median risk difference: 11.6% (-1% to 40%).
7
Balas et al. 2000
Improving preventive care by prompting physicians.
Review Medium effects on adherence to guidelines (cancer screening, blood pressure monitoring, diabetes care, immunizations, etc.): cumulative rate difference: 13.1% (10.5-15.6%).
4
Chaurhry et al. 2006
Systematic review: Impact of health information technology on quality, efficiencey, and costs of medical care.
Systematic Review
Provider reminders were generally effective in improving quality of care.
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Thomas et al. 2000
Guidelines in professions allied to medicine.
Review Insufficient evidence for the effect of provider reminders on process outcomes.
7
Zwarenstein et al. 2009
Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes.
Review Insufficient evidence to draw any conclusions regarding the effects of provider reminders on interprofessional collaboration.
7
Akbari et al. 2008
Interventions to improve outpatient referrals from primary care to secondary care.
Review Insufficient evidence to draw any conclusions regarding the effects of provider reminders on interprofessional collaboration.
7
Stone and Morton 2002
Interventions that increase use of adult immunization and cancer screening services: a meta-analysis.
Meta-Analysis Provider reminders increased immunization uptake: OR = 3.80 (95% CI: 3.31. 4.37).
9
Glynn et al. 2010
Interventions used to improve control of blood pressure in patients with hypertension.
Review Provider reminders alone were unlikely to be effective in the management of hypertension.
10
Flodgren et al. 2010
Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people.
Review Insufficient evidence to draw conclusions about provider reminders in the management of obesity.
9
Gilbody et al. 2003
Educational and organisational interventions to improve the management of depression in primary care.
Review Insufficient evidence to draw conclusions about provider reminders in the management of depression.
6
de Belvis et al. 2009
Can primary care professionals’ adherence to Evidence Based Medicine tools improve quality of care in Type 2 diabetes mellitus? A systematic review.
Systematic Review
Insufficient evidence to draw conclusions about provider reminders in the management of diabetes.
7
Kawamoto et al. 2005
Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success.
Systematic Review
After meta-regression, 94% of studies where CDSS incorporated the following components (based on univariate analyses) found CDSS to be effective for general disease management: 1) automatic provision of decision support; 2) provided at point of care; 3) recommendations provided; 4) computer generated
5
Lu et al. 2008 Interventions designed to improve the quality and efficiency of medication use in managed care: a critical review of the literature 2001-2007 (Provisional abstract).
Review Insufficient evidence for the effectiveness of reminders in disease management.
4
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Durieux et al. 2008
Computerized advice on drug dosage to improve prescribing practice.
Review Improved initial dose (standardized mean difference 1.12, 95% CI 0.33 to 1.92), serum concentrations (standardized mean difference 1.12, 95% CI 0.43 to 1.82), time to therapeutic stabilization (standardized mean difference -0.55, 95%CI -1.03 to -0.08), risk of toxic drug level (rate ratio 0.45, 95% CI 0.30 to 0.70) and length of hospital stay (standardized mean difference -0.35, 95% CI -0.52 to -0.17).
7
Bennett and Glasziou 2003
Computerised reminders and feedback in medication management: a systematic review of randomized controlled trials.
Systematic Review
Improved drug choices for outpatients (RD: 22% (10.7% and 34%).
4
Yourman et al.
Use of computer decision support interventions to improve medication prescribing in older adults: a systematic review.
Systematic Review
Improved drug choices for outpatients. 5
Ioannidis and Lau 2001
Evidence on interventions to reduce medical errors: an overview and recommendations for future research.
Review Improved drug choices for outpatients. 4
Ammenwerth et al. 2008
The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review.
Systematic Review
Increased appropriate use and drug safety.
5
Kaushal et al. 2003
Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.
Systematic Review
Increased appropriate use and drug safety. 5
Pearson et al. 2009
Do computerised clinical decision support systems for prescribing change practice? A systematic review of the literature (1990-2007).
Systematic Review
Combining CPOE + CDSS best reduced adverse drug events.
5
Garg et al. 2005
Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.
Systematic Review
Mixed results on effectiveness of CDSS. 5
Arnold and Straus 2005
Interventions to improve antibiotic prescribing practices in ambulatory care.
Systematic Review
Mixed results on effectiveness of CDSS. 7
Randell et al. 2007
Effects of computerized decision support systems on nursing performance and patient outcomes: a systematic review.
Systematic Review
Insufficient evidence to draw conclusions on the effectiveness of CDSS.
6
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team Structure
Authors Title Article Type Effects Quality Score
Boult et al., 2009
Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine’s “retooling for an aging America” report.
Systematic Review
(Narrative) A team composed of a primary care physician and one or more allied health professionals has improved several indices of the quality of multimorbid patients’ PHC, and many have improved patients’ quality of life and functional autonomy. For most of the different team structures, available evidence of success is limited to a single randomized trial. Only teams focused on heart failure have improved patients’ survival and have been evaluated in enough studies to allow a meta-analysis, which reported significant reductions in hospital admissions and total costs (actual estimates not provided).
7
Bower et al., 2006
Collaborative care for depression in primary care. Making sense of a complex intervention: systematic review and meta-regression
Meta-Analysis Using collaborative care in depression management OR 1.92, 95% CI 1.54-2.39 I2 80% = improved antidepressant use and SMD 0.24, 95% CI 0.17 - 0.32, I2 54% = better depressive outcomes.
4
Bower and Rowland, 2009
Effectiveness and cost effectiveness of counseling in primary care.
Systematic Review
Greater clinical effectiveness in the counseling group compared with usual care in the short term (standardized mean difference -0.28, 95% CI -0.43 to -0.13) but not in the long term (standardized mean difference -0.09, 95% CI -0.27 to 0.10).
8
Carter et al., 2009
The potency of team-based care interventions for hypertension: a meta-analysis.
Meta-Analysis Adding a pharmacist to primary practice improves blood pressure control: OR 2.17 95% 1.75 - 2.68; adding a nurse improves blood pressure control: OR 1.69 95% 1.48 - 1.93. There were no significant differences between the nursing and pharmacy studies (P=0.19).
4
Chang-Quan et al., 2009
Collaborative care interventions for depression in the elderly: a systematic review of randomized controlled trials.
Systematic Review
Using a collaborative care intervention (care systems integrated mental health providers and primary care) was more effective in improving depression symptoms than usual care during each follow-up period. Compared with baseline, thoughts of suicide in subjects receiving intervention significantly decreased (OR= 0.52; 95% CI 0.35- 0.77), but not that in those receiving usual care (OR=0.85; 95% CI, 0.50-1.43).
8
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 55
Chapman et al., 2004
Systematic review of recent innovations in service provision to improve access to primary care.
Systematic Review
(Narrative) Lack of rigorous evidence. Substituting nurses for GPs or the telephone for face-to-face consultations may be effective in improving access where GP recruitment and retention is a challenge, however may infringe on equality of access for some, including people who do not speak English or who have hearing impairments. Weak evidence that patients can be safely managed by pharmacists’ advice and treatment.
4
Craven and Bland, 2006
Better practices in collaborative mental healthcare: an analysis of the evidence base
Systematic Review
(Narrative) A trend towards positive outcomes in studies with collaboration. Using collaborative care improves mental healthcare outcome.
4
Gensichen et al., 2006
Case management to improve major depression in primary healthcare: a systematic review
Meta-Analysis Standard mean difference/effect size on symptom severity after 6–12 months of -0.40 (95% CI -0.60 to –0.20). Patients in case management group more likely to achieve remission after 6-12 months compared to control group: RR 1.39, 95% 1.30-1.48. Intervention group more likely to achieve better medication adherence compared to control: RR=1.5, 95% 1.28-1.86.
8
Gilbody et al., 2003
Educational and organizational interventions to improve the management of depression in primary care: a systematic review
Systematic Review
(Narrative) Adding a pharmacist improved antidepressant prescribing in patients 60 years and older: RR 0.55, 95% 0.33-0.92. Adding a nurse/coordination improved adherence to medication: OR 2.7, 95% 1.6-4.8 (individual study). Adding a nurse practitioner improved medication adherence: OR 1.99, 95% 1.23-3.22 (individual study), and improved clinical response: OR 2.22, 95% 1.31-3.75 (individual study).
6
Glynn et al., 2010
Interventions used to improve control of blood pressure in patients with hypertension
Systematic Review
(Narrative) Nurse- or pharmacist-led care may be a promising way forward, with the majority of RCTs being associated with improved blood pressure control and mean systolic blood pressure and diastolic blood pressure, but these interventions require further evaluation.
9
Hudon et al., 2008
Single risk factor interventions to promote physical activity among patients with chronic diseases: systematic review
Systematic Review
(Narrative)Insufficient evidence for the effects of collaborative care. One study showed a positive trend from the least intensive intervention (usual care) to the more intensive interventions (prescription by a FP and counseling by a nurse) toward increased physical activity at one month. Another study found no significant effect. Suggests that face-to-face consultation with a counselor is more effective than over-the-phone consultation.
7
Canadian HealtH ServiCeS reSearCH Foundation 56
Laurant et al., 2005
Substitution of doctors by nurses in primary care
Systematic Review
(Narrative) In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource use or cost. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care.
