Impact of a provincial quality-improvement program on primary health care in Ontario: a population-based controlled before-and-after study

Michael E. Green; Stewart B. Harris; Susan Webster-Bogaert; Han Han; Jyoti Kotecha; Alexander Kopp; Minnie M. Ho; Richard V. Birtwhistle; Richard H. Glazier

doi:10.9778/cmajo.20160104

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Table 1: Demographic and practice characteristics of physicians in the QIIP and control groups

Characteristic	QIIP group n = 53	Control group n = 1178	p value
Male sex, no. (%)	34 (64.2)	699 (59.3)	0.5
Canadian graduate, no. (%)	49 (92.4)	1035 (87.9)	0.3
Rurality Index of Ontario category, no. (%)			0.1
Major urban (1-9)	26 (49.0)	644 (54.7)
Suburban (10-39)	12 (22.6)	330 (28.0)
Rural (≥ 40)	15 (28.3)	190 (16.1)
Missing	0 (0.0)	14 (1.2)
Rurality Index of Ontario score, mean ± SD	27.00 ± 30.86	17.95 ± 23.12	0.006
Age, mean ± SD	49.85 ± 8.40	48.27 ± 9.47	0.2
Years since graduation, mean ± SD	24.9 ± 9.12	22.5 ± 9.87	0.2
No. of patients, mean ± SD	1475 ± 620	1410 ± 694	0.5

Note: QIIP = Quality Improvement and Innovation Partnership, SD = standard deviation..

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Table 2: Demographic and clinical characteristics of patients of physicians in the QIIP and control groups

Characteristic	No. (%) of patients*
Characteristic	QIIP group n = 78 192	Control group n =1 661 152
Male sex	37 061 (47.4)	773 869 (46.6)
Health card registration within 10 yr of baseline	2431 (3.1)	70 507 (4.2)
Age, yr
≤ 4	3797 (4.8)	87 171 (5.2)
5-9	4242 (5.4)	90 263 (5.4)
10-18	9386 (12.0)	194 222 (11.7)
19-34	13 713 (17.5)	314 618 (18.9)
35-49	17 421 (22.3)	374 856 (22.6)
50-64	17 062 (21.8)	336 481 (20.2)
65-74	6653 (8.5)	136 228 (8.2)
75-84	4421 (5.6)	93 977 (5.6)
≥ 85	1497 (1.9)	33 336 (2.0)
Rurality Index of Ontario category
Major urban (1-9)	38 688 (49.5)	883 085 (53.2)
Suburban (10-39)	22 644 (29.0)	502 829 (30.3)
Rural (≥ 40)	14 148 (18.1)	250 538 (15.1)
Missing	2712 ( .5)	24 700 (1.5)
Income quintile
1 (low)	13 171 (16.8)	288 115 (17.3)
2	14 218 (18.2)	318 724 (19.2)
3	14 925 (19.1)	330 089 (19.9)
4	17 296 (22.1)	358 818 (21.6)
5 (high)	18 062 (23.1)	351 419 (21.2)
Missing	520 (0.7)	13 987 (0.8)
Diagnosis
Diabetes	6225 (8.0)	129 523 (7.8)
Previous acute myocardial infarction	1090 (1.4)	23 082 (1.4)
Asthma	10 539 (13.5)	223 053 (13.4)
Chronic heart failure	1602 (2.0)	32 455 (2.0)
Chronic obstructive pulmonary disorder	5462 (7.0)	105 023 (6.3)
Hypertension	16 859 (21.6)	352 751 (21.2)
Mental health disorder	15 295 (19.6)	316 221 (19.0)
Adjusted Diagnosis Group
0	4538 (5.8)	94 961 (5.7)
1-5	41 814 (53.5)	871 048 (52.4)
6-9	26 956 (34.5)	587 558 (35.4)
≥ 10	4884 (6.2)	107 585 (6.5)
Resource Utilization Band, mean ± SD	2.62 ± 1.10	2.63 ± 1.10

Note: QIIP = Quality Improvement and Innovation Partnership, SD = standard deviation.

*Except where noted otherwise.

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Table 3: Rates of completion of diabetes management measures by physicians in the QIIP and control groups

Measure		Time; % of physicians		Adjusted % change, QIIP group v. control group (95% CI)*
Measure		12 mo before intervention or index date	12 mo after intervention or index date	Adjusted % change, QIIP group v. control group (95% CI)*
Hemoglobin A_1c test: ≥ 2 in previous 12 mo	QIIP group	41.1	51.4	4.3 (1.2 to 7.5)
Hemoglobin A_1c test: ≥ 2 in previous 12 mo	Control group	42.7	48.0
Retinal examination: ≥ 1 in previous 24 mo	QIIP group	72.5	76.6	2.5 (0.8 to 4.4)
Retinal examination: ≥ 1 in previous 24 mo	Control group	71.6	73.3
Low-density lipoprotein cholesterol test: ≥ 1 in previous 12 mo	QIIP group	56.9	64.0	1.3 (-2.1 to 4.6)
	Control group	59.5	64.7
Billing for diabetes flow sheet (K030): ≥ 1 in previous yr	QIIP group	27.6	42.8	8.8 (4.1 to 13.5)
Billing for diabetes flow sheet (K030): ≥ 1 in previous yr	Control group	34.4	39.0
Billing for preventive care of diabetes (Q040)	QIIP group	21.7	39.1	8.9 (2.9 to 14.9)
Billing for preventive care of diabetes (Q040)	Control group	28.8	35.0
Diabetes medication management for patients with type 2 diabetes > 65 yr
Prescribed statin	QIIP group	66.5	74.5	3.4 (0.8 to 6.0)
Prescribed statin	Control group	67.6	71.9
Prescribed angiotensin-converting-enzyme inhibitor or angiotensin receptor blocker	QIIP group	74.1	78.4	4.1 (1.8 to 6.4)
	Control group	76.0	75.0
Prescribed orally administered hypoglycemic agent	QIIP group	59.6	59.2	0.8 (-1.8 to 3.3)
Prescribed orally administered hypoglycemic agent	Control group	58.7	57.6
Prescribed insulin	QIIP group	17.1	18.5	-0.3 (-2.3 to 1.7)
Prescribed insulin	Control group	15.9	17.9

