The new forms of organization of healthcare services entail the development of new clinical practices that are grounded in collaboration. Despite recent advances in research on the subject of ...collaboration, there is still a need for a better understanding of collaborative processes and for conceptual tools to help healthcare professionals develop collaboration amongst themselves in complex systems. This study draws on D'Amour's structuration model of collaboration to analyze healthcare facilities offering perinatal services in four health regions in the province of Quebec. The objectives are to: 1) validate the indicators of the structuration model of collaboration; 2) evaluate interprofessional and interorganizational collaboration in four health regions; and 3) propose a typology of collaboration
A multiple-case research strategy was used. The cases were the healthcare facilities that offer perinatal services in four health regions in the province of Quebec (Canada). The data were collected through 33 semi-structured interviews with healthcare managers and professionals working in the four regions. Written material was also analyzed. The data were subjected to a "mixed" inductive-deductive analysis conducted in two main stages: an internal analysis of each case followed by a cross-sectional analysis of all the cases.
The collaboration indicators were shown to be valid, although some changes were made to three of them. Analysis of the data showed great variation in the level of collaboration between the cases and on each dimension. The results suggest a three-level typology of collaboration based on the ten indicators: active collaboration, developing collaboration and potential collaboration.
The model and the typology make it possible to analyze collaboration and identify areas for improvement. Researchers can use the indicators to determine the intensity of collaboration and link it to clinical outcomes. Professionals and administrators can use the model to perform a diagnostic of collaboration and implement interventions to intensify it.
People aged 65 years or more represent a growing group of emergency department users. We investigated whether characteristics of primary care (accessibility and continuity) are associated with ...emergency department use by elderly people in both urban and rural areas.
We conducted a cross-sectional study using information for a random sample of 95,173 people aged 65 years or more drawn from provincial administrative databases in Quebec for 2000 and 2001. We obtained data on the patients' age, sex, comorbidity, rate of emergency department use (number of days on which a visit was made to an emergency department per 1000 days at risk i.e., alive and not in hospital during the 2-year study period), use of hospital and ambulatory physician services, residence (urban v. rural), socioeconomic status, access (physician: population ratio, presence of primary physician) and continuity of primary care.
After adjusting for age, sex and comorbidity, we found that an increased rate of emergency department use was associated with lack of a primary physician (adjusted rate ratio RR 1.45, 95% confidence interval CI 1.41-1.49) and low or medium (v. high) levels of continuity of care with a primary physician (adjusted RR 1.46, 95% CI 1.44-1.48, and 1.27, 95% CI 1.25-1.29, respectively). Other significant predictors of increased use of emergency department services were residence in a rural area, low socioeconomic status and residence in a region with a higher physician:population ratio. Among the patients who had a primary physician, continuity of care had a stronger protective effect in urban than in rural areas.
Having a primary physician and greater continuity of care with this physician are factors associated with decreased emergency department use by elderly people, particularly those living in urban areas.
Cancer is the leading cause of death in Canada. Early cancer diagnosis could improve patients' prognosis and quality of life. This study aimed to analyze the factors influencing elapsed time between ...the first help-seeking trigger and cancer diagnosis with respect to the three most common and deadliest cancer types: lung, breast, and colorectal.
This paper presents the qualitative component of a larger project based on a sequential explanatory design. Twenty-two patients diagnosed were interviewed, between 2011 to 2013, in oncology clinics of four hospitals in the two most populous regions in Quebec (Canada). Transcripts were analyzed using the Model of Pathways to Treatment.
Pre-diagnosis elapsed time and phases are difficult to appraise precisely and vary according to cancer sites and symptoms specificity. This observation makes the Model of Pathways to Treatment challenging to use to analyze patients' experiences. Analyses identified factors contributing to elapsed time that are linked to type of cancer, to patients, and to health system organization.
This research allowed us to identify avenues for reducing the intervals between first symptoms and cancer diagnosis. The existence of inequities in access to diagnostic services, even in a universal healthcare system, was highlighted.
Purpose: Nurses are identified as a key provider in the management of
patients in primary care. The objective of this study was to evaluate patients’ experience
of care in primary care as it ...pertained to the nursing role. The aim was to test the
hypothesis that, in primary health care organizations (PHCOs) where patients are
systematically followed by a nurse, and where nursing competencies are therefore optimally
used, patients’ experience of care is better. Method: Based on a
cross-sectional analysis combining organizational and experience of care surveys, we built
2 groups of PHCOs. The first group of PHCOs reported having a nurse who systematically
followed patients. The second group had a nurse who performed a variety of activities but
did not systematically follow patients. Five indicators of care were constructed based on
patient questionnaires. Bivariate and multivariate linear mixed models with random
intercepts and with patients nested within were used to analyze the experience of care
indicators in both groups. Results: Bivariate analyses revealed a better
patient experience of care in PHCOs where a nurse systematically followed patients than in
those where a nurse performed other activities. In multivariate analyses that included
adjustment variables related to PHCOs and patients, the accessibility indicator was found
to be higher. Conclusion: Results indicated that systematic follow-up of
patients by nurses improved patients’ experience of care in terms of accessibility. Using
nurses’ scope of practice to its full potential is a promising avenue for enhancing both
patients’ experience of care and health services efficiency.