8
Lindenmeyer et al., 2006
Interventions to improve adherence to medication in people with type 2 diabetes mellitus: a review of the literature on the role of pharmacists.
Systematic Review
(Narrative) Three studies evaluated pharmacist-led integrated management and education programs designed to improve glycaemic control for under-served patient populations. They all succeeded in lowering glycated haemoglobin, but it remains unclear whether this resulted from improved patient adherence. One included study reported a decrease of HbA1c by 2.2% in the intervention group compared to usual care.
7
Loveman et al., 2003
Specialist nurses in diabetes mellitus Systematic Review
(Narrative) One study demonstrated a significant reduction in HbA1c in the presence of the diabetes specialist nurse/nurse case manager at six months. Significant differences in episodes of hypoglycaemia and hyperglycaemia between intervention and control groups were found in one trial.
9
McAlister et al., 2004
Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials.
Systematic Review
(Narrative) One study found that collaborative care reduced mortality compared to usual care: RR 0.75, 95% 0.59-0, reduced heart failure hospitalizations: RR 0.74, 95% CI 0.63 - 0.87 and reduced all-cause hospitalizations: RR 0.81, 95% CI 0.71 - 0.92.
7
Renders et al., 2000 (Published as up to date in 2009)
Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings
Systematic Review
Nurse partly replaced physician with positive impacts on glycaemic control. More evidence needed for pharmacist replacing physician for diabetes care; using a nurse practitioner to increase patient education or facilitate adherence to treatment. Using case management and multidisciplinary teams showed favorable effects on process and patient outcomes. One of the included studies found improvements in HbA1c: absolute difference of 0.6 and relative improvement of 8%. Baseline: 7.4±1.6 vs 7.4±1.9; post intervention: 7.0±1.3 vs 7.6±1.5
7
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 57
Rice and Stead, 2009
Nursing interventions for smoking cessation
Meta-Analysis Adding a pharmacist: (OR 0.92, 95% 0.81-1.05) RCTs only but (OR 0.64, 95% 0.43-0.96) = for all pharm-led interv effective in reducing hospital admissions; adding a nurse/coordinator: (RR 1. 28, 95% 1.18-1.38) nursing interv to help patients quit smoking.
9
Stone et al. 2002
Interventions that increase use of adult immunization and cancer screening services: a meta-analysis.
Meta-Analysis Organizational change results in a significant increase in immunization uptake; OR = 16.0 (95% CI: 11.2, 22.8).
9
Tsai and Wadden, 2009
Treatment of obesity in primary care practice in the United States: a systematic review.
Systematic Review
dding a counselor: positive results for multidisciplinary model with physical activity counselors. For 1) PHC counseling alone, (2) PHC counseling + pharmacotherapy, and (3) “collaborative” obesity care (treatment delivered by a non-physician provider), weight losses in the active treatment arms of these categories of studies ranged from 0.1 to 2.3 kg, 1.7 to 7.5 kg, and 0.4 to 7.7 kg, respectively.
9
Canadian HealtH ServiCeS reSearCH Foundation 58
APPENDIX E: SYSTEMATIC REVIEW – STUDY PROTOCOLProject Title: Economic analysis of the consequences of achieving a high-quality PHC system in CanadaStudy title: Systematic review of the cost-effectiveness of multidisciplinary PHC teams in improving PHC (PHC) performanceFocused review title: Systematic review of the economic impact of adding a pharmacist to PHC team
1.0 Introduction1.1 BackgroundThere is now good evidence demonstrating the substantive contributions of primary care services to health and equity of health within populations.4 Concerns remain, however, that changes at the system level have not kept pace with available evidence. It has been suggested that scientists conducting international research on health services should more closely examine the impact that primary care has on health services, patients, providers and the system as a whole.170 The development and performance of the Canadian PHC sector have lagged in comparison to other wealthy industrialized countries,13;14 despite the $800 million investment made by Health Canada between 2000 and 2006 through the PHC Transition Fund (PHCTF)171 to support reform initiatives within the provinces and territories. Sixty-eight projects and project envelopes were resourced through the PHCTF, but more work is needed to disseminate the knowledge arising from these initiatives and to bring a national focus to PHC in Canada,– particularly with respect to defining priorities for research and stimulating evidence-informed policy and practice that will strengthen the healthcare system and improve the health of Canadians. In her recent commentary on the state of PHC in Canada, Barbara Starfield noted that “Canada seems to have stalled in its commitment to strengthening primary care. One reason for this lack of movement may be the poor investment in primary care research and evaluation. In this regard, Canada is probably at least 10 years behind.”172
An analysis of the health and economic consequences of closing the gap in access and quality between evidence-based practice and current PHC performance will provide a better understanding of the opportunities for improvement in Canada. Multidisciplinary primary care teams have been suggested as one PHC intervention that has potential to improve access and quality, at a reduced cost to the healthcare system. The proposed study aims to review and integrate the current literature on the health and economic impact of multidisciplinary care teams as they relate to the addition of allied health professionals to the primary-care practice. For the purposes of the report to the Canadian Health Services Research Foundation, the health and economic impact of adding or integrating a pharmacist to a primary-care practice will be evaluated and presented.
1.2 ObjectivesTo systematically review the literature and provide a narrative analysis of the potential health and economic impact of pharmacist-physician collaborative care within the primary-care practice setting.
1.3 Project time lineProject Start Date: August 6, 2010Anticipated Draft Report Due Date: November 15, 2010
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 59
2.0 Key questions 2.1 Questions that the review will address
Principal Questions:
1. What economic outcomes can be attributed to multidisciplinary primary care teams, and in particular the contribution of pharmacist-physician collaborative care?
2. Is pharmacist-physician collaboration in primary care cost effective? 3. For which diseases is pharmacist-physician collaborative care in PHC cost effective?
additional Questions:
◥ What methods have been used to assess the economic impacts of multidisciplinary teams? ◥ When have the economic benefits of multidisciplinary primary care teams been evaluated? ◥ How can international approaches and findings be applied to the Canadian context (generalizability)?
2.2 Population(s)
include:
PHC practice and professionals providing PHC within the primary practice setting (i.e. involving healthcare providers as the first point of consultation for patients, or any kind of healthcare providers acting as first points of consultation for patients).177 Include healthcare providers within the settings of family practice, general practice and family medicine, including FPs or other PHC workers (e.g. nurses, physicians’ assistants, pharmacists, etc.) For the CHSRF report, results will be reported for the inclusion of pharmacists in primary-care practices.
exclude:
Institutions and persons providing solely secondary and/or tertiary healthcare; private institutions providing PHC; and traditional healthcare not locally recognized as being part of official healthcare system. For the CHSRF report, those studies that assess the health economic impact of multidisciplinary teams that include other non-pharmacist allied health professionals will be excluded. Assessment of other types of multidisciplinary care teams will be conducted and reported on at a later time.
2.3 Interventions
include:
To improve/affect: accessibility, relational continuity, prevention/screening, immunization, diabetes and/or cardiovascular disease within the PHC context. Examples of multidisciplinary primary care include the addition within a primary-care practice of an allied health professional to a FP, such as a nurse practitioner, registered nurse, pharmacist and/or mental health counselor, psychotherapist or social worker. For the purposes of the CHSRF report, results will be reported for the intervention of pharmacist-physician collaborative care in primary-care practices.
exclude:
Studies with no active intervention, any multidisciplinary care provided outside the primary practice setting including outpatient care, home care or care provided in a nursing home/long-term care facility. Exclude evaluations of allied health professionals as substitutes for the primary care physician or those working in collaboration but who work outside the practice, such as community-based care. Exclude studies that assess the impact of multidisciplinary teams for less-significant diseases, for example
Canadian HealtH ServiCeS reSearCH Foundation 60
headache, dermatological issues, etc. For the purposes of the CHSRF report, the review will exclude findings for all non-pharmacist interventions. The health economic impact of multidisciplinary primary care teams that include other allied health professionals will be evaluated and reported on at a later time.
2.4 ComparatorsCurrent standard of care and/or other intervention
For the purposes of the CHSRF report, the comparators of interest include pharmacist integration in primary-care practice versus usual care within a PHC setting (i.e. family/general practice).
2.5 OutcomesAt least one economic outcome measure reported, including costs related to the PHC intervention, health resource use, medication usage, etc. Effectiveness outcomes are any improvements in care or clinical outcomes, including improvements in accessibility, relational continuity, health resource use and/or other chronic diseases including hypertension, diabetes and overweight/obesity. Other cost-effectiveness outcomes including cost-effectiveness ratios or incremental cost-effectiveness ratios i.e. cost per effect or cost per benefit gained when evaluating comparators.
3.0 Method 3.1 Study design
include:
◥ Published literature and grey literature from January 1990 to August 2010 ◥ English language ◥ Full economic evaluation studies (i.e. cost-effectiveness analyses, cost-utility analyses, cost-benefit
analyses) of [intervention(s) versus comparator(s)] ◥ Partial economic evaluations (i.e. cost analyses, cost-description studies, cost-outcome
descriptions) of [intervention(s) and comparator(s)]; and randomized trials reporting more limited information, such as estimates of resource use or costs associated with [intervention(s) and comparator(s)].
