Age equity in different models of primary care practice in Ontario

Simone Dahrouge; William Hogg; Meltem Tuna; Grant Russell; Rose Ann Devlin; Peter Tugwell; Elizabeth Kristjansson

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Table 1

Scales for the measurement of performance; range of overall PCAT* scores was 86% to 88% (N = 5073): A) Dimensions of quality of health care service delivery; B) Technical quality of clinical care delivery.

A)
QUALITY OF HEALTH CARE SERVICE DELIVERY^{^†^‡} (ITEMS ON THE SCALE, CATEGORIES ON THE LIKERT SCALE OF EACH ITEM)	N^§	SCORE RANGE,^‖ %

Access
• First-contact accessibility (4, 4)	5033	74 to 83
• First-contact utilization (3, 4)	5323	96 to 98
Patient-provider relationship
• Cultural competency (3, 4)	4755	83 to 85
• Family-centredness (3, 4)	5146	89 to 90
• Humanism (8, 7)	5292	90 to 91
• Trust (10, 5)	5031	87 to 88
Continuity
• Ongoing care (4, 4)	5252	85 to 90

B)
TECHNICAL QUALITY OF CLINICAL CARE DELIVERY—ADHERENCE TO RECOMMENDED GUIDELINES (ITEMS ON THE SCALE)^¶	N^§	SCORE RANGE,^‖ %

Health promotion^‡
Healthy lifestyle counseling (6)	4642	46 to 59
• Exercise	4562	32 to 40
• Healthy foods	4592	17 to 28
• Family conflicts	4528	10 to 17
• Smoking	4574	13 to 18
• Alcohol	4551	8 to 14
• Home safety	4527	3 to 7
Prevention^#
Preventive care (6) (eligibility)	3284	52 to 68
• Colorectal cancer screening (individuals > 50 y)	1753	30 to 46
• Breast cancer screening (women 50 to 69 y)	698	73 to 85
• Cervical cancer screening (women 17 to 69 y)	1954	65 to 84
• Vision impairment screening (individuals > 65 y)	735	27 to 41
• Hearing impairment (individuals > 65 y)	651	14 to 21
• Influenza immunization (individuals at high risk or > 65 y)	1365	59 to 70
Chronic disease management^#
Chronic disease management (9)	514	60 to 72
• Coronary artery disease (3)	263	66 to 79
• Diabetes (4)	313	52 to 69
• Congestive heart failure (2)	57	56 to 76

PCAT—Primary Care Assessment Tool.
↵* Overall PCAT score was computed as the sum of all 17 PCAT questions divided by the maximum potential score (68 if all questions were answered).
↵† All health care service delivery scales are based on the PCAT,^20,21 except for the humanism²³ and trust²⁵ scales. A respondent’s scale was included only if at least 50% of its items contained a response. Performance scores for health service delivery scales were derived by summing the individual item scores and normalizing these to a percentage; for example, for first-contact accessibility, the sum of the scores for the 4 questions, each on a likert scale of 1 to 4, is divided by 16.
↵‡ Patient survey.
↵§ The sample size showing represents the number of cases for which age was available and that were included in the age analysis.
↵‖ Indicates the range of each scale’s average scores across the 4 models.
↵¶ Health promotion and prevention evaluations were based on the Canadian Task Force on Preventive Health Care clinical practice guidelines.²⁶ Chronic disease management was assessed against recommended guidelines accepted in Ontario for the management of the conditions.^27–33 For health promotion, patients were asked to indicate which of the 7 subjects were discussed with them on that day’s visit. One question relating exclusively to individuals older than 65 years of age (about how to prevent falls) was excluded. We assessed whether at least 1 of the 6 subjects was discussed on that visit, and we analyzed each subject individually.
↵# Chart audit. Preventive care was determined by assessing whether 6 indicator maneuvers were documented in the chart as performed or recommended in the previous 24 months. The prevention score was the proportion of preventive maneuvers for which the individual was eligible that were documented as performed or recommended. Chronic disease management was also evaluated by chart audit using 2 to 4 indicators in each of the 3 conditions. For each condition, the score was derived as for prevention, and the overall chronic disease management score was the average of the individual disease scores.

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Table 2

Profile of patients by age groups: A) Survey patient profile; B) Chart audit patient profile.

