The Economic Impact of Improvements in Primary Healthcare ...€¦ · tHe eConoMiC iMPaCt oF...

Canadian Health Services Research Foundation

The Economic Impact of Improvements in Primary Healthcare Performance

Canadian Health Services Research Foundation

TEAMInvestigators:Simone DahrougeRose Anne DevlinBill HoggGrant RussellDoug CoyleDean Fergusson

Research Associates:Thy DinhClaude HébertKarina MillMichelle PrenticeNatalie Ward

chsrf.ca

Canadian HealtH ServiCeS reSearCH Foundation

This document is available at www.chsrf.ca.

This research report is a publication of the Canadian Health Services Research Foundation. Funded through an agreement with the Government of Canada, CHSRF is an independent, not-for-profit organization that is dedicated to accelerating healthcare improvement and transformation for Canadians. The views expressed herein are those of the authors and do not necessarily represent the views of CHSRF or the Government of Canada.

ISBN 978-1-927024-43-0

The Economic Impact of Improvements in Primary Healthcare Performance © 2012, Canadian Health Services Research Foundation.

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tHe eConoMiC iMPaCt oF iMProveMentS in PriMarY HealtHCare PerForManCe 3

TABLE OF CONTENTSPrimary healthcare ...............................................................................................................8

This report .............................................................................................................................8

The gaps in canada’s PHC performance level.....................................................................9

Technical quality of care (Figure 1) ...................................................................................10Accessibility (Figure 2) ........................................................................................................11Quality improvement initiatives (Figure 3) .....................................................................12Practice organization (Figure 4) ........................................................................................13Discussion .............................................................................................................................13

Interventions to improve quality in primary healthcare ................................................14

Quality improvement initiatives ........................................................................................14Information technology ......................................................................................................15Human resources .................................................................................................................15Discussion .............................................................................................................................16

Economic impact of improvements in PHC ....................................................................17

The link between PHC services and economics: A review of the literature ...............17The link between PHC and health (Arrow 1) ..................................................................17Macroeconomic factors and health (Arrow 2) ................................................................18Microeconomic factors and health (Arrow 3) .................................................................19Conclusions ...........................................................................................................................19

The economic impact of adding a pharmacist in a PHC practice: A systematic review ............................................................................................................20

Introduction ..........................................................................................................................20Methods .................................................................................................................................20Results ....................................................................................................................................21Discussion .............................................................................................................................23

A simulation of the impact of improvements in influenza vaccination rates ...............25

Model based simulator ........................................................................................................25Scenarios ................................................................................................................................26Data ........................................................................................................................................26Results ....................................................................................................................................27Sensitivity analysis ................................................................................................................29Conclusions ...........................................................................................................................30

Canadian HealtH ServiCeS reSearCH Foundation 4

Economic impact of improvements in selected indicators .............................................31

Introduction ..........................................................................................................................31Hypertension ........................................................................................................................31Diabetes .................................................................................................................................32Cancer ....................................................................................................................................33Continuity .............................................................................................................................34Discussion .............................................................................................................................35

Recommendations and expert commentaries .................................................................36

Findings .................................................................................................................................36National coordination body ...............................................................................................36Investments in primary healthcare ....................................................................................36Investing in high quality PHC research/evaluation ........................................................37Limitations ............................................................................................................................37Conclusions ...........................................................................................................................37

APPENDICES ....................................................................................................................38

Appendix: A: Result-based logic model for PHC ............................................................38Appendix: B: OECD framework ........................................................................................39Appendix: C: Synthesis of review literature – study protocol .......................................40Appendix: D: Description of studies included in the section on interventions to improve PHC performance ...............................................................46Appendix: E: Systematic review – study protocol ...........................................................58Appendix: F: Quality assessment checklist and quality assessment results ................64Appendix: G: Flow diagram summarizing the flow of information through the different phases of the systematic review. ...............................................66Appendix: H: Included studies ...........................................................................................67Appendix: I: Elderly population projections from 2010 to 2036 ..................................71Appendix: J: Population vaccination rates for elderly population in 2007 .................71Appendix: K: Simulation results by province ..................................................................72Appendix: L: References ......................................................................................................78


KEY MESSAGES ◥ The performance of Canada’s primary healthcare (PHC) system lags behind that of other

industrialized countries. Well-targeted investments in PHC can improve the health of individuals and populations, which can in turn have a positive impact on macro-economic indicators, such as employment rates, productivity and economic growth.