◥ Primary studies that assess the cost and effectiveness of pharmacist-physician collaborative care within primary-care practice
exclude:
◥ Studies that specifically refer to cost-effectiveness of treatment interventions (i.e., micro-economic studies)
◥ Methodology studies ◥ Non-primary studies, reviews, commentaries and editorials.
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 61
3.2 Searching for the evidence: Literature search strategies for identification of relevant studies to answer the key questions
3.2.1 Grey literature
The search of grey literature was performed for a previous component of the broader project (deliverable 2). The following search strategy was employed to identify the relevant grey literature:
◥ a search of web pages of international organizations, bilateral agencies and nongovernmental organizations (NGOs) involved in PHC research
◥ a search for primary studies referred to in bibliographies of reviews and other articles ◥ reports and articles in press that were recommended by experts in the field ◥ documents that refer to economic evaluations of multidisciplinary primary care and, in particular pharmacist-
physician collaborative care in primary-care practice will be included
Websites studied included:
◥ CHSRF (www.chsrf.ca/) ◥ Commonwealth Fund organization (www.commonwealthfund.org/) ◥ Health Canada (http://www.hc-sc.gc.ca/index-eng.php) ◥ RAND corporation (www.rand.org) ◥ Canadian Nurses Association (www.cna-nurses.ca/cna/) ◥ College of Family Physicians of Canada (www.cfpc.ca/) ◥ Provincial college of family physician and nurses (www.ocfp.on.ca/ and www.cno.org) ◥ OECD (www.oecd.org) ◥ World Health Organization (www.who.int/en/) ◥ Australian PHC Research Institute (www.anu.edu.au/aphcri/) ◥ Department of Health – Primary Care (UK) (www.dh.gov.uk/en/index.htm), National ◥ Primary Care Research and Development Centre (www.npcrdc.ac.uk/About_NPCRDC.cfm) ◥ The European Observatory on Health Systems and Policies (www.euro.who.int/observatory) ◥ Provincial health quality councils (e.g. for Ontario http://www.ohqc.ca/en/index.php) ◥ Health Quality Council of Canada (http://www.healthcouncilcanada.ca/en/) ◥ NIH (http://health.nih.gov/) ◥ Institute for Health Improvement (http://www.ihi.org/ihi)
3.2.2 Databases
The following databases will be used to identify published relevant studies:
◥ Cochrane library, specifically the NHS Economic Evaluation Database (NHSEED) ◥ OVID Medline ◥ Econlit
Canadian HealtH ServiCeS reSearCH Foundation 62
3.3 Search strategy
Cochrane library
A broader search was conducted using the Cochrane library in order to ensure large capture. The MeSH trees were used, specifically the exploded term “PHC.” Selected databases: Economic Evaluations
Search Strategy #identified studies
1 (“PHC” or “primary care” or “family practice” or “general practice” or “family medicine” or “general practitioner”) and (mutlidisciplin* or nurse* or pharmacist* or counsel* or psychotherap* or “allied health”) restrict to years 1990–2010
571
ovid Medline(r)1950 to august Week 1 2010
Search Strategy #identified studies
1 PHC/ 42,6152 (Primary care or family practice or general practice or family medicine or general
practitioner or PHC).mp.143,747
3 1 or 2 143,7474 multidisciplin$.mp. 28,2585 nurse$.mp. 222,2316 pharmacist$.mp. 17,8447 counsel$.mp. 17,8448 pssycotherap$.mp. 58,0309 Allied Health Personnel/ 9,24810 social work$.mp. 17,86311 or/4-10 401,71412 3 and 11 19,07513 Economics, Dental/ or Economics, Nursing/ or Economics/ or Economics, Medical/ or
Economics, Hospital/ or Economics, Pharmaceutical/50,282
14 exp “costs and cost analysis”/ 151,68215 (economic$ or cost or costs or costly or costing or price or prices or pricing or
pharmacoeconomic$).ti,ab.317,081
16 (expenditure$ not energy).ti,ab. 13,55017 (value adjl money).ti,ab. 1518 Budget&.ti,ab. 13,78719 or/13-18 426,270
20 ((energy or oxygen) adj cost).ti,ab. 2,21321 (metabolic adj cost).ti,ab. 56222 ((energy or oxygen) adj expenditure).ti,ab. 12,48423 or/20-22 14,67024 19 not 23 422,91525 letter.pt. 686,35226 editorial.pt. 260,53827 Historical article.pt. 266,86228 or/25-27 1,201,751
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 63
Search Strategy #identified studies
29 12 and 24 2,37729 29 not 28 2,33931 Animals/ 4,626,40032 Humans/ 11,364,78633 32 not 31 10,172,71434 30 and 33 2,05135 limit 34 to yr=”1990 -Current” 1,850
econlit
Restricted to years 1990 to 2011
Search Strategy #identified studies
1 KW=(“PHC” or “primary care” or “family practice” or “general practice” or “family medicine” or “general practitioner”) and (mutlidisciplin* or nurse* or pharmacist* or counsel* or psychotherap* or “allied health”)
24
3.3.1 Screening
Total number of articles for screening = 2,445
Documents identified by the preliminary grey literature and database search will be screened twice for potential relevance based on title and a rapid content scan through the grey literature and title and abstract scan through the database articles. Two reviewers (TD and LZ) will each screen titles and abstracts of all identified articles separately. All articles identified by each reviewer will be included for the second screening process. For the second screening process, documents and articles that are identified as being potentially relevant to the study will be retrieved for confirmation of relevance and, if eligible, for data abstraction. Discordance will be resolved through a consensus process between the two reviewers. If there is lack of consensus, a third person (DC) will be used to resolve any discordance in selected included studies at the end of the second screening process. For the purposes of the final report to CHSRF, only economic evaluations looking at the cost effectiveness of including a pharmacist within a PHC setting, specifically within a family or general practice, at second screening, will be included for quality assessment and data extraction. Final recommendations will be made in the context of including pharmacist(s) within PHC.
3.3.2 Assessment of methodological quality of individual studies
Those studies that are identified as relevant after the second screening process will undergo a methodological quality assessment. The methodological quality of included studies will be evaluated using the CHEC list, consisting of 19 items for assessment of the quality of economic evaluations.109 The list was developed through a Delphi procedure involving 23 international experts in the field of health economics. Data will be abstracted from only those studies rated moderate-to-high quality. Moderate quality would be rated as 50%–75% met criteria and high quality would be rated as >75% met criteria. High-quality studies must meet criteria #1 through #15. Quality assessment will be performed by two reviewers and discordance of ratings will be resolved via consensus. Any rating disagreements will be resolved by the third person.
Canadian HealtH ServiCeS reSearCH Foundation 64
3.3.3 Data abstraction and data management
Data extraction of moderate-to-high quality studies will be undertaken by one reviewer and checked by a second reviewer. A standard data extraction form will be used to record information on pre-determined items for each included study. The data extraction form will allow for the recording of information pertaining to the evaluation of methodological quality elements used by Polisena et al. (2009).178 Abstracted data will include information pertaining to the research question posed, the study’s perspective, the methodology used, the comparators, and the quality of evidence, the costs outcomes considered, discounting, marginal analysis and sensitivity analysis.
4.0 Results reporting4.1 Identified studiesA flow diagram will summarize the flow of information through the different phases of the systematic review as outlined in the PRISMA Statement.179
4.2 Data synthesisFor each included economic evaluation study, information on outcomes, demographics, settings and study quality will be summarized in text and tables/figures. Also, evidence summaries will be used to qualitatively synthesize the evidence for each intervention.
4.3 RecommendationsThe results of the systematic review of evaluations will provide narrative information on the cost effectiveness of multidisciplinary PHC teams and provide an evidence base for adoption of the intervention in primary care in Canada.
APPENDIX F: QUALITY ASSESSMENT CHECKLIST AND QUALITY ASSESSMENT RESULTSitem Yes no
1. Is the study population clearly described?2. Are competing alternatives clearly described?3. Is a well-defined research question posed in answerable form?4. Is the economic study design appropriate to the stated objective?5. Is the chosen time horizon appropriate to include relevant costs and consequences?6. Is the actual perspective chosen appropriate?7. Are all important and relevant costs for each alternative identified?8. Are all costs measured appropriately in physical units?9. Are costs valued appropriately?10. Are all important and relevant outcomes for each alternative identified?11. Are all outcomes measured appropriately?12. Are outcomes valued appropriately?13. Is an incremental analysis of costs and outcomes of alternatives performed?14. Are all future costs and outcomes discounted appropriately?15. Are all important variables, whose values are uncertain, appropriately subjected to sensitivity analysis?
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 65
16. Do the conclusions follow from the data reported?17. Does the study discuss the generalizability of the results to other settings?18. Does the article indicate that there is no potential conflict of interest of study researcher(s) and funder(s)?19. Are ethical and distributional issues discussed appropriately?