A)	AGE GROUP
SURVEY PATIENT PROFILE	< 30 Y (N = 714)	30–64 Y (N = 3297)	≥ 65 Y (N = 1100)

Sociodemographic and economic profile^*
• Sex,^† % women	76.0	66.0	61.0
• Household income,^† % below LICO^‡	21.0	16.0	14.0
• Low education,^† % with less than high school diploma	14.0	13.0	33.0
• Do not speak English or French at home,^† %	2.6	1.6	1.5
• Aboriginal,^§ %	1.1	1.6	0.6
• Uninsured (in Canada),^† %	4.6	1.5	0.6
• Do not work outside the home,^† %	33.0	34.0	89.0
• Recent immigrant (< 5 y),^† %	3.3	2.6	0.5
• Rurality index,^† mean	11.0	13.0	15.0
• Distance from home to practice > 10 km,^† %	23.0	25.0	19.0
Health status^*
• Average no. of d with poor mental health in past 30 d^†	5.1	4.7	2.4
• Average no. of d with poor physical health in past 30 d	5.1	5.4	5.4
• Average no. of d limited by poor mental or physical health in past 30 d	3.8	4.2	3.7
• Physical, mental, or emotional problem lasting > 1 y,^† %	32.0	45.0	41.0
• Self-perceived health as very good to excellent,^† %	53.0	56.0	39.0
• Presence of at least 1 chronic disease, %/no. of chronic diseases^†^‖	56/1.2	70/1.7	90/2.7
Relationship with the practice
• Provider is a nurse practitioner,^† %	10.0	5.0	2.0
• Seeing his or her own provider at that visit,^† %	91.0	94.0	96.0
• Attending the practice for more than 2 y,^† %	75.0	82.0	88.0
• No. of visits to the office in previous year, mean^¶/median^§	5.7/4	6.5/4	6.2/5
• Main reason for visit, %, checkup/chronic problem/recent problem^†	43/19/38	33/29/38	36/34/30

B)	AGE GROUP
CHART AUDIT PATIENT PROFILE	< 30 Y (N = 741)	30–64 Y (N = 2631)	≥ 65 Y (N = 736)

Uninsured in Ontario (OHIP),^§ %	98	99	100
Sex, % women	70	59	55

LICO—low income cutoffs, OHIP—Ontario Health Insurance Plan.
↵* Socioeconomic factors and health status were used for adjustment in the analyses.
↵† P < .001 compared by Pearson χ² or independent t test.
↵‡ Low income cutoff is a measure of household deprivation used by Statistics Canada.³⁴
↵§ P < .05 compared by Pearson χ² or independent t test.
↵‖ Thirteen chronic diseases assessed (self reported).
↵¶ P < .01 compared by Pearson χ² or independent t test.

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Table 3

Dimensions of health service delivery in the various models of primary care among age groups: Statistically significant results (P < .05) are boldface.

		AGE EFFECT,^†β (95% CI)
DIMENSIONS OF HEALTH SERVICE DELIVERY	AGE GROUP, Y^*	CHC	FFS	FHN	HSO
Overall PCAT score^‡	30 to 64	2.1 (0.5 to 3.6)	2.6 (1.1 to 4.2)	3.3 (1.8 to 4.8)	3.9 (2.5 to 5.3)
Overall PCAT score^‡	≥ 65	1.9 (−0.4 to 4.2)	2.6 (0.5 to 4.7)	5.6 (3.7 to 7.6)	5.7 (3.8 to 7.6)
First-contact accessibility	30 to 64	0.7 (−2.1 to 3.5)	3.3 (0.5 to 6.1)	3.9 (1.2 to 6.6)	4.0 (1.8 to 6.2)
First-contact accessibility	≥ 65	0.6 (−3.5 to 4.6)	5.2 (1.4 to 9.0)	7.3 (3.8 to 10.8)	6.9 (3.9 to 9.9)
First-contact utilization	30 to 64	3.0 (1.5 to 4.5)	3.7 (2.4 to 5.0)	4.7 (3.4 to 6.0)	3.7 (2.5 to 4.9)
First-contact utilization	≥ 65	5.0 (2.8 to 7.2)	4.7 (3 to 6.4)	5.5 (3.8 to 7.2)	4.8 (3.2 to 6.5)
Cultural competency	30 to 64	2.7 (0.1 to 5.3)	3.5 (0.8 to 6.3)	4.3 (1.6 to 7.1)	4.7 (1.9 to 7.5)
Cultural competency	≥ 65	−1.3 (−5.1 to 2.5)	1.4 (−2.3 to 5.1)	4.7 (1.1 to 8.3)	4.9 (1.1 to 8.8)
Family-centred care	30 to 64	2.1 (0.1 to 4.2)	1.8 (−0.5 to 4.0)	3.6 (1.5 to 5.6)	4.4 (2.2 to 6.6)
Family-centred care	≥ 65	0.0 (−3.0 to 3.0)	−1.3 (−4.4 to 1.7)	4.2 (1.5 to 6.9)	5.9 (3.0 to 8.9)
Relational continuity	30 to 64	3.3 (1.0 to 5.6)	3.1 (1.0 to 5.2)	2.2 (0.1 to 4.3)	3.6 (1.7 to 5.5)
Relational continuity	≥ 65	3.8 (0.4 to 7.1)	4.2 (1.4 to 7.0)	6.5 (3.7 to 9.2)	6.1 (3.5 to 8.7)
Humanism	30 to 64	3.3 (1.3 to 5.3)	4.9 (2.8 to 6.9)	5.4 (3.3 to 7.5)	5.0 (2.9 to 7.1)
Humanism	≥ 65	4.4 (1.4 to 7.4)	7.2 (4.4 to 10)	8.9 (6.2 to 11.7)	9.5 (6.7 to 12.4)
Trust	30 to 64	2.5 (0.6 to 4.5)	4.1 (2.2 to 6.1)	3.4 (1.4 to 5.4)	4.4 (2.5 to 6.3)
Trust	≥ 65	3.9 (1.1 to 6.7)	5.9 (3.2 to 8.5)	6.0 (3.4 to 8.7)	7.3 (4.6 to 9.9)