◥ There are important gaps in Canadian PHC systems that require improvement. These include accessibility of PHC services, technical quality of care, quality improvement initiatives and practice organization.

◥ Various interventions and investments have been shown to enhance the performance of PHC, improve the quality of care and produce economic savings. These include incorporating pharmacists into PHC teams, case-management strategies to enhance chronic disease management, and electronic medical records that include patient recall and provider reminders for preventive care and chronic disease management.

◥ This report presents the results of four different approaches to evaluate the economic impact of enhancements to PHC:1. A synthesis of the literature on the macro- and micro-economic effects of good health, with

specific relevance to PHC performance.2. A systematic review of the economic impact of incorporating a pharmacist into a PHC practice.3. A simulation exercise that evaluates the economic impact of improvements to influenza

immunization rates for older adults brought about by provider reminder systems in PHC.4. A literature review of reductions in burden of illness associated with four specific

enhancements to chronic disease management in PHC that produce health benefits. These include PHC improvements that result in improved blood pressure control, enhanced diabetes management, increased uptake of cancer screening and improved continuity of care.

◥ Three of the four approaches used in the report suggest that improvements to the performance of PHC in Canada would yield economic benefits. Better health outcomes have a positive impact on employment, productivity and economic growth. Simulation results indicate that increasing the influenza vaccination rate of the elderly population results in cost savings. Improved health outcomes for chronic disease management were linked to cost savings through reductions in hospitalizations, professional visits, emergency room visits and increased productivity; and higher continuity of care was associated with lower resource utilization and reduced healthcare costs. Despite literature that shows a positive health benefit of pharmacist integration in PHC, studies of the economic impact are inconclusive.

◥ There are knowledge gaps and weaknesses in the current structure of Canadian PHC systems. The creation of a National Coordination Body, additional investment to improve Canada’s PHC performance and additional investment in PHC research and evaluation is recommended.


EXECUTIVE SUMMARYThe objective of this report is to illustrate the economic impact of improvements in PHC. Commonwealth data show that PHC services delivered in Canada are of moderate technical quality and are poorly accessible. This hinders the PHC system’s ability to provide technically adequate care to patients and negatively affects the efficiency of the entire healthcare system, because it results in a deflection of care to other sectors. Improvement in both technical quality and accessibility of PHC services could be achieved if organizational and structural support were made available to Canadian PHC practices, yet Canada has fewer quality improvement initiatives and poorer practice organization than other countries.

The use of quality improvement initiatives such as audit and feedback, and interventions aimed at optimizing practice organization through information technology (e.g., EMR-based patient-recall systems and provider reminders for processes of care, clinical decision making and drug order entry), and care delivery through multidisciplinary teams can improve the quality of care delivered. The performance of Canada’s PHC system can be enhanced through strategic national investments in these areas.

Four different approaches to evaluate the potential economic impact of enhancements to the PHC system are used. First, the macro- and micro-economic effects of good health are described and linked to PHC performance. Second, the results of a systematic review to assess the economic consequences of effective PHC intervention, adding a pharmacist to a PHC practice are presented. Third, a simulation exercise to evaluate the economic impact of improvement in influenza immunization for older adults through the use of a practice-based reminder system is carried out and the results are presented. Finally, examples from the available literature that demonstrate the potential cost consequences of four specific improvements in PHC are presented: improved blood pressure control; enhanced diabetes management; increased uptake of cancer screening; and better continuity of care.

