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Research ArticleResearch

Comparison of primary care physician payment models in the management of hypertension

Karen Tu, Karen Cauch-Dudek and Zhongliang Chen
Canadian Family Physician July 2009; 55 (7) 719-727;
Karen Tu
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  • For correspondence: karen.tu@ices.on.ca
Karen Cauch-Dudek
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Zhongliang Chen
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    Figure 1

    Hypertension screening, treatment, and control rates by primary care payment model

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    Table 1

    Physician demographics by model of care: A) Number and proportion of physicians with various characteristics; B) Mean age, age at graduation, weekly hours worked, and number of physicians in group.

    A)
    MODEL
    PHYSICIAN CHARACTERISTICSCHC, N (%)(N = 45)FFS, N (%)(N = 45)PCN, N (%)(N = 45)OVERALL, N (%)(N = 135)P VALUE
    Female23 (51.1)15 (33.3)22 (48.9)60 (44.4).18
    Hospital privileges*32 (71.1)35 (77.8)45 (100.0)112 (83.0)< .01
    Rural practice18 (40.0)10 (22.2)18 (40.0)46 (34.1).12
    Community practice (vs academic practice)40 (88.9)44 (97.8)40 (88.9)124 (91.9).23
    Solo practice*≤ 517 (37.8)16 (35.6)34 (25.2)< .01
    Nurse available in practice*39 (86.7)20 (44.4)30 (66.7)89 (65.9)< .01
    Nurse practitioner available in practice*45 (100.0)≤ 525 (55.6)73 (54.1)< .01
    Computerized progress notes*≤ 5≤ 5 (11.1)38 (84.4)46 (34.1)< .01
    Computerized cumulative patient profiles*27 (60.0)10 (22.2)37 (82.2)74 (54.8)< .01
    B)
    MODEL
    PHYSICIAN CHARACTERISTICSCHC, MEAN (SD) (N = 45)FFS, MEAN (SD) (N = 45)PCN, MEAN (SD) (N = 45)OVERALL, MEAN (SD) (N = 135)P VALUE
    Physician age in 200546.3 (8.6)46.8 (7.9)50.2 (8.6)47.7 (8.5).06
    Physician age at graduation27.0 (3.6)26.3 (1.9)26.0 (2.3)26.4 (2.7).21
    Physician weekly hours worked*39.3 (10.2)46.1 (13.9)43.0 (11.5)42.8 (12.2)†.04
    Physicians in group4.0 (1.6)4.0 (7.3)4.0 (3.1)4 (4.6).89
    • CHC–community health centre, FFS–fee-for-service, PCN–primary care network.

    • ↵* P < .05, statistically significant difference between models.

    • ↵† This information was not available for 13 of the physicians.

    • View popup
    Table 2

    Patient demographics by model of care: A) All patients; B) Patients with hypertension.

