Baseline Group, physician and patient characteristics comparing HCES respondents in interprofessional teams versus non-interprofessional teams
As of March 31st, 2015, there were 465 FHO physician groups with HCES respondents of which 177 (38%) were interprofessional teams and 288 (62%) were non-interprofessional teams. Interprofessional teams with HCES respondents had more physicians per group as compared to non-interprofessional teams (means= 13.1 versus 8.84, respectively) and more years under the capitation model (means= 6.0 versus 4.3 respectively).
In this period, there were 4,518 FHO physicians with HCES respondents of whom 2,131 (47.2%) were practicing in interprofessional teams and 2,387 (52.8%) were practicing in non-interprofessional teams. Interprofessional teams compared to non-interprofessional team physicians had: fewer patients per physician (mean=1,366 versus 1,555, respectively); more female physicians (46.3% versus 43.8%, respectively); more physicians in the younger age group under 40 years old (15.4% versus 9.3%, respectively); more physicians who were Canadian graduates (80.9% versus 74.4%, respectively); fewer years in practice (29.1% versus 17.6%, respectively in the 5 to 15 years category) (Table 1A).
There were 10,102 HCES respondents included in this study of whom 42.4% were in interprofessional teams and 42.3% were in non-interprofessional teams. Interprofessional as compared to non-interprofessional teams had fewer HCES respondents who were immigrants (3.1% versus 5.1 %, respectively); fewer HCES respondents in the highest income quintile (23.3% versus 26.4%, respectively); more HCES respondents residing in rural areas (14.2% versus 5.8%, respectively) and fewer patients with two or more comorbidities (42.6% versus 44.3%, respectively) (Table 1B).
Patient-reported timely access to care and after-hours access to care comparing HCES respondents in interprofessional teams versus non-interprofessional teams
HCES respondents in interprofessional teams were slightly more likely to report timely access to care (same/next day) when compared to patients in non-interprofessional teams (39.9% versus 39.1%). HCES respondents in interprofessional teams were less likely to report easy or somewhat easy access to after-hours care compared to patients in non-interprofessional teams (30.8% versus 35.2%).
Patient-reported walk-in clinic visits and emergency department use comparing HCES respondents in interprofessional teams versus non-interprofessional teams
HCES respondents in interprofessional teams reported a lower percent of walk-in clinic visits compared to patients in non-interprofessional teams (19.7% versus 28.2%, respectively) (Table 4 B). A higher percent of HCES respondents in interprofessional teams had emergency department visits as compared to patients in non-interprofessional teams (26.7% versus 23.5%, respectively) (Table 5B).
Association between enrollment in an interprofessional team and the outcomes
When we examined timely access to care while adjusting for physician group, physician and patient characteristics, we found that being in an interprofessional team was associated with an increased odds of patient-reported timely (same/next day) access to care of 12% (OR=1.12 CI=1.00 to 1.24 p-value 0.0436) and decreased odds of self-reporting walk-in clinic use of 16% (OR=0.84 CI=0.75 to 0.94 p-value 0.0019). We did not find significant differences after adjustment between interprofessional and non-interprofessional teams in patient-reported after-hours access to care or in emergency department use (Tables 6).
When we stratified the analyses by sex and by rurality, we did not find a consistent pattern across the outcomes when comparing interprofessional teams with non-interprofessional teams (results not included but can be made available upon request).
We linked the HCES to administrative databases to examine the association between receiving care from interprofessional primary care teams and patient-reported timely access and after-hours access to care, patient-reported use of walk-in clinics and emergency department use. We found that HCES respondents receiving care from interprofessional teams self-reported more timely access to care and less walk-in clinic use. We did not find a significant difference in patient-reported after-hours access to care or in emergency department visits.
The professional management and clinical structure available through interprofessional teams, such as having an Executive Director and allied health professionals can theoretically support access to care.