In terms of macroeconomic effects, the literature reviewed in this study suggests that better primary care leads to better health outcomes, which themselves may lead to increased employment and increased growth and productivity.

Based on the review findings, pharmacist integration in PHC practice has the potential to be cost effective based on the estimated return on investment, especially in the control of common chronic diseases, including blood pressure control among patients with hypertension and haemoglobin levels among patients with diabetes. However, stronger evidence and better quality studies are required to draw confident conclusions.

Based on the results of a simulation exercise, an increase in the performance of PHC (as measured by increased immunization rates) would confer a significant economic benefit in cost savings associated with reduced healthcare utilization. The simulation exercise is based on the use of telephone reminder systems in PHC to increase rates of influenza vaccinations among the elderly. If an increase in the influenza vaccination rate of 2.5 percentage points for the elderly were achieved, conservative estimates suggest that healthcare costs could fall by more than $16 million, with net benefits of $8.7 million after taking the costs of affecting this increase into account. Additional benefit, not captured in the estimates may result from additional contact with a healthcare professional in order to get vaccinated, which may strengthen the patient-physician relationship and foster better continuity of care (factors that could improve care at future encounters).

The literature suggests that improvements in PHC can result in improved health outcomes for three chronic diseases (hypertension, diabetes and cancer) and through improved continuity of care. Estimates of the value of the improvement in health can be derived from estimates of the burden of disease; however, these


estimates focus only on the potential economic gains of improving health and do not include the costs of interventions that are required to achieve these improvements. The estimates suggest substantial potential reductions in burden of illness; however, the magnitudes must be interpreted with caution because most of the available literature can be considered more advocacy than scientific in nature.

This report finds that significant gaps in Canada’s PHC performance exist, and that several PHC interventions offer the possibility of improving its current status. Three of the four approaches to measuring the value of improvements to PHC demonstrated that improvements in PHC performance would yield economic benefits. While all studies suggested a cost saving, none have adequately considered all facets of costs, and most were deemed only of moderate reporting quality.

The international comparison conducted by the Commonwealth Fund demonstrates that Canada’s performance in several indicators of the strength of its PHC sector is poor. These deficiencies create inefficiencies in care delivery. A poor PHC system reduces the effectiveness of other healthcare sectors. Strengthening PHC can significantly alleviate pressures in other parts of the healthcare system.

There are several interventions for which strong evidence of effectiveness exists. For example, the use of information technology can improve preventive care, as exemplified in the stimulation of an EMR-facilitated increase in influenza vaccination uptake described herein. It is recommended that a comprehensive and systematic review be conducted to assess the strength of the evidence supporting different strategies. Decisions about the optimal investment areas within PHC is best determined by combining information about each intervention’s effectiveness, acceptability to the user and estimated economic impact.

It is recommended that a national coordination body be established to facilitate dialogue and planning efforts across jurisdictions to improve PHC in Canada. Canada has a tremendous opportunity to learn from the natural experiment currently taking place across its jurisdictions, as well as from a better understanding of the policies, practices and organizational structure of successful PHC in OECD countries, through a similar scoping exercise to that conducted by the Commonwealth Fund Commission.

There is currently insufficient information about the economic impact of PHC investment strategies to inform further investments. Most current economic evaluations are far too narrow in scope, poorly reported and suffer from too short a time horizon. More rigorous economic evaluation (such as cost-effectiveness or cost-benefit research) that considers all costs and includes an assessment of longer-term impacts on costs and health benefits is required. Where long-term study designs are not feasible, the use of modeling (simulations) can predict long-term effects.

Canada requires an ongoing monitoring strategy that would allow continuous assessment of its performance and permit researchers to evaluate the impact of various reform strategies on the quality of care delivered, the efficiency of the system and the economic burden of PHC-sensitive illnesses. For this to be feasible, a common reporting structure of indicators, with standardized data, is required across Canadian jurisdictions. Such a strategy may be facilitated by a national coordinating body.