    A)
    MODEL
    PATIENT CHARACTERISTICSCHC, MEAN (SD)FFS, MEAN (SD)PCN, MEAN (SD)OVERALL, MEAN (SD)P VALUE
    Female, %58.7 (16.0)54.6 (16.5)59.6 (18.7)57.6 (17.1).33
    Age at date of abstraction, y54.1 (5.7)56.3 (4.2)55.5 (3.9)55.3 (4.7).08
    Socioeconomic status, %
     • Income quintile 1 (lowest)*40.0 (23.3)15.4 (13.1)16.9 (12.8)24.1 (20.4)< .01
     • Income quintile 221.8 (12.7)22.1 (9.7)19.3 (10.9)21.1 (11.2).44
     • Income quintile 3*14.7 (8.8)20.0 (10.6)18.9 (11.1)17.9 (10.4).04
     • Income quintile 4*12.6 (11.8)19.5 (9.7)20.3 (11.4)17.5 (11.5)< .01
     • Income quintile 5 (highest)*10.8 (11.4)23.0 (13.6)24.5 (20.4)19.4 (16.7)< .01
    Cardiovascular-related comorbidities, %
     • Dyslipidemia31.5 (13.3)34.4 (16.5)33.3 (12.7)33.1 (14.2).63
     • Stroke2.4 (2.8)2.7 (3.3)2.3 (2.8)2.5 (3.0).80
     • Transient ischemic attack2.0 (3.1)1.5 (2.1)1.7 (2.2)1.7 (2.5).64
     • Angina5.1 (6.0)6.0 (5.2)6.2 (6.3)5.8 (5.8).67
     • Myocardial infarction4.9 (4.9)4.4 (5.6)4.8 (6.3)4.7 (5.6).88
     • Congestive heart failure2.3 (3.3)1.7 (2.9)1.4 (2.4)1.8 (2.9).35
     • Atrial fibrillation2.1 (3.3)2.8 (4.3)2.6 (3.0)2.5 (3.6).63
     • Coronary artery bypass graft1.4 (2.7)1.7 (2.5)2.1 (4.0)1.7 (3.1).65
     • Previous angioplasty or stent1.8 (2.6)1.3 (2.8)2.5 (3.4)1.9 (3.0).15
     • Peripheral vascular disease3.3 (5.0)3.2 (3.7)2.0 (3.2)2.8 (4.0).23
     • Diabetes12.9 (8.9)13.5 (8.2)11.5 (8.9)12.6 (8.6).54
     • Renal disease1.2 (2.0)1.7 (3.0)2.6 (3.7)1.9 (3.0).08
     • Hypothyroidism7.0 (6.0)6.0 (5.7)9.3 (7.1)7.4 (6.4).05
     • Current smoker*31.6 (15.6)23.9 (15.3)25.9 (13.9)27.1 (15.2).04
    B)
    MODEL
    PATIENT CHARACTERISTICSCHC, MEAN (SD)FFS, MEAN (SD)PCN, MEAN (SD)OVERALL, MEAN (SD)P VALUE
    Female, %60.6 (22.0)49.8 (21.8)57.0 (23.5)55.8 (22.7).07
    Age at date of abstraction, y61.0 (6.8)62.1 (6.4)63.7 (4.3)62.2 (6.0).11
    Socioeconomic status, %
     • Income quintile 1 (lowest)*42.2 (28.1)17.3 (19.8)18.6 (17.3)26.0 (24.9)< .01
     • Income quintile 225.0 (18.6)24.1 (16.1)20.0 (17.3)23.1 (17.4).36
     • Income quintile 3*11.6 (11.9)20.0 (17.4)18.8 (16.9)16.8 (15.9).02
     • Income quintile 4*11.8 (15.7)20.3 (19.8)20.9 (19.3)17.7 (18.7).04
     • Income quintile 5 (highest)*9.4 (12.2)18.3 (15.8)21.8 (24.8)16.5 (19.0)< .01
    Cardiovascular-related comorbidities, %
     • Dyslipidemia55.0 (19.0)53.5 (22.9)58.4 (18.8)55.6 (20.3).51
     • Stroke4.0 (6.9)5.5 (7.3)7.1 (8.9)5.5 (7.8).17
     • Transient ischemic attack3.4 (5.5)3.4 (5.4)3.9 (5.8)3.5 (5.5).88
     • Angina10.6 (12.8)12.4 (11.6)12.8 (11.7)11.9 (12.0).64
     • Myocardial infarction9.9 (11.0)9.8 (12.2)11.1 (14.6)10.3 (12.6).87
     • Congestive heart failure4.9 (7.4)4.1 (6.9)3.6 (6.9)4.2 (7.1).70
     • Atrial fibrillation3.1 (6.0)4.0 (5.9)5.4 (9.5)4.1 (7.3).21
     • Coronary artery bypass graft3.3 (5.4)2.8 (5.9)5.1 (8.0)3.8 (6.6).34
     • Previous angioplasty or stent3.3 (6.3)5.9 (8.4)5.8 (8.7)5.0 (7.9).21
     • Peripheral vascular disease7.0 (9.1)7.0 (9.9)4.5 (7.3)6.2 (8.9).29
     • Diabetes28.0 (16.9)28.2 (16.5)30.0 (20.7)28.7 (18.0).84
     • Renal disease*2.0 (4.5)4.6 (9.2)6.8 (10.0)4.5 (8.5).03
     • Hypothyroidism10.3 (11.3)7.0 (8.6)11.6 (12.1)9.6 (10.9).12
     • Current smoker30.3 (22.5)20.8 (18.3)21.6 (22.1)24.2 (21.3).07
    • CHC–community health centre, FFS–fee-for-service, PCN–primary care network.