CHC—community health centre, CI—confidence interval, FFS—fee-for-service, FHN—family health network, HSO—health service organization, PCAT—Primary Care Assessment Tool.
↵* Individuals younger than 30 years of age make up the reference category.
↵† Age effect (β value for the age group) adjusted for socioeconomic status only (95% CIs) is shown. Results from regressions predicting the overall PCAT score in which health factors are included show a slightly attenuated effect: CHC, FFS, FHN, and HSO for ages 30 to 64, β value is 1.6, 2.4, 3.1, and 3.6, respectively; for ages 65 and older, β value is 0.8, 2.2, 5.1, and 4.9, respectively.
↵‡ The overall PCAT score was derived from all 17 questions contained in the 5 scales.

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Table 4

Health promotion across age groups among primary care models: A) ORs of having discussed lifestyle topics at the index visit; B) Estimated likelihood of discussing at least 1 topic.

A)		OR^† OF HAVING DISCUSSED LIFESTYLE SUBJECTS (95% CI)
LIFESTYLE TOPICS FOR DISCUSSION	AGE GROUP, Y^*	CHC	FFS	FHN	HSO

At least 1 subject	30–64	0.65 (0.45–0.94)^‡	1.10 (0.76–1.59)	0.97 (0.67–1.41)	0.88 (0.60–1.29)
At least 1 subject	≥ 65	0.60 (0.35–1.04)	1.01 (0.60–1.69)	0.96 (0.58–1.58)	0.92 (0.54–1.57)
Healthy foods	30–64	0.59 (0.41–0.86)^‡	0.68 (0.43–1.06)	1.08 (0.69–1.71)	0.89 (0.56–1.42)
Healthy foods	≥ 65	0.44 (0.25–0.77)^‡	0.71 (0.36–1.40)	1.10 (0.60–2.02)	0.67 (0.34–1.31)
Home safety	30–64	0.71 (0.37–1.35)	0.67 (0.24–1.91)	0.48 (0.17–1.34)	0.30 (0.11–0.82)^‡
Home safety	≥ 65	0.64 (0.24–1.72)	1.86 (0.47–7.30)	0.63 (0.14–2.74)	0.97 (0.23–4.03)
Family conflict	30–64	0.75 (0.49–1.14)	1.78 (0.93–3.40)	0.91 (0.52–1.60)	0.59 (0.34–1.04)
Family conflict	≥ 65	0.26 (0.11–0.60)^‡	0.66 (0.23–1.88)	0.57 (0.24–1.34)	0.75 (0.32–1.76)
Exercise	30–64	0.95 (0.66–1.35)	1.14 (0.77–1.71)	1.06 (0.72–1.58)	1.09 (0.72–1.66)
Exercise	≥ 65	0.95 (0.56–1.62)	0.88 (0.50–1.55)	1.13 (0.67–1.93)	0.96 (0.54–1.72)
Smoking	30–64	0.66 (0.43–1.00)	0.78 (0.49–1.26)	0.88 (0.56–1.37)	0.80 (0.49–1.30)
Smoking	≥ 65	0.11 (0.04–0.29)^‡	0.43 (0.20–0.91)^‡	0.44 (0.22–0.87)^‡	0.64 (0.28–1.42)
Alcohol	30–64	0.45 (0.28–0.71)^‡	0.73 (0.41–1.31)	1.10 (0.63–1.93)	0.68 (0.38–1.22)
Alcohol	≥ 65	0.16 (0.07–0.36)^‡	0.48 (0.18–1.27)	0.56 (0.25–1.26)	0.38 (0.15–0.97)^‡

