Characteristics of primary care practices associated with high quality of care

Background:

No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care.

Methods:

We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling.

Results:

The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0–35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8–14.4), presence of allied health professionals (15.3; 95% CI 5.4–25.2) and/or specialist physicians (19.6; 95% CI 8.3–30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0–12.4) and average organizational access to the practice (4.9; 95% CI 2.6–7.2). The number of physicians (1.2; 95% CI 0.6–1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1–2.5) were modestly associated with high-quality care.

Interpretation:

We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.A health care system is only as strong as its primary care sector,¹ which provides “entry into the system for all new needs and problems, provides person-focused (not disease-oriented) care over time, provides care for all but very uncommon or unusual conditions …”² Patient enrolment, team-based care, information technology, and funding and remuneration schemes that foster comprehensiveness and collaboration are key characteristics of effective primary care systems.³ None can be singled out as the most determining, but how they are clustered defines a limited set of organizational models that have been associated with a variety of outcomes.⁴ Canadian provinces have implemented different primary care models with different scopes of changes.⁵ Research has not yet identified a “winning” model. For example, in Ontario, community health centres deliver better chronic illness care⁶ but have less accessibility than fee-for-service enrolment models,⁷ and no model provided more comprehensive preventive care.⁸ Walk-in clinics achieved better quality scores than did family medicine clinics for treatment of a set of acute problems.⁹ How the work is organized may be as important, if not more important, than what the model is called.These observations suggest that the challenges associated with providing high-quality services differ depending on the nature of care considered.^9–11 Even if chronic illness is a major challenge, the quality of care must not be improved at the expense of accessibility, preventive or good episodic care, which are all essential components of primary care.In this study, we report the results of the quantitative component of a multimethod observational study conducted in Quebec to determine which organizational characteristics of primary care practices are associated with high-quality care. We sought to find a quality measure of care that would encompass the comprehensive nature of primary care (episodic, chronic and preventive care), and we explored how the contribution of organizational characteristics varied based on the type of care provided.