Source: Evers S, Goossens M, Vet H, van Tulder M, Ament A: Criteria list for assessment of methodological quality of economic evaluations: Consensus on Health Economic Criteria. International Journal of Technology Assessment in Healthcare 2005, 21(2):240-245
Quality assessment Criteria % studies that meet criteria (n=33)
1. Is the study population clearly described? 42%
2. Are competing alternatives clearly described? 39%
3. Is a well-defined research question posed in answerable form? 33%
4. Is the economic study design appropriate to the stated objective? 36%
5. Is the chosen time horizon appropriate to include relevant costs and consequences?
39%
6. Is the actual perspective chosen appropriate? 12%
7. Are all important and relevant costs for each alternative identified? 24%
8. Are all costs measured appropriately in physical units? 61%
9. Are costs valued appropriately? 33%
10. Are all important and relevant outcomes for each alternative identified? 18%
11. Are all outcomes measured appropriately? 39%
12. Are outcomes valued appropriately? 24%
13. Is an incremental analysis of costs and outcomes of alternatives performed? 3%
14. Are all future costs and outcomes discounted appropriately? 48%
15. Are all important variables, whose values are uncertain, appropriately subjected to sensitivity analysis?
6%
16. Do the conclusions follow from the data reported? 58%
17. Does the study discuss the generalizability of the results to other settings? 21%
18. Does the article indicate that there is no potential conflict of interest of study researcher(s) and funder(s)?
15%
19. Are ethical and distributional issues discussed appropriately? 9%
Canadian HealtH ServiCeS reSearCH Foundation 66
APPENDIX G: FLOW DIAGRAM SUMMARIZING THE FLOW OF INFORMATION THROUGH THE DIFFERENT PHASES OF THE SYSTEMATIC REVIEW.
Identification
Screening
Eligibility
Included
# of records identified through database searching (published
journal articles)2,445
# of additional records identified through other sources (grey literature)
6
# of records after duplicates removed1787
Keep only pharmacist related studies
# of records screened249
# of full-text documents assessed for eligibility
33
# of documents included in qualitative synthesis
8
# of records exluded215
# of full-text documents excluded, with reasons
25
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 67
APP
END
IX H
: IN
CLU
DED
STU
DIE
Sa
utho
r (Ye
ar)
title
res
earc
h Q
uest
ion(
s)S
ettin
g an
d P
opul
atio
nd
isea
se fo
cus
Stu
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esig
n
tim
e H
oriz
on
(tH
)
res
ults
Bore
nste
in (2
003)
115
Phys
icia
n-ph
arm
acist
co
man
agem
ent o
f hy
pert
ensio
n: a
rand
omiz
ed,
com
para
tive t
rial
Wha
t is t
he
effec
tiven
ess o
f co
man
agem
ent
by p
rim
ary
care
ph
ysic
ians
and
ph
arm
acist
s co
mpa
red
to u
sual
ca
re in
redu
cing
bl
ood
pres
sure
in
pat
ient
s with
un
cont
rolle
d hy
pert
ensio
n?
US
Patie
nts
with
capi
tate
d he
alth
insu
ranc
e fr
om tw
o m
ain
med
ical
pra
ctic
es
of g
ener
al
inte
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s and
in
tern
al m
edic
ine
subs
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alist
s
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ando
miz
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cont
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ial.
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nts w
ith
unco
ntro
lled
hype
rten
sion
rand
omiz
ed
to e
ither
usu
al
care
(UC
) or
a ph
ysic
ian-
phar
mac
ist c
o m
anag
emen
t gr
oup
(PPC
M)
TH: 1
yea
r
Clin
ical
out
com
es:
Base
line-
12 m
os --
SBP
redu
ctio
n in
PPC
M v
s usu
al
care
gro
up =
diff
eren
ce o
f 11
mg
HG
(p<0
.01)
. D
BP re
duct
ion
in P
PCM
vs u
sual
car
e gr
oup
= di
ffere
nce
of -1
mm
HG
(p=0
.53)
. Blo
od p
ress
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goal
s ach
ieve
d in
15%
mor
e of
PPC
M v
s usu
al c
are
patie
nts (
p=0.
02).
Econ
omic
out
com
es:
Aver
age
prov
ider
visi
t cos
ts/p
atie
nt fo
r PPC
M v
s us
ual c
are
(UC
) gro
up =
diff
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ce o
f $35
mor
e in
usu
al c
are
grou
p. D
iffer
ence
resu
lted
from
a
redu
ctio
n in
num
ber o
f visi
ts to
pri
mar
y ca
re
phys
icia
n in
PPC
M p
atie
nts (
3.4
vs 6
.6 v
isits
, p<
0.01
). M
ore
tota
l pro
vide
r visi
ts (p
hysic
ian
and
phar
mac
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n PP
CM
vs U
C (8
.0 v
s 6.6
, p=0
.06)
. G
reat
er in
crea
se in
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g co
sts f
rom
bas
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vs U
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($11
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vs $
4.25
, p=0
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Fors
trom
(199
0)11
6Eff
ect o
f a c
linic
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mac
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rogr
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O
fam
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Wha
t is t
he
impa
ct o
f a c
linic
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phar
mac
y se
rvic
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the
cost
of
antih
yper
tens
ive
drug
ther
apy
in
an H
MO
fam
ily
prac
tice
clin
ic?
US
(Sea
ttle,
Was
hing
ton)
G
roup
Hea
lth
Coo
pera
tive
of
Puge
t Sou
nd
fam
ily p
ract
ice
clin
ic w
ith fi
ve
phys
icia
ns a
nd
5,50
0 pa
tient
s
Hyp
erte
nsio
nN
on-e
quiv
alen
t co
ntro
l gro
up
desig
n. N
o di
rect
pat
ient
in
terv
entio
n by
ph
arm
acist
s -
patie
nts u
naw
are
of st
udy.
dura
tion
of th
e stu
dy an
d fo
llow
up
= 6
mon
ths
Econ
omic
out
com
es:
Aver
age
daily
dru
g co
st (A
DD
C) s
igni
fican
tly
grea
ter i
n in
terv
entio
n gr
oup
vs c
ontr
ol a
t bas
elin
e. A
t 6 m
os, A
DD
C d
ecre
ased
in in
terv
entio
n gr
oup
whi
le in
crea
sed
in c
ontr
ol g
roup
. At e
nd o
f 6 m
os,
diffe
renc
e in
AD
DC
bet
wee
n in
terv
entio
n an
d co
ntro
l gro
up n
o lo
nger
sign
ifica
nt. A
DD
C fo
r in
terv
entio
n gr
oup
redu
ced
by $
0.56
per
pat
ient
-da
y (1
6.8%
) ove
r 6 m
onth
s. A
nnua
lized
savi
ngs o
f $2
0.61
per
pat
ient
per
yea
r.
Canadian HealtH ServiCeS reSearCH Foundation 68
aut
hor (
Year
)ti
tler
esea
rch
Que
stio
n(s)
Set
ting
and
Pop
ulat
ion
dis
ease
focu
sS
tudy
des
ign
tim
e H
oriz
on (t
H)
res
ults
Isse
tts.
(200
3)11
1C
linic
al a
nd
econ
omic
out
com
es
of m
edic
atio
n th
erap
y m
anag
emen
t ser
vice
s: Th
e M
inne
sota
ex
peri
ence
1. W
hat a
re th
e clin
ical
eff
ects
ass
ocia
ted
with
the
prov
ision
of m
edic
atio
n th
erap
y m
anag
emen
t (M
TM) s
ervi
ces
2. W
hat i
s the
pe
rcen
tage
of p
atie
nts
achi
evin
g H
ealth
care
Ef
fect
iven
ess D
ata
and
Info
rmat
ion
Set
(HED
IS) g
oals
for
hype
rten
sion
and
hy
perl
ipid
emia
in
the
MTM
ser
vice
s in
terv
entio
n gr
oup
com
pare
d to
the
cont
rol
grou
p
3. W
hat a
re th
e to
tal
heal
th e
xpen
ditu
res f
or
the
year
bef
ore
and
after
re
ceiv
ing
MTM
serv
ices
? U
S (M
inne
sota
)
US
(Min
neso
ta)
Blue
cros
s Bl
uesh
ield
hea
lth
plan
ben
efici
arie
s w
ith o
ne o
r m
ore
of 1
2 st
udy
med
ical
co
nditi
ons
Hyp
erte
nsio
n
Hyp
erlip
idem
ia
Pros
pect
ive
Befo
re a
nd
after
- hi
stor
ical
con
trol
C
ost a
naly
sis a
nd c
linic
al
outc
omes
(hyp
erte
nsio
n/
hype
rlipi
dem
ia)
Q
uasi-
cos
t-be
nefit
ana
lysis
Re
turn
on
inve
stm
ent (
ROI)
TH: 6
mon
ths
Clin
ical
out
com
es:
4% o
f pat
ient
s’ go
als o
f the
rapy
wer
e be
ing
met
from
bas
elin
e to
end
of s
tudy
.
Hyp
erte
nsio
n:
Sign
ifica
nt, 1
2% m
ore
patie
nts i
n in
terv
entio
n gr
oup
met
HED
IS c
riter
ia
vs c
ompa
riso
n gr
oup.