B)		ESTIMATED LIKELIHOOD OF DISCUSSING AT LEAST 1 TOPIC,^§ %
LIFESTYLE TOPIC FOR DISCUSSION	AGE GROUP, Y	CHC	FFS	FHN	HSO

At least 1 subject	< 30	56	42	42	41
	30–64	45	45	41	38
	≥ 65	43	43	41	39

CHC—community health centre, FFS—fee-for-service, FHN—family health network, HSO—health service organization, OR—odds ratio.
↵* Individuals younger than 30 years of age make up the reference category.
↵† The ORs of having discussed at least 1 healthy lifestyle subject and having discussed each individual lifestyle subject at the index visit among age groups are shown. The estimate is adjusted for socioeconomic information and health status, using multilevel linear regressions. Results of the regression analyses in which health status variables are not included eliminate the statistical significance of the effect in CHCs: ORs for CHC, FFS, FHN, and HSO for ages 30 to 64 years are 0.73, 1.11, 0.97, and 0.89, respectively; for ages ≥ 65 years, 0.72, 0.99, 0.95, and 0.92, respectively.
↵‡ Statistically significant (P < .05) results.
↵§ For the “typical” patient, the estimated likelihood of reporting at least 1 healthy lifestyle subject being discussed in each age group of the primary care models is derived from the multivariate logistic regression in which socioeconomic information and health status are included. The typical individual is an individual with the most common features: woman, without features of disadvantage (ie, low education, income below low cutoff, language barrier, aboriginal status, uninsured), travel distance less than 10 km, not rural, no limitations owing to physical or mental health or problems lasting more than 1 year, health good to excellent, and the presence of at least 1 chronic disease.

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Table 5

Preventive care* among age groups in the various models of primary care: A) Age effect for overall prevention score and ORs for screening; B) Estimated overall prevention score by age groups and sex.

A)		MODELS OF PRIMARY CARE
VARIABLES	AGE GROUP, Y	CHC	FFS	FHN	HSO

Age effect for overall prevention score,^{^†^‡} % (95% CI)
• Men	50 to 64 vs 17 to 49	−7 (−24 to 9)	7 (−7 to 21)	8 (−8 to 25)	4 (−10 to 18)
• Men	≥ 65 vs 17 to 49	−5 (−24 to 14)	5 (−10 to 21)	5 (−12 to 22)	9 (−4 to 23)
• Women	50 to 64 vs 17 to 49	−18 (−11 to −24)^§	−13 (−7 to −20)^§	−12 (−6 to −18)^§	−22 (−15 to −30)^§
• Women	≥ 65 vs 17 to 49	−33 (−25 to −41)^§	−32 (24 to −40)^§	−30 (−22 to −37)^§	−34 (−26 to −42)^§
ORs (95% CI) for screening or immunization (women and men included)^‖
• Breast cancer	60 to 69 vs 52 to 59	0.95 (0.41 to 2.23)	1.15 (0.55 to 2.41)	0.71 (0.32 to 1.54)	0.79 (0.38 to 1.67)
• Cervical cancer	45 to 69 vs 19 to 44	0.53 (0.33 to 0.86)^§	0.90 (0.57 to 1.40)	0.58 (0.36 to 0.94)^§	0.41 (0.25 to 0.66)^§
• Colorectal cancer	≥ 75 vs 52 to 74	0.85 (0.46 to 1.56)	0.46 (0.25 to 0.83)^§	0.42 (0.25 to 0.71)^§	0.56 (0.33 to 0.94)^§
• Influenza	≥ 65 vs 19 to 64	2.76 (1.62 to 4.71)^§	3.16 (1.89 to 5.25)^§	4.54 (2.58 to 7.98)^§	6.59 (3.91 to 11.12)^§
• Vision	≥ 75 vs 67 to 74	1.18 (0.54 to 2.62)	2.13 (0.91 to 5.02)	2.26 (1.03 to 4.96)^§	0.99 (0.54 to 1.83)
• Hearing	≥ 75 vs 67 to 74	0.94 (0.30 to 2.96)	1.28 (1.05 to 1.50)	1.00 (0.35 to 2.90)	1.44 (0.57 to 3.60)

