Ten years of the Primary Care Assessment Tool in Canadian Family Physician: what is next?

Ten years using the PCAT in Canada

In December 2019, Moe and colleagues³ described a study of repeated panels of PCAT use in Alberta (2007, 2010, 2013, and 2016). Their article marked the 10th anniversary of Canadian Family Physician’s first publication on the use of the PCAT to assess the extent of affiliation and primary care orientation of primary care models in 3 Canadian provinces. The series began in 2010 with the publication of Tourigny and colleagues’ evaluation of the use of the PCAT in Quebec.⁴

In 2010, Muldoon and colleagues¹ analyzed the community orientation domain from the key baseline COMP-PC (Comparison of Models of Primary Care in Ontario) study from the perspectives of users and providers—both family physicians and nurse practitioners. To date, this baseline study is the largest Canadian study using the PCAT, with a random sample of more than 5000 adult users and providers. In 2011, 2013, and 2014, Dahrouge et al,⁵ Mayo-Bruinsma et al,⁶ and Muggah et al,⁷ respectively, chose other attributes measured by the PCAT for their analyses of the COMP-PC results. Their chosen attribute was family-centred care; patient-reported access and age equity (in terms of access) in different models were also considered. In 2016, Carroll et al^8,9 published 2 articles that used the adult expanded version of the PCAT in Toronto, Ont, to assess academic family health teams and demonstrated that new strategies were necessary to enhance access to care.

Moe and colleagues³ were pioneering, in that they were the only researchers to follow the same patient panel over time using the PCAT as an instrument. This permitted them to follow trends at the WestView Primary Care Network in Alberta, for instance. In 2006, the WestView Primary Care Network implemented a new primary care model that included community-based family practice clinics, collaborative team-based care, and nonphysician health care professionals; it was important to have a rigorous methodology to evaluate the pioneering changes.

New challenges with primary health care (PHC) reforms in Canada

Since the beginning of the 2000s, Canadian PHC reforms have created new variables of interest in primary care models in each province and territory. New domains of interest included team-based care, new capitation schemes, new payment systems, and the use of telemedicine. In 2021, primary care merits a reassessment, as does the PCAT itself. There is a need to adapt, complement, and validate the questionnaire from the original Canadian cross-cultural version to one that better represents Canadian demographic characteristics today. This revised version could be based on a complex statistical sampling plan, as is used in the CCHS, and could provide several opportunities: to collect an appropriate statistical sample size to represent the PHC domains and provinces, to calculate the coefficients of variation of estimates, and to detail nonsampling errors. As Wonnacott and Wonnacott have pointed out, “one of the fundamental tasks of statistics would be to answer the question—‘how small is this error?’”¹⁰ Almost 20 years ago, one of the first studies using the PCAT in Canada did not find results that validated accessibility—the first-contact access domain—with certainty.¹¹

What is next?

A new federal model for financing PHC was created by the Brazilian Ministry of Health in 2019.¹² One of the assessment tools considered for this important initiative was a federal pay-for-perfomance evaluation scheme for the 27 Brazilian states.¹³ This initiative was piloted using the PCAT-Brazil; it was validated first by Starfield and Brazilian colleagues¹⁴ in 2006 and later by the Brazilian Ministry of Health in 2010 and again in 2020.¹⁵

To further fulfil this mission, the IBGE agreed to include a set of questions from the adult short version of the PCAT¹⁶ in one of the modules of the Brazilian National Health Survey (known as PNS-2019), and the IBGE plans to include questions from the child short version of the PCAT in the IBGE countrywide survey by 2021. In PNS-2019, more than 100 000 households were visited¹⁷ and face-to-face interviews were conducted in all states. Mobile devices were used for electronic data collection and these automatically transmitted the records to a national database. It is worth noting that in Brazil, more than half of the territory is covered by the Amazon rainforest and there are inhospitable locations with limited geographic accessibility, similar to areas in Canada. Additionally, owing to extreme weather, certain areas were only reachable by boat or aircraft.

Brazil’s new and innovative approach to health data gathering using the PCAT might offer inspiration to Statistics Canada to innovate its collection methodology for the CCHS,¹⁸ in particular to adapt the existing PHC module to contain elements of the adult version of the PCAT. The Brazilian experience demonstrated that although adding the adult version of the PCAT to the PNS-2019 demanded a substantial effort in terms of data collection, its addition to the CCHS ultimately would enable the creation of a national and provincial baseline by which to measure the important elements of patient experience in primary care. First results of the PNS-2019 demonstrate that those who use PHC services more frequently in Brazil do a better job at assessing their attributes.¹⁹