In 2011, the Agence de la santé et des services sociaux de Montréal (ASSSM), in partnership with the region's Centres de santé et de services sociaux (CSSS), coordinated the implementation of a ...program on cardiometabolic risk based on the Chronic Care Model. The program, intended for patients suffering from diabetes or hypertension, involved a series of individual follow-up appointments, group classes and exercise sessions. Our study assesses the impact on patient health outcomes of variations in the implementation of some aspects of the program among the six CSSSs taking part in the study.
The evaluation was carried out using a quasi-experimental "before and after" design. Implementation variables were constructed based on data collected during the implementation analysis regarding resources, compliance with the clinical process set out in the regional program, the program experience and internal coordination within the care team. Differences in differences using propensity scores were calculated for HbA1c results, achieving the blood pressure (BP) target, and two lifestyle targets (exercise level and carbohydrate distribution) at the 6- and 12-month follow-ups, based on greater or lesser patient exposure to the implementation of various aspects of the program under study.
The results focus on 1185 patients for whom we had data at the 6-month follow- up and the 992 patients from the 12-month follow-up. The difference in differences analysis shows no clear association between the extent of implementation of the various aspects of the program under study and patient health outcomes.
The program produces effects on selected health indicators independent of variations in program implementation among the CSSSs taking part in the study. The results suggest that the effects of this type of program are more highly dependent on the delivery of interventions to patients than on the organizational aspects of its implementation.
Chronic disease management requires substantial services integration. A cardiometabolic risk management program inspired by the Chronic Care Model was implemented in Montréal for patients with ...diabetes or hypertension. One of this study's objectives was to assess the impact of care coordination between the interdisciplinary teams and physicians on patient participation in the program, lifestyle improvements and disease control.
We obtained data on health outcomes from a register of clinical data, questionnaires completed by patients upon entry into the program and at the 12-month mark, and we drew information on the program's characteristics from the implementation analysis. We conducted multiple regression analyses, controlling for patient sociodemographic and health characteristics, to measure the association between interdisciplinary team coordination with primary care physicians and various health outcomes.
A total of 1689 patients took part in the study (60.1% participation rate). Approximately 40% of patients withdrew from the program during the first year. At the 12-month follow-up (n = 992), we observed a significant increase in the proportion of patients achieving the various clinical targets. The perception by the interdisciplinary team of greater care coordination with primary care physicians was associated with increased participation in the program and the achievement of better clinical results.
Greater coordination of patient services between interdisciplinary teams and primary care physicians translates into benefits for patients.
Size of primary health care (PHC) practices is often used as a proxy for various organizational characteristics related to provision of care. The objective of this article is to identify some of ...these organizational characteristics and to determine the extent to which they mediate the relationship between size of PHC practice and patients’ experience of care, preventive services, and unmet needs. In 2010, we conducted population and organization surveys in 2 regions of the province of Quebec. We carried out multilevel linear and logistic regression analyses, adjusting for respondents’ individual characteristics. Size of PHC practice was associated with organizational characteristics and resources, patients’ experience of care, unmet needs, and preventive services. Overall, the larger the size of a practice, the higher the accessibility, but the lower the continuity. However, these associations faded away when organizational variables were introduced in the analysis model. This result supports the hypothesized mediating effect of organizational characteristics on relationships between practice size and patients’ experience of care, preventive services, and unmet needs. Our results indicate that size does not add much information to organizational characteristics. Using size as a proxy for organizational characteristics can even be misleading because its relationships with different outcomes are highly variable.