Cho
lest
erol
: Si
gnifi
cant
, 22%
mor
e pa
tient
s in
inte
rven
tion
grou
p m
et H
EDIS
crit
eria
vs
com
pari
son
grou
p.
Econ
omic
out
com
es:
Dec
reas
e in
ann
ual h
ealth
exp
endi
ture
s pe
r per
son
per y
ear a
mon
g 18
6 M
TM
inte
rven
tion
grou
p pa
tient
s - a
redu
ctio
n of
31.
5% fr
om p
re-in
terv
entio
n to
pos
t-in
terv
entio
n (p
<0.0
01).
Dec
reas
e of
57.
9%
in fa
cilit
ies c
laim
s exp
endi
ture
s and
de
crea
se o
f 11.
1% fo
r pro
fess
iona
l cla
ims
in in
terv
entio
n gr
oup.
Dru
g ex
pend
iture
s in
inte
rven
tion
grou
p in
crea
sed
by 1
9.7%
. Re
duct
ion
in to
tal e
xpen
ditu
res f
or
inte
rven
tion
grou
p =
$3,6
78 p
er p
erso
n pe
r yea
r. RO
I = $
12.1
5 pe
r $1
in M
TM
cost
Mal
one
(200
0)11
2A
n ec
onom
ic a
naly
sis
of a
rand
omiz
ed,
cont
rolle
d,
mul
ticen
ter s
tudy
of
clin
ical
pha
rmac
ist
inte
rven
tions
for
high
-risk
vet
eran
s: th
e IM
PRO
VE
stud
y
Wha
t is e
cono
mic
and
hu
man
istic
impa
ct o
f cl
inic
al p
harm
acis
ts in
an
am
bula
tory
, hig
h-ri
sk p
opul
atio
n?
US
Nin
e Vet
eran
s A
ffairs
med
ical
ce
ntre
s and
th
eir p
atie
nts
iden
tified
as h
igh
risk
to e
xper
ienc
e a
med
icat
ion-
rela
ted
prob
lem
Non
e sp
ecifi
ed
Pros
pect
ive,
mul
tisite
, ra
ndom
ized
con
trol
led
tria
l TH
: one
yea
r bef
ore,
one
year
aft
er
Res
ourc
e us
e:
Sign
ifica
ntly
mor
e pr
ovid
er v
isits
in
inte
rven
tion
grou
p. S
igni
fican
tly m
ore
lab
test
s in
usua
l car
e gr
oup
com
pare
d to
in
terv
entio
n.
Econ
omic
: M
ean
annu
al d
rug
cost
s not
sign
ifica
ntly
di
ffere
nt (p
=0.0
7). M
edia
n la
b co
sts h
ighe
r in
con
trol
gro
up v
s int
erve
ntio
n gr
oup
(p=0
.05)
. Hos
pita
l cos
ts n
ot si
gnifi
cant
ly
diffe
rent
bet
wee
n in
terv
entio
n an
d co
ntro
l gr
oup
(p=0
.21)
. No
signi
fican
t diff
eren
ce
for a
ll co
sts c
ombi
ned
(p=0
.06)
.
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 69
aut
hor (
Year
)ti
tler
esea
rch
Que
stio
n(s)
Set
ting
and
Pop
ulat
ion
dis
ease
focu
sS
tudy
des
ign
tim
e H
oriz
on (t
H)
res
ults
Mon
te
(200
9)11
3C
linic
al a
nd e
cono
mic
im
pact
of a
dia
bete
s cl
inic
al p
harm
acy
serv
ice
prog
ram
in
a u
nive
rsity
and
pr
imar
y ca
re-b
ased
co
llabo
ratio
n m
odel
Wha
t is t
he im
pact
of
clin
ical
pha
rmac
y se
rvic
es (C
PS) i
n pa
tient
s with
type
2
diab
etes
?
US
Regi
onal
pr
imar
y ca
re
grou
p in
Buff
alo,
N
Y\Pa
tient
s with
ty
pe 2
dia
bete
s id
entifi
ed b
y FP
, ref
erre
d to
Med
Sens
e pr
ogra
m.
Dia
bete
sLo
ngitu
dina
l pre
-pos
t coh
ort
stud
y. TH
: one
yea
rC
linic
al o
utco
mes
: A
t 6 m
os, i
mpr
ovem
ents
seen
in e
very
m
etab
olic
par
amet
er, e
xcep
t HD
L.
Hem
oglo
bin
A1C
dec
reas
ed b
y 1.
1%
(p<0
.000
1), F
PG d
ecre
ased
by
39 m
g/dL
(P
=-0.
003)
. LD
L, T
G, B
P, an
d ov
erw
eigh
t/ob
esity
redu
ced
but n
ot si
gnifi
cant
ly fr
om
base
line.
At 1
2 m
os, m
etab
olic
par
amet
ers
rela
tivel
y co
nsta
nt.
Econ
omic
out
com
es:
Mea
n co
sts p
er p
atie
nt a
t 6 a
nd 1
2 m
os
inte
rval
s pos
t-in
terv
entio
n de
crea
sed
for c
ardi
ovas
cula
r-re
late
d m
edic
al c
osts
by
$11
2 (p
=0.2
23) a
nd $
295
(p=0
.007
). N
on-c
ardi
ovas
cula
r rel
ated
cos
ts m
odes
tly
incr
ease
d by
$53
and
$15
at 6
and
12
mos
re
spec
tivel
y (n
on-s
igni
fican
t diff
eren
ces)
. C
osts
of m
edic
al c
are
decr
ease
d at
6 m
os
by $
73 (p
=0.7
99) a
nd a
t 12
mos
by
$331
(p
=0.2
54).
Med
icat
ion
cost
s inc
reas
ed a
t 6
and
12 m
os, b
ut n
ot st
atist
ical
ly. T
otal
di
rect
med
ical
cos
ts re
duce
d by
$84
and
by
$21
6 at
6 a
nd 1
2 m
os (n
on-s
igni
fican
t di
ffere
nces
)
Rag
ucci
(2
005)
114
Effec
tiven
ess
of p
harm
acist
-ad
min
ister
ed d
iabe
tes
mel
litus
edu
catio
n an
d m
anag
emen
t ser
vice
s
Wha
t is t
he e
ffect
iven
ess
of p
harm
acist
-ad
min
ister
ed d
iabe
tes
mel
litus
edu
catio
n an
d m
anag
emen
t ser
vice
s on
sele
cted
dia
bete
s pe
rfor
man
ce m
easu
res?
Thre
e un
iver
sity-
base
d pr
imar
y ca
re c
linic
s and
th
eir p
atie
nts.
Dia
bete
sO
bser
vatio
nal s
tudy
C
ost a
void
ance
TH
: one
yea
r
Clin
ical
out
com
es:
Mor
e offi
ce v
isits
ass
ocia
ted
with
im
prov
ed A
1C va
lues
(OR=
1.31
, p<0
.05)
w
hen
com
pari
ng b
asel
ine
to e
nd o
f stu
dy.
Sign
ifica
nt im
prov
emen
t in
aver
age
bloo
d pr
essu
re (d
ecre
ase)
and
asp
irin
use
(in
crea
se) f
rom
bas
elin
e to
end
of s
tudy
. Th
erap
eutic
goa
ls fo
r A1C
valu
es a
nd L
DL
leve
ls m
et, b
ut n
ot fo
r blo
od p
ress
ure.
40%
of p
atie
nts r
each
ed A
1C g
oals
at 1
ye
ar c
ompa
red
to 1
2% a
t bas
elin
e (2
8%
abso
lute
impr
ovem
ent)
. 42%
reac
hed
LDL
goal
at 1
yea
r, bu
t non
-sig
nific
ant c
hang
e fr
om b
asel
ine.
Econ
omic
out
com
es:
Base
d on
est
imat
ed sa
ving
s of $
820
for
each
1%
dec
reas
e in
A1C
, cos
t avo
idan
ce
was
cal
cula
ted
as $
59,0
40.
aut
hor (
Year
)ti
tler
esea
rch
Que
stio
n(s)
Set
ting
and
Pop
ulat
ion
dis
ease
focu
sS
tudy
des
ign
tim
e H
oriz
on (t
H)
res
ults
Isse
tts.