Although more timely access to care among patients in interprofessional teams is not an expectation in the contractual agreement between teams and the Ministry of Health, previous evidence indicates that enhanced interprofessional team structure can support the availability of the primary care provider by shifting some of their duties to other team members.[i],[ii],[iii],[iv],[v],[vi] The evaluations of Patient-Centered Medical Homes in the United States related to timely access to care suggest that greater availability of providers can free more of their time for patient encounters.[vii] Our findings of generally low timely access to care are comparable to other reports that found only 43% of Canadians report that they were able to have same- or next-day appointment at their regular place of care and identified that Canada continues to perform below the average on timely access to care when compared to other counties included in the Commonwealth Fund International Health Surveys.[viii]
Our findings showed a non-significant difference in patient-reported after-hours access to care between interprofessional and non-interprofessional teams. The provision of after-hours care is an expectation that all FHOs need to meet as part of their contractual agreement with the Ministry of Health.[ix] Although some interprofessional teams operate out of multiple locations, the after-hours services only need to be offered at one location, which may not be convenient for many of the enrolled patients. Also, only one physician is required to be available during each after-hours block which might not be sufficient evening and weekend availability to meet patients’ needs. Previous evidence that compared a slightly different after-hours access to care measure (asking if respondents providers have an after-hours clinic as opposed how easy or difficult was it to get care without going to the emergency department) found that respondents in interprofessional teams self-reported more after-hours access to care.[x]
Although both interprofessional and non-interprofessional teams get penalised equally if their patients visit a walk-in clinic, our finding of significantly lower patient-reported walk-in clinic visits by HCES respondent among interprofessional teams may be explained by the higher patient-reported timely access to care in interprofessional teams, which can contribute to the lower walk-in clinic use. Patients may be less likely to seek care elsewhere if their provider is accessible to them in a timely manner. Additionally, the enhanced administrative structure of interprofessional teams can support reinforcing to patients the need to refrain from walk-in visits as part of being on the group roster. Our findings of a non-significant difference in emergency department use between interprofessional and non-interprofessional teams is consistent with evidence from Canada that looked at utilization in relation to interprofessional team-based care and found differences in quality but not in healthcare utilization.[xi],[xii],[xiii],[xiv]
Some of our findings are not fully consistent with an Ontario provincial analysis where throughout the investigated years (2014 to 2017) timely access to care ranged between 44.3% and 39.9% (compared to 39.5% in our study population), easy or somewhat easy after-hours access to care ranged between 48.0% and 46.0% (vs. 33% in our sample) and walk-in clinic use ranged between 29.6% and 30.5% (vs. 24% in our study).[xv] Those differences can be explained by the slightly different timeframe, inclusion of respondents from all primary care models and slightly larger sample that includes people who declined to have their data linked (6%) for the provincial analysis. Additionally, for the timely access to care question, the provincial analysis included respondents with and without a family doctor whereas our study includes only respondents with a family doctor. Through a personal communication with the Ministry of Health representative who is responsible for the survey, we have confirmed that our study results can be mainly explained by those differences.
Interprofessional teams in Ontario had access to several quality improvement initiatives that hypothetically can contribute to improved outcomes over non-interprofessional teams. The Association of Family Health Teams of Ontario through an initiative called Data to Decisions (D2D) supported interprofessional teams in informing quality improvement through performance measurement. D2D was made possible through the investment in more than 30 Quality Improvement Decision Support Specialists (QIDS Specialists) across Ontario to help interprofessional teams to access and use better data to improve care.[xvi] Timely access to care and emergency department use were among the measurement areas monitored through this initiative.[xvii] The Quality Improvement and Innovation Partnership (QIIP) was another province wide quality-improvement program implemented between 2008 and 2010 to support interprofessional teams to improve the care they provide.[xviii] The learning collaboratives used the Institute for Healthcare Improvement's Breakthrough Series learning model and interprofessional teams were provided with a quality improvement coach who supported and mentored participants throughout the program.[xix] Improved access to care was one of the supported quality improvement areas through QIIP.[xx] Those investments should theoretically be reflected in better outcomes among interprofessional teams. The government’s first priority in establishing interprofessional teams was to increase access to primary care and health services utilization.[xxi] Our results show that interprofessional teams perform better than non-teams in some but not all aspects related to access to care and health services utilization.
Our study has limitations. First, this is an observational study that cannot address causation. It is also cross-sectional so it is not possible to distinguish whether the outcomes examined were pre-existing or were the result of joining or not joining an interprofessional team. Self-reported timely and after-hours access to care are subject to limitations as measures of performance, respondent recall bias being one of them. People living in institutions, people with non-residential phone numbers, and people with invalid/missing household addresses in the Registered Persons Database (RPDB) are not captured in the HCES. Respondents who were unable to speak English or French or were not healthy enough (physically or mentally) to complete the interview were not surveyed. Second, there are other unmeasured factors that might contribute to the decision of having a walk-in clinic visit or using the emergency department that this study cannot capture. These could include personal preference or judgment during the time the service was needed. Third, access to care can be measured in many different ways. The access questions we investigated in this study provide a specific perspective restricted to timely and after-hours access to care. Previous evidence suggests that different measures of timely access are needed to understand health care system performance.[xxii] Fourth, joining interprofessional team-based care was voluntary and our findings could be influenced by some unmeasured factors for physicians who chose to join this model of primary care delivery. Nonetheless, we aimed to capture all measured factors that can be traced through administrative databases. Finally, administrative databases have not been originally collected for research purposes, which presents a limitation in generating and interpreting the information. However, all the databases used for deriving the emergency department measure used in this study have been validated in the Ontario context.