Physicians’ gender can have an impact on many aspects of patient experience of care. Organization processes through which the influence of gender is exerted have not been fully explored. The aim of ...this article is to compare primary health care (PHC) organizations in which female or male doctors are predominant regarding organization and patient characteristics, and to assess their influence on experience of care, preventive care delivery, use of services, and unmet needs. In 2010, we conducted surveys of a population stratified sample (N = 9180) and of all PHC organizations (N = 606) in 2 regions of the province of Québec, Canada. Patient and organization variables were entered sequentially into multilevel regression analyses to measure the impact of gender predominance. Female-predominant organizations had younger doctors and nurses with more expanded role; they collaborated more with other PHC practices, used more tools for prevention, and allotted more time to patient visits. However, doctors spent fewer hours a week at the practice in female-predominant organizations. Patients of these organizations reported lower accessibility. Conversely, they reported better comprehensiveness, responsiveness, counseling, and screening, but these effects were mainly attributable to doctors’ younger age. Their reporting unmet needs and emergency department attendance tended to decrease when controlling for patient and organization variables other than doctors’ age. Except for accessibility, female-predominant PHC organizations are comparable with their male counterparts. Mean age of doctors was an important confounding variable that mitigated differences, whereas other organization variables enhanced them. These findings deserve consideration to better understand and assess the impacts of the growing number of female-predominant PHC organizations on the health care system.
Introduction
En 2011, l’Agence de la santé et des services sociaux de Montréal (ASSSM),
en partenariat avec les Centres de santé et de services sociaux (CSSS) de la région, a coordonné
la mise en ...oeuvre d’un programme sur le risque cardiométabolique s’inspirant du
Chronic Care Model. Ce programme destiné aux patients diabétiques ou hypertendus
comporte une séquence de suivis individuels, des cours de groupe et des séances
d’activité physique. Notre étude évalue l’impact de la variation dans l’implantation de
certains aspects du programme entre les six CSSS participant à l’étude sur les résultats de
santé des patients.
Méthodologie
L’évaluation a été réalisée à l’aide d’un devis quasi-expérimental « avantaprès
». Des variables d’implantation ont été construites à partir de données colligées lors
de l’analyse d’implantation concernant les ressources, la conformité au processus clinique
prévu dans le programme régional, l’expérience du programme et la coordination interne
au sein de l’équipe de soins. Des différences de différences utilisant des scores de propension
ont été calculées pour les résultats d’HbA1c, l’atteinte de la cible de tension artérielle
(TA) et de deux cibles d’habitudes de vie (niveau d’activité physique et répartition des
glucides alimentaires) à 6 mois et à 12 mois de suivi, en fonction de l’exposition des
patients à un degré plus ou moins important d’implantation de divers aspects du programme
à l’étude.
Résultats
Les résultats portent sur les 1 185 patients pour lesquels on disposait de données
de suivi à 6 mois et les 992 patients pour le suivi à 12 mois. Les analyses de différences
de différences ne révèlent aucune association claire entre le degré d’implantation
des divers aspects du programme à l’étude et les résultats de santé chez les patients.
Conclusion
Le programme produit des effets sur les indicateurs de santé sélectionnés
indépendamment des variations dans l’implantation du programme entre les CSSS participant
à l’étude. Les résultats suggèrent que les effets d’un tel programme sont davantage
tributaires de la prestation des interventions auprès des patients que des aspects organisationnels
liés à son implantation.
Introduction
La gestion des maladies chroniques nécessite une grande intégration des
services. Un programme de gestion du risque cardiométabolique inspiré du Chronic Care
Model a été implanté à ...Montréal pour les patients atteints de diabète ou d’hypertension.
Un des objectifs de notre étude était d’apprécier l’impact de la coordination des soins
entre les équipes interdisciplinaires et les médecins sur la participation des patients au
programme et sur l’amélioration des habitudes de vie et le contrôle de la maladie.
Méthodologie
Nous avons utilisé des données sur les résultats de santé issues d’un registre
de données cliniques et de questionnaires aux patients à leur entrée dans le programme
et à 12 mois de suivi, ainsi que des données sur les caractéristiques du programme
provenant de l’analyse de son implantation. Nous avons réalisé des analyses de
régression multiple, contrôlant pour les caractéristiques sociodémographiques et de santé
des patients, pour mesurer l’association entre la coordination de l’équipe interdisciplinaire
avec les médecins de première ligne et différents résultats de santé.
Résultats
Au total, 1689 patients ont participé à l’évaluation (taux de participation
60,1 %). Environ 40 % des patients ont abandonné le programme durant la première
année. À 12 mois de suivi (n = 992), nous avons observé une augmentation significative
de la proportion des patients atteignant les différentes cibles cliniques. La perception par
l’équipe interdisciplinaire d’une meilleure coordination des soins avec les médecins de
première ligne était associée à une plus grande participation des patients au programme
et à l’atteinte de meilleurs résultats cliniques.
Conclusion
Une plus grande coordination des services aux patients entre des équipes
interdisciplinaires et les médecins de première ligne se traduit par des effets bénéfiques
chez les patients.
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