(200
3)11
1C
linic
al a
nd
econ
omic
out
com
es
of m
edic
atio
n th
erap
y m
anag
emen
t ser
vice
s: Th
e M
inne
sota
ex
peri
ence
1. W
hat a
re th
e clin
ical
eff
ects
ass
ocia
ted
with
the
prov
ision
of m
edic
atio
n th
erap
y m
anag
emen
t (M
TM) s
ervi
ces
2. W
hat i
s the
pe
rcen
tage
of p
atie
nts
achi
evin
g H
ealth
care
Ef
fect
iven
ess D
ata
and
Info
rmat
ion
Set
(HED
IS) g
oals
for
hype
rten
sion
and
hy
perl
ipid
emia
in
the
MTM
ser
vice
s in
terv
entio
n gr
oup
com
pare
d to
the
cont
rol
grou
p
3. W
hat a
re th
e to
tal
heal
th e
xpen
ditu
res f
or
the
year
bef
ore
and
after
re
ceiv
ing
MTM
serv
ices
? U
S (M
inne
sota
)
US
(Min
neso
ta)
Blue
cros
s Bl
uesh
ield
hea
lth
plan
ben
efici
arie
s w
ith o
ne o
r m
ore
of 1
2 st
udy
med
ical
co
nditi
ons
Hyp
erte
nsio
n
Hyp
erlip
idem
ia
Pros
pect
ive
Befo
re a
nd
after
- hi
stor
ical
con
trol
C
ost a
naly
sis a
nd c
linic
al
outc
omes
(hyp
erte
nsio
n/
hype
rlipi
dem
ia)
Q
uasi-
cos
t-be
nefit
ana
lysis
Re
turn
on
inve
stm
ent (
ROI)
TH: 6
mon
ths
Clin
ical
out
com
es:
4% o
f pat
ient
s’ go
als o
f the
rapy
wer
e be
ing
met
from
bas
elin
e to
end
of s
tudy
.
Hyp
erte
nsio
n:
Sign
ifica
nt, 1
2% m
ore
patie
nts i
n in
terv
entio
n gr
oup
met
HED
IS c
riter
ia
vs c
ompa
riso
n gr
oup.
Cho
lest
erol
: Si
gnifi
cant
, 22%
mor
e pa
tient
s in
inte
rven
tion
grou
p m
et H
EDIS
crit
eria
vs
com
pari
son
grou
p.
Econ
omic
out
com
es:
Dec
reas
e in
ann
ual h
ealth
exp
endi
ture
s pe
r per
son
per y
ear a
mon
g 18
6 M
TM
inte
rven
tion
grou
p pa
tient
s - a
redu
ctio
n of
31.
5% fr
om p
re-in
terv
entio
n to
pos
t-in
terv
entio
n (p
<0.0
01).
Dec
reas
e of
57.
9%
in fa
cilit
ies c
laim
s exp
endi
ture
s and
de
crea
se o
f 11.
1% fo
r pro
fess
iona
l cla
ims
in in
terv
entio
n gr
oup.
Dru
g ex
pend
iture
s in
inte
rven
tion
grou
p in
crea
sed
by 1
9.7%
. Re
duct
ion
in to
tal e
xpen
ditu
res f
or
inte
rven
tion
grou
p =
$3,6
78 p
er p
erso
n pe
r yea
r. RO
I = $
12.1
5 pe
r $1
in M
TM
cost
Mal
one
(200
0)11
2A
n ec
onom
ic a
naly
sis
of a
rand
omiz
ed,
cont
rolle
d,
mul
ticen
ter s
tudy
of
clin
ical
pha
rmac
ist
inte
rven
tions
for
high
-risk
vet
eran
s: th
e IM
PRO
VE
stud
y
Wha
t is e
cono
mic
and
hu
man
istic
impa
ct o
f cl
inic
al p
harm
acis
ts in
an
am
bula
tory
, hig
h-ri
sk p
opul
atio
n?
US
Nin
e Vet
eran
s A
ffairs
med
ical
ce
ntre
s and
th
eir p
atie
nts
iden
tified
as h
igh
risk
to e
xper
ienc
e a
med
icat
ion-
rela
ted
prob
lem
Non
e sp
ecifi
ed
Pros
pect
ive,
mul
tisite
, ra
ndom
ized
con
trol
led
tria
l TH
: one
yea
r bef
ore,
one
year
aft
er
Res
ourc
e us
e:
Sign
ifica
ntly
mor
e pr
ovid
er v
isits
in
inte
rven
tion
grou
p. S
igni
fican
tly m
ore
lab
test
s in
usua
l car
e gr
oup
com
pare
d to
in
terv
entio
n.
Econ
omic
: M
ean
annu
al d
rug
cost
s not
sign
ifica
ntly
di
ffere
nt (p
=0.0
7). M
edia
n la
b co
sts h
ighe
r in
con
trol
gro
up v
s int
erve
ntio
n gr
oup
(p=0
.05)
. Hos
pita
l cos
ts n
ot si
gnifi
cant
ly
diffe
rent
bet
wee
n in
terv
entio
n an
d co
ntro
l gr
oup
(p=0
.21)
. No
signi
fican
t diff
eren
ce
for a
ll co
sts c
ombi
ned
(p=0
.06)
.
Canadian HealtH ServiCeS reSearCH Foundation 70
aut
hor (
Year
)ti
tler
esea
rch
Que
stio
n(s)
Set
ting
and
Pop
ulat
ion
dis
ease
focu
sS
tudy
des
ign
tim
e H
oriz
on (t
H)
res
ults
Ram
alho
(2
010)
110
Med
icat
ion
ther
apy
man
agem
ent:
10
year
s of e
xper
ienc
e in
a la
rge
inte
grat
ed
heal
thca
re sy
stem
Wha
t are
the
clin
ical
, ec
onom
ic, a
nd
hum
anist
ic o
utco
mes
of
10
year
s of d
eliv
erin
g m
edic
atio
n th
erap
y m
anag
emen
t (M
TM)
serv
ices
to p
atie
nts i
n a
heal
thca
re d
eliv
ery
syst
em?
US
(Min
neso
ta)
Patie
nts a
ged
21 a
nd o
ver
who
eith
er m
et
heal
thca
re p
ayer
’s re
imbu
rsem
ent
crite
ria
for
inte
rven
tion
or p
aid
for
inte
rven
tion
out
of p
ocke
t. U
nder
Fa
irvi
ew H
ealth
Se
rvic
es.
Dia
bete
sRe
tros
pect
ive
coho
rt
Cos
t-av
oida
nce
(sav
ings
) an
alys
is TH
: 10
year
s
Hea
lth o
utco
mes
: 80
% o
f dru
g th
erap
y pr
oble
ms i
dent
ified
in
MTM
pro
gram
wer
e re
solv
ed w
ith
dire
ct in
volv
emen
t of p
hysic
ians
. 55%
of
con
ditio
ns im
prov
ed, 2
3% w
ere
unch
ange
d, a
nd 2
2% w
orse
ned
duri
ng
MTM
serv
ices
. Am
ong
Dia
bete
s pat
ient
s-
abso
lute
cha
nge
of 2
5.4%
; mor
e pa
tient
s ac
hiev
ed D
5 go
als f
rom
bas
elin
e to
end
of
stud
y
Econ
omic
out
com
es:
MTM
cos
t sav
ings
= $
86.4
5 pe
r enc
ount
er.
Aver
age
cost
of M
TM v
isit w
as $
67.0
0 in
la
st 3
mon
ths o
f 200
8. R
OI =
$1.
29 p
er $
1 in
MTM
cos
ts.
Sello
rs
(200
3)11
7A
rand
omiz
ed
cont
rolle
d tr
ial
of a
pha
rmac
ist
cons
ulta
tion
prog
ram
fo
r FPs
and
thei
r el
derly
pat
ient
.
Can
an
inte
rven
tion
by a
spec
ially
trai
ned
phar
mac
ist re
duce
th
e nu
mbe
r of d
aily
m
edic
atio
n un
its ta
ken
by e
lder
ly p
atie
nts,
as w
ell a
s cos
ts a
nd
heal
thca
re u
se?
Can
ada
Twen
ty-f
our
fam
ily p
ract
ices
in
Ont
ario
. Pa
tient
s age
d 65
an
d ol
der t
akin
g fiv
e or
mor
e m
edic
atio
ns, a
nd
who
had
visi
ted
thei
r phy
sicia
n w
ithin
the
past
12
mon
ths
Non
e sp
ecifi
edR
ando
miz
ed c
ontr
olle
d tr
ial
Cos
ting
Hea
lthca
re u
sage
TH
: five
mon
ths
Med
icat
ion
adhe
renc
e an
d qu
ality
of l
ife:
Inte
rven
tion
was
sim
ilar t
o co
ntro
l in
mea
n nu
mbe
r of d
aily
med
icat
ion
units
us
ed (p
=0.5
0) a
nd n
umbe
r of m
edic
atio
ns
take
n pe
r day
(p=0
.87)
. Afte
r five
mon
ths,
phys
icia
ns su
cces
sful
ly im
plem
ente
d 46
.4%
of r
ecom
men
datio
ns a
nd p
artia
lly
fulfi
lled
9.3%
of r
ecom
men
datio
ns. N
o sig
nific
ant d
iffer
ence
in Q
OL
scor
es
betw
een
inte
rven
tion
and
cont
rol g
roup
.
Econ
omic
out
com
es:
Inte
rven
tion
Tota
l cos
t of i
nter
vent
ion
vs c
ontr
ol: $
5.01
vs $
4.82
, p=0
.72,
and
in
OD
BP c
osts
: $3.
57 v
s $3.
76, p
= 0.
78.
Incl
udin
g co
st o
f pha
rmac
ist in
terv
entio
n an
d on
ly d
rug-
rela
ted
hosp
ital s
tays
, mea
n co
st o
f hea
lthca
re re
sour
ces p
er p
erso
n =
$128
1.27
in in
terv
entio
n gr
oup
vs
$129
9.37
in c
ontr
ol g
roup
(p=0
.45)
.