B)		ESTIMATED OVERALL PREVENTION SCORE IN THE MODELS OF PRIMARY CARE,^¶ %
SEX	AGE GROUP, Y	CHC	FFS	FHN	HSO

Men	17 to 49	49	32	42	31
	50 to 64	42	39	50	35
	≥ 65	44	37	47	40
Women	17 to 49	82	75	78	74
	50 to 64	64	62	66	52
	≥ 65	49	43	48	40

CHC—community health centre, CI—confidence interval, FFS—fee-for-service, FHN—family health network, HSO—health service organization, OR—odds ratio.
↵* Cervical cancer screening: women 17–69 years. Breast cancer screening: women 50–69 years. Influenza immunization: 65 years or older or any age with a chronic condition putting patients at higher risk of influenza. Colorectal cancer screening: 50 years or older. Visual impairment screening: 65 years or older. Auditory impairment screening: 65 years or older.
↵† For each of the 6 maneuvers making up the prevention score, we evaluated the presence of the maneuver being performed in the previous 24 months in those for whom the maneuver was recommended: the age effect for those aged 50–64 was significantly larger in HSOs (−22%, 95% CI 15% to −30%) than FHNs (−12%, 95% CI −6% to −18%).
↵‡ For the overall prevention score, individuals younger than 50 years of age make up the reference category. For individual maneuvers, the younger age group for which the maneuver is indicated make up the reference category.
↵§ Statistically significant (P < .05) results.
↵‖ ORs (95% CI) for older individuals compared with younger individuals, adjusted for sex, rurality, and insurance status are shown.
↵¶ The estimated prevention score for the “typical” individual is shown. The typical individual is urban and has public health insurance.

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Table 6

Chronic disease management among age groups across models of primary care: A) Percentage of age effect between age groups; B) Estimated chronic disease management score.

A)		AGE EFFECT,^† % (95% CI)
VARIABLE	AGE GROUP, Y^*	CHC	FFS	FHN	HSO

Overall chronic disease management score	60 to 69	5.7 (−9.1 to 20.5)	17.4 (3.4 to 31.3)^‡	21.3 (8.3 to 34.2)^‡	24.4 (11.6 to 37.2)^‡
Overall chronic disease management score	≥ 70	5.0 (−7.5 to 17.5)	11.6 (−0.4 to 23.6)	8.0 (−3.0 to 19.0)	8.6 (−2.3 to 19.5)
Diabetes	60 to 69	−0.5 (−18.7 to 17.6)	13.6 (−1.5 to 28.6)	17.0 (1.8 to 32.3)^‡	15.8 (−0.2 to 31.9)
Diabetes	≥ 70	2.3 (−13.8 to 18.4)	9.2 (−6.7 to 25.1)	3.1 (−10.4 to 16.6)	3.4 (−10.0 to 16.8)
Coronary artery disease	60 to 69	−2.3 (−26.7 to 22.2)	21.6 (−1.2 to 44.3)	9.9 (−14.5 to 34.3)	9.4 (−11.7 to 30.5)
Coronary artery disease	≥ 70	−3.6 (−26.1 to 18.9)	−0.3 (−22.1 to 22.3)	−5.7 (−27.2 to 15.9)	−5.2 (−24.9 to 14.4)

B)		ESTIMATED CHRONIC DISEASE SCORES,^§ %
VARIABLE	AGE GROUP, Y	CHC	FFS	FHN	HSO

Overall chronic disease management score	< 60	64	47	50	53
	60 to 69	70	64	71	78
	≥ 70	69	59	58	62

CHC—community health centre, CI—confidence interval, FFS—fee-for-service, FHN—family health network, HSO—health service organization.
↵* Individuals younger than 60 years of age make up the reference category.
↵† The age effect (95% CI) adjusted for sex, rurality, and public insurance is shown.
↵‡ Statistically significant (P < .05) results.
↵§ The estimated performance for different age groups in each model is shown for the “typical” patient profile, which is an individual with the most common features: an urban woman with public health insurance.