Note: CI = confidence interval, QIIP = Quality Improvement and Innovation Partnership.

*Generalized linear regression adjusted for baseline value, sex, rurality, age and comorbidity (Johns Hopkins Adjusted Diagnosis Groups³⁰).

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Table 4: Rates of completion of screening measures for colorectal cancer and cervical cancer by physicians in the QIIP and control groups

Measure		Time; % of physicians		Adjusted change, QIIP group v. control group (95% CI)*
Measure		12 mo before intervention or index date	12 mo after intervention or index date	Adjusted change, QIIP group v. control group (95% CI)*
Colorectal cancer
Fecal occult blood testing within previous 2 yr	QIIP group	41.1	52.2	8.5 (5.1 to 12.0)
Fecal occult blood testing within previous 2 yr	Control group	39.5	42.8	8.5 (5.1 to 12.0)
Colonoscopy within previous 5 yr	QIIP group	24.5	29.7	0.02 (-1.7 to 1.8)
Colonoscopy within previous 5 yr	Control group	26.6	31.7	0.02 (-1.7 to 1.8)
Flexible sigmoidoscopy/barium enema	QIIP group	5.8	3.8	-0.03 (-0.1 to 0.3)
Flexible sigmoidoscopy/barium enema	Control group	6.3	4.4	-0.03 (-0.1 to 0.3)
Any screening	QIIP group	57.2	67.1	5.4 (3.1 to 7.8)
Any screening	Control group	57.6	62.4	5.4 (3.1 to 7.8)
Cervical cancer
Papanicolaou test within previous 2 yr	QIIP group	61.7	63.5	2.3 (0.5 to 4.1)
Papanicolaou test within previous 2 yr	Control group	62.3	61.4	2.3 (0.5 to 4.1)
Papanicolaou test within previous 3 yr	QIIP group	72.2	75.1	2.7 (0.9 to 4.6)
Papanicolaou test within previous 3 yr	Control group	72.9	72.7	2.7 (0.9 to 4.6)

Note: CI = confidence interval, QIIP = Quality Improvement and Innovation Partnership.

*General linear regression for baseline value, sex, rurality, age and comorbidity (Johns Hopkins Adjusted Diagnosis Groups³⁰).

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Table 5: Rates of access to care (emergency department visits, hospital admission and hospital readmission) for physicians in the QIIP and control groups

Measure		Time; rate		Adjusted change, QIIP group v. control group (95% CI)
Measure		12 mo before intervention or index date	12 mo after intervention or index date	Adjusted change, QIIP group v. control group (95% CI)
Emergency department visits per 100 patients per yr
Canadian Triage and Acuity Scale score 1-3	QIIP group	20.8	24.7	0.1 (-1.3 to 1.5)
Canadian Triage and Acuity Scale score 1-3	Control group	22.0	24.9	0.1 (-1.3 to 1.5)
Canadian Triage and Acuity Scale score 4-5 (low acuity)	QIIP group	36.7	29.3	-1.0 (-3.3 to 1.2)
Canadian Triage and Acuity Scale score 4-5 (low acuity)	Control group	28.8	24.6	-1.0 (-3.3 to 1.2)
Hospital admission for ambulatory-care-sensitive condition per 10 000 patients per yr
Overall	QIIP group	52.8	51.5	3.0 (-5.0 to 11.0)
Overall	Control group	42.7	42.1	3.0 (-5.0 to 11.0)
Diabetes	QIIP group	8.0	8.4	0 (-3.0 to 3.0)
Diabetes	Control group	7.5	7.2	0 (-3.0 to 3.0)
Asthma	QIIP group	5.0	2.9	-1.0 (-2.0 to 1.0)
Asthma	Control group	4.1	3.3	-1.0 (-2.0 to 1.0)
Chronic obstructive pulmonary disease	QIIP group	25.9	28.1	6.0 (1.0 to 11.0)
Chronic obstructive pulmonary disease	Control group	18.5	18.3	6.0 (1.0 to 11.0)
Cardiac heart failure	QIIP group	13.9	12.1	-3.0 (-6.0 to 1.0)
Cardiac heart failure	Control group	12.7	13.2	-3.0 (-6.0 to 1.0)
Hospital readmission (% of those admitted to hospital)
Within 30 d	QIIP group	5.5	5.5	-0.03 (-0.08 to 0.08)
Within 30 d	Control group	5.1	5.3	-0.03 (-0.08 to 0.08)
Within 1 yr	QIIP group	17.0	17.4	0.2 (-1.1 to 1.6)
Within 1 yr	Control group	15.8	15.9	0.2 (-1.1 to 1.6)