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 71
APPENDIX I: ELDERLY POPULATION PROjECTIONS FROM 2010 TO 2036 (NUMBER OF INDIVIDUALS ×1000)
Province/Year 2010 2011 2012 2013 2014 2015 2016 2021 2026 2031 2036
Newfoundland and Labrador
77.9 81.2 85.1 88.6 92.4 96.0 99.8 118.5 135.2 148.5 154.3
Prince Edward Island
22.1 23.0 24.2 24.2 26.1 27.1 28.2 33.1 38.5 43.2 45.5
Nova Scotia 151.4 155.8 161.9 168.2 173.6 179.2 184.7 214.9 247.6 275.4 285.6
New Brunswick 119.6 123.2 128.6 133.8 139.1 143.9 149.0 175.6 202.3 224.5 232.9
Quebec 1209.7 1,251.5 1,297.6 1,342.2 1,388.1 1,434.2 1,481.5 1,739.9 2,20.7 2,256.0 2,357.3
Ontario 1,836.1 1,890.6 1,968.4 2,042.6 2,113.3 2,184.6 2,257.8 2,676.1 3,177.5 3,694.4 4,040.6
Manitoba 171.6 175.3 180.9 186.2 191.3 196.8 202.6 236.6 276.0 311.7 332.7
Saskatchewan 153.5 156.1 159.9 164.0 168.0 172.5 177.2 209.7 247.6 283.0 3322.7
Alberta 399.0 414.0 434.2 455.0 475.1 496.2 518.2 653.0 810.6 958.6 1,070.3
British Colombia 675.6 696.4 726.7 756.4 785.4 816.2 846.9 1,18.6 1,209.1 1,394.4 1532.8
Yukon 2.8 3.1 3.5 3.7 4.1 4.3 4.8 6.3 8.0 9.3 10.0
NWT 2.4 2.6 3.0 3.2 3.5 3.8 3.9 5.6 7.4 8.7 9.5
Nunavut 1.1 1.1 1.2 1.3 1.4 1.6. 1.7 2.0 2.7 3.1 3.4
Canada 4,822.8 4.973.9 5,175.2 5,370.4 5,561.4 5.756.4 5,956.3 7,090.8 8,383.2 9,610.8 10,378.7
APPENDIX j: POPULATION VACCINATION RATES FOR ELDERLY POPULATION IN 2007
Province/Year Pct
Newfoundland and Labrador 48%
Prince Edward Island 62%
Nova Scotia 71%
New Brunswick 57%
Quebec 70%
Ontario 57%
Manitoba 70%
Saskatchewan 60%
61% 56%
British Colombia 61%
Yukon 74%
NWT 71%
Nunavut 85%
Canada 64%
aut
hor (
Year
)ti
tler
esea
rch
Que
stio
n(s)
Set
ting
and
Pop
ulat
ion
dis
ease
focu
sS
tudy
des
ign
tim
e H
oriz
on (t
H)
res
ults
Ram
alho
(2
010)
110
Med
icat
ion
ther
apy
man
agem
ent:
10
year
s of e
xper
ienc
e in
a la
rge
inte
grat
ed
heal
thca
re sy
stem
Wha
t are
the
clin
ical
, ec
onom
ic, a
nd
hum
anist
ic o
utco
mes
of
10
year
s of d
eliv
erin
g m
edic
atio
n th
erap
y m
anag
emen
t (M
TM)
serv
ices
to p
atie
nts i
n a
heal
thca
re d
eliv
ery
syst
em?
US
(Min
neso
ta)
Patie
nts a
ged
21 a
nd o
ver
who
eith
er m
et
heal
thca
re p
ayer
’s re
imbu
rsem
ent
crite
ria
for
inte
rven
tion
or p
aid
for
inte
rven
tion
out
of p
ocke
t. U
nder
Fa
irvi
ew H
ealth
Se
rvic
es.
Dia
bete
sRe
tros
pect
ive
coho
rt
Cos
t-av
oida
nce
(sav
ings
) an
alys
is TH
: 10
year
s
Hea
lth o
utco
mes
: 80
% o
f dru
g th
erap
y pr
oble
ms i
dent
ified
in
MTM
pro
gram
wer
e re
solv
ed w
ith
dire
ct in
volv
emen
t of p
hysic
ians
. 55%
of
con
ditio
ns im
prov
ed, 2
3% w
ere
unch
ange
d, a
nd 2
2% w
orse
ned
duri
ng
MTM
serv
ices
. Am
ong
Dia
bete
s pat
ient
s-
abso
lute
cha
nge
of 2
5.4%
; mor
e pa
tient
s ac
hiev
ed D
5 go
als f
rom
bas
elin
e to
end
of
stud
y
Econ
omic
out
com
es:
MTM
cos
t sav
ings
= $
86.4
5 pe
r enc
ount
er.
Aver
age
cost
of M
TM v
isit w
as $
67.0
0 in
la
st 3
mon
ths o
f 200
8. R
OI =
$1.
29 p
er $
1 in
MTM
cos
ts.
Sello
rs
(200
3)11
7A
rand
omiz
ed
cont
rolle
d tr
ial
of a
pha
rmac
ist
cons
ulta
tion
prog
ram
fo
r FPs
and
thei
r el
derly
pat
ient
.
Can
an
inte
rven
tion
by a
spec
ially
trai
ned
phar
mac
ist re
duce
th
e nu
mbe
r of d
aily
m
edic
atio
n un
its ta
ken
by e
lder
ly p
atie
nts,
as w
ell a
s cos
ts a
nd
heal
thca
re u
se?
Can
ada
Twen
ty-f
our
fam
ily p
ract
ices
in
Ont
ario
. Pa
tient
s age
d 65
an
d ol
der t
akin
g fiv
e or
mor
e m
edic
atio
ns, a
nd
who
had
visi
ted
thei
r phy
sicia
n w
ithin
the
past
12
mon
ths
Non
e sp
ecifi
edR
ando
miz
ed c
ontr
olle
d tr
ial
Cos
ting
Hea
lthca
re u
sage
TH
: five
mon
ths
Med
icat
ion
adhe
renc
e an
d qu
ality
of l
ife:
Inte
rven
tion
was
sim
ilar t
o co
ntro
l in
mea
n nu
mbe
r of d
aily
med
icat
ion
units
us
ed (p
=0.5
0) a
nd n
umbe
r of m
edic
atio
ns
take
n pe
r day
(p=0
.87)
. Afte
r five
mon
ths,
phys
icia
ns su
cces
sful
ly im
plem
ente
d 46
.4%
of r
ecom
men
datio
ns a
nd p
artia
lly
fulfi
lled
9.3%
of r
ecom
men
datio
ns. N
o sig
nific
ant d
iffer
ence
in Q
OL
scor
es
betw
een
inte
rven
tion
and
cont
rol g
roup
.
Econ
omic
out
com
es:
Inte
rven
tion
Tota
l cos
t of i
nter
vent
ion
vs c
ontr
ol: $
5.01
vs $
4.82
, p=0
.72,
and
in
OD
BP c
osts
: $3.
57 v
s $3.
76, p
= 0.
78.
Incl
udin
g co
st o
f pha
rmac
ist in
terv
entio
n an
d on
ly d
rug-
rela
ted
hosp
ital s
tays
, mea
n co
st o
f hea
lthca
re re
sour
ces p
er p
erso
n =
$128
1.27
in in
terv
entio
n gr
oup
vs
$129
9.37
in c
ontr
ol g
roup
(p=0
.45)
.