    • ↵* P < .05, statistically significant difference between models.

    • View popup
    Table 3

    Hypertension screening rates and number of visits in the past 3 years by model of care

    MODEL
    SCREENINGCHC, MEAN (SD)FFS, MEAN (SD)PCN, MEAN (SD)OVERALL, MEAN (SD)P VALUE
    At least 1 BP visit in past 3 y, %93.5 (8.9)93.3 (7.2)90.6 (9.6)92.5 (8.7).22
    Average no. of visits in the past 3 y,* %14.9 (3.7)12.9 (4.2)9.9 (2.2)12.6 (4.0)< .01
    Proportion of total visits in the past 3 y in which BP was measured43.3 (13.1)48.7 (15.0)47.0 (17.0)46.3 (15.2).22
    • BP–blood pressure, CHC–community health centre, FFS–fee-for-service, PCN–primary care network.

    • ↵* P <.05, statistically significant difference between models.

    • View popup
    Table 4

    Adjusted treatment and control rates for patients with hypertension by model of care

    MODEL
    TREATMENTS AND MEASURES OF CONTROLCHC, MEAN (SD)FFS, MEAN (SD)PCN, MEAN (SD)OVERALL, MEAN (SD)ANOVA P VALUE
    Patients with hypertension, %*33.7 (10.5)36.7 (8.8)30.3 (8.4)33.6 (9.3).01
    Currently taking at least 1 BP medication, %*81.0 (4.9)87.4 (4.5)90.9 (4.9)86.4 (4.6).01
    Currently taking at least 2 BP medications, %*47.7 (6.2)60.0 (5.3)59.8 (5.9)55.8 (6.6)< .01
    Currently taking ASA, %34.9 (10.5)38.7 (9.9)37.9 (7.4)37.2 (9.4).67
    Currently taking lipid-lowering medication, %36.4 (8.1)44.5 (6.3)46.4 (6.9)42.4 (7.6).06
    Types of medication, %
     • ACE inhibitors47.8 (4.2)56.5 (5.0)57.1 (4.0)53.8 (5.0).06
     • Angiotensin II receptor blockers*8.9 (4.6)19.1 (4.5)15.1 (3.9)14.3 (4.2).03
     • β-Blockers*25.2 (3.0)32.2 (5.7)34.6 (4.2)30.7 (4.6).03
     • Calcium channel blockers24.1 (7.8)28.2 (6.2)29.9 (7.0)27.4 (7.1).19
     • Diuretics50.7 (6.0)50.3 (4.5)53.9 (4.8)51.6 (5.2).67
    Last individual BP reading below target,*† %38.6 (5.9)41.6 (6.8)54.5 (5.6)44.9 (6.7)< .01
    Average no. of visits in the past 3 y*19.1 (1.2)16.9 (1.3)14.0 (1.0)16.7 (1.4)< .01
    Proportion of total visits in the past 3 y in which BP was measured63.4 (3.8)67.8 (3.5)66.5 (3.7)65.9 (3.8).22
    • ACE–angiotensin-converting enzyme, ANOVA–analysis of variance, ASA–acetylsalicylic acid, BP–blood pressure, CHC–community health centre, FFS–fee-for-service, PCN–primary care network.

    • ↵* P < .05, statistically significant difference between models.

    • ↵† Target BP < 140/80 mm Hg, < 130/80 mm Hg for patients with diabetes, and < 120/75 for patients with renal disease.

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Canadian Family Physician: 55 (7)
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Comparison of primary care physician payment models in the management of hypertension
Karen Tu, Karen Cauch-Dudek, Zhongliang Chen
Canadian Family Physician Jul 2009, 55 (7) 719-727;

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