Canadian HealtH ServiCeS reSearCH Foundation 72
APPENDIX K: SIMULATION RESULTS BY PROVINCE: PROjECTED YEARS 2010 AND 2031
Projected Year 2010: target vaccination rate
66.5% 69.0% 74.0% 80.0%
alberta
EventsGP Visits 545 1,093 2,179 3,5211ED Visits 233 484 986 1,597Hosp. 182 389 755 1,218
CostsGP Visits 19,088 38,244 76,250 123,233ED Visits 51,168 106,448 216,831 351,238Hosp. 1,168,460 2,493,418 4,847,777 7,817,453
Total Cost 1,238,716 2,638,109 5,149,857 8,291,924
British Colombia
EventsGP Visits 923 1,850 3,689 5,962
ED Visits 394 819 1,669 2,703Hosp. 308 819 1,669 2,703
CostsGP Visits 32,320 64,755 129,109 208,663ED Visits 86,639 180,241 367,145 594,727Hosp. 1,978,475 4,22,938 8,208,416 13,236,769
Total Cost 2,097,434 4,466,934 8,704,669 14,040,159
Manitoba
EventsGP Visits 235 470 937 1,514ED Visits 100 208 424 687Hosp. 78 167 325 524
CostsGP Visits 8,209 16,448 32,7993 53,00ED Visits 22,006 45,780 93.254 151,059
Hosp. 502,526 1,072,357 2,084,090 3,362.093Total Cost 532,742 1,134,585 2,210,955 3566,151
new Brunswick
EventsGP Visits 163 328 653 1,055ED Visits 70 145 2995 479Hosp. 55 116 226 365
CostsGP Visits 5,721 11,464 22,856 36,939ED Visits 15,338 31,908 64,995 105,283Hosp. 350,245 747,401 1,453,118 2,343,277
Total Cost 371,304 790,772 1,540,969 2,485,499
newfoundland & labrador
EventsGP Visits 106 213 425 687ED Visits 45 94 192 312Hosp. 36 76 147 238
CostsGP Visits 3,272 7,467 14,887 24,060ED Visits 9,990 20,783 42,334 68,575Hosp. 228,844 486,810 946,471 1,526,265
Total Cost 241,844 515,059 1,003,691 1,618,899
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 73
Projected Year 2010: target vaccination rate
66.5% 69.0% 74.0% 80.0%
nova Scotia
EventsGP Visits 207 415 827 1,336ED Visits 88 184 374 606Hosp. 69 147 287 462
CostsGP Visits 7,243 14,511 28,933 46,761ED Visits 19,416 40,391 82,276 133,277Hosp. 443,371 946,124 1,839,482 2,966,322
Total Costs 470,029 1,001,027 1,950,691 3,156,359
nunavut
EventsGP Visits 2 3 6 10ED Visits 1 1 3 4Hosp. 1 1 2 3
CostsGP Visits 53 105 210 340ED Visits 141 293 598 968Hosp. 3,221 6,874 13,365 21,552
Total Costs 3,415 7,273 14,173 22,860
northwest territories
EventsGP Visits 3 7 13 21ED Visits 1 3 6 10Hosp. 1 2 5 7
CostsGP Visits 115 230 459 741ED Visits 308 640 1,304 2,113Hosp. 7,028 14,998 29,160 47,022
Total Costs 7,451 15,868 30,922 49,876
ontario
EventsGP Visits 2,510 5,028 10,025 16,203ED Visits 1,070 2,227 4,535 7,347Hosp. 838 1,788 3,476 5,605
CostsGP Visits 87,836 175,988 350,883 567,090ED Visits 235,462 489,846 997,802 1,616,310Hosp. 5,376,966 11,474,098 22,308,277 35,973,997
Total Costs 5,700,265 12,139,931 23,656,962 38,157,396
Prince edward island
EventsGP Visits 30 61 121 195ED Visits 13 27 55 88Hosp. 10 22 42 67
CostsGP Visits 1,057 2,118 4,223 6,826ED Visits 2.834 5,896 12,010 19,455Hosp. 64,719 138,107 268,511 432,997
Total Costs 68,611 146,121 285,744 459,277
Canadian HealtH ServiCeS reSearCH Foundation 74
Projected Year 2010: target vaccination rate
66.5% 69.0% 74.0% 80.0%
Quebec
EventsGP Visits 1,653 3,313, 6,605 10,675ED Visits 705 1,467 2,988 4,840Hosp. 552 1,178 2,290 3,693
CostsGP Visits 57,870 115,948 231,176 373,623ED Visits 155,132 322,731 657,394 1,064,893Hosp. 3,542,572 7,559,619 14,697,,632 23,701,183
Total Costs 3,755,574 7,998,298 15,586,202 25,139,699
Saskatchewan
EventsGP Visits 210 420 838 1,355ED Visits 89 186 379 614Hosp. 70 149 291 469
CostsGP Visits 7,343 14,713 29,334 47,409ED Visits 19,685 40,,9952 83,417 135,125Hosp. 449,520 959,247 1,864,997 3,007,466
Total Costs 476,548 1,014,912 1,977,748 3,190,001
Yukon
EventsGP Visits 4 8 15 25ED Visits 2 3 7 11Hosp. 1 3 5 9
CostsGP Visits 134 268 535 865ED Visits 359 474 1,522 2.465Hosp. 8,200 17,498 34,019 54,859
Total Costs 8,693 18,513 36,076 58,189
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 75
Projected Year 2031: target vaccination rate
66.5% 69.0% 74.0% 80.0%
alberta
EventsGP Visits 1,310 2,625 5,234 8,459ED Visits 559 1,162 2,368 3,836Hosp. 437 933 1,815 2,926
CostsGP Visits 45,858 91,881 183,191 296,069ED Visits 122,931 255,741 520,937 843.851Hosp. 2,807,233 5,990,453 11,646,814 18,718,479
Total Cost 2,975,022 6,338,074 12,350,942 12,921,398
British Colombia
EventsGP Visits 1,906 3,819 7,614 12,305
ED Visits 813 1,691 3,444 5,579Hosp. 636 1,358 2,640 4,257
CostsGP Visits 66,706 133,651 266,473 430,668ED Visits 178,818 372,007 757,767 1,227,484Hosp. 4,083,460 8,713,840 16,941,704 27,319,940
Total Cost 4,3228,985 9,219,498 17,965,944 28,978,092
Manitoba
EventsGP Visits 426 854 1,702 2.751ED Visits 182 378 770 1,247Hosp. 142 304 590 952
CostsGP Visits 14,911 29,876 59,576 96,270ED Visits 182 378 770 1,247
Hosp. 142 304 590 952Total Cost 967,688 2,060,899 4,016,053 6,477,676
new Brunswick
EventsGP Visits 307 615 1,226 19,81ED Visits 131 272 555 898Hosp. 102 219 425 685
CostsGP Visits 10,740 21,518 42,902 69,338ED Visits 28,790 59,8993 122,001 197,626Hosp. 657,442 1,402,938 2,727,634 4,398,542
Total Cost 696,972 1,484,350 2,892,537 4,667,506
newfoundland & labrador
EventsGP Visits 203 407 811 1,310ED Visits 87 180 367 594Hosp. 68 145 281 453
CostsGP Visits 7.10004 14,234 28,379 45,865ED Visits 19,044 39,618 80,700 130,724Hosp. 434.878 928,001 1,804,428 2,909,503
Total Cost 461,0226 981,853 1,913,327 3,086,0922
Canadian HealtH ServiCeS reSearCH Foundation 76
Projected Year 2031: target vaccination rate
66.5% 69.0% 74.0% 80.0%
nova Scotia
EventsGP Visits 376 754 1,504 2,430ED Visits 161 334 680 1,102Hosp. 126 268 521 841
CostsGP Visits 13,175 26,397 52,630 85,059ED Visits 35,175 26,397 52,630 85,059Hosp. 806,501 1.721,021 3,346,059 5,395,806
Total Costs 854,993 1,820,891 3,548,351 5,723,298
nunavut
EventsGP Visits 12 24 48 77ED Visits 5 11 21 35Hosp. 4 8 16 27
CostsGP Visits 416 834 1,663 2,687ED Visits 1,116 2,321 4,728 7,659Hosp. 25,478 54,368 105,703 170,456
Total Costs 27,010 57,523 112,09994 180,801
northwest territories
EventsGP Visits 4 8 17 27ED Visits 2 4 8 12Hosp. 1 3 6 9
CostsGP Visits 148 297 592 957ED Visits 398 827 1,685 4,398,542Hosp. 9,078 19,372 37,664 60,737
Total Costs 9,624 20,497 39,941 64,423
ontario
EventsGP Visits 5,050 10,117 20,172 32,601ED Visits 2,154 4,480 9,126 14,783Hosp. 1,686 3,597 6,994 11,278
CostsGP Visits 176,735 354,104 706,008 1,141,036ED Visits 473,771 985,614 2,007,668 3,252,162Hosp. 10,818,944 23,086,927 44,886,2280 72,382,948
Total Costs 11,469,450 24,426,645 47,599,956 76,776,147
Prince edward island
EventsGP Visits 59 118 236 381ED Visits 25 52 107 173Hosp. 20 42 82 132
CostsGP Visits 2,067 4,141 8,256 13,343ED Visits 5,540 11,525 23,476 38,029Hosp. 126,510 269,964 524,872 846,4001
Total Costs 134,117 285,630 556,604 897,772
tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 77
Projected Year 2031: target vaccination rate
66.5% 69.0% 74.0% 80.0%
Quebec
EventsGP Visits 3,084 6,178 12,318 19,908ED Visits 1,315 2,736 5,573 9,027Hosp. 1,029 2,197 4,271 6,887
CostsGP Visits 107,924 216,235 431,126 626,778ED Visits 289,310 601,869 1,225,991 1,985,946Hosp. 6,606,631 14,098,124 27,409,986 44,200,935
Total Costs 7,0030,865 14,916,228 29,067,103 46,883,659
Saskatchewan
EventsGP Visits 387 775 1,545 2,497ED Visits 165 343 699 1,132Hosp. 129 276 536 864
CostsGP Visits 13,538 27,125 54,082 87,406ED Visits 36,292 75,500 1,685 4,398,542Hosp. 828,757 1,768,515 3,438,398 5,544,710
Total Costs 878,588 1871,140 3,646,272 5,881,239
Yukon
EventsGP Visits 13 25 51 82ED Visits 5 11 23 37Hosp. 4 9 18 28
CostsGP Visits 445 891 1,777 2,872ED Visits 1,193 2,481 5,054 8,187Hosp. 227,235 58,117 112,993 182,211
Total Costs 28,827 61,490 119,824 193,270
Canadian HealtH ServiCeS reSearCH Foundation 78
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