Because of the complex nature of PHC, the impact of an investment in PHC to achieve one endpoint is likely to have a much broader effect. The true potential impact across the entire healthcare system is likely underestimated in the report.


PRIMARY HEALTHCAREThe last 20 years have seen an increasing recognition of the importance of primary healthcare (PHC) to population health.1-6 Countries with a greater PHC orientation have lower rates of mortality and better health outcomes.5-9 PHC also improves and sustains the healthcare system at other levels. For instance, when PHC practitioners are the gatekeepers of healthcare delivery, they can reduce unnecessary costs and the need for specialty care through improving the quality of prevention, coordination and continuity of care.4;10

Organisation for Economic Co-operation and Development (OECD) countries have made PHC their central focus for achieving healthcare reform.11 Within Canada, it is held that, in reference to efforts to strengthen PHC, “no other initiative holds as much potential for improving health and sustaining our healthcare system.”2 Recent surveys conducted by the Commonwealth Fund suggest that, compared to other developed countries, Canada’s PHC sector is poorly organized and supported, suggesting that considerable gains can be achieved through strategic investments in that sector.12-15

THIS REPORTThe objective of this report is to illustrate the economic impact of improvements in PHC. To achieve this, we begin by highlighting the current gaps in the Canadian PHC system. We then demonstrate that there are effective interventions and investments that can enhance the system’s performance. To demonstrate this, we report on selected reviews that have shown a positive effect of specific PHC interventions on the quality of care. We then apply four different approaches to evaluate the potential economic impact of enhancements to the PHC system. First, we describe the macro- and micro-economic effects of good health and link these effects to PHC performance. Second, we highlight the results of a systematic review we undertook to assess the economic consequences of another effective PHC intervention: adding a pharmacist to a PHC practice. We chose this intervention because a knowledge synthesis of published literature suggests a potential positive economic impact. Third, we report on a simulation exercise we performed to evaluate the economic impact of improvement in influenza immunization for older adults which can be achieved through the use of a practice based reminder system. Finally, we provide examples from the available literature that demonstrate the potential cost consequences of four specific improvements in PHC: improved blood pressure control, enhanced diabetes management, increased uptake of cancer screening and better continuity of care. We conclude the report with recommendations for future investment.

The ultimate goal of healthcare improvements is to achieve better health. In many studies, the indicators used are intermediate outcomes that are known to be related to the desired health outcome. For these studies, we relied on the logic model developed by Watson et al. (Appendix A), which “links (PHC) resource inputs to activities performed, services delivered, and outcomes achieved” to relate gains in PHC performance to health gains.16 The logic model allows us to conceptually demonstrate the connection between the performance measures on which many studies report and the ultimate health outcome.

We used the conceptual framework for the OECD Healthcare Quality Indicators to guide our economic evaluation (Appendix B). This framework ties together quality of care, accessibility and costs.


THE GAPS IN CANADA’S PHC PERFORMANCE LEVELIn recent years, concerns have emerged regarding the quality and accessibility of PHC in Canada. International and national comparisons suggest that Canada ranks below other nations and displays significant regional variability in the quality of PHC.12;15;17-19

In this section, we compare Canada to other countries across four sets of indicators. Two of these (accessibility and technical quality of care) are measures of the quality of care delivered that have been linked to better health outcomes. The other two (the presence of quality-improvement initiatives and practice organization) are indicators of practice- or system-level initiatives that are expected to support better delivery of care. These indicators are taken from the Commonwealth Fund studies evaluating PHC performance.12;15;18 While the Commonwealth Fund studies report on a large number of indicators and are commonly used to assess the quality of PHC, we felt that not all the indicators used were demonstrated to be associated with better care or health outcomes. For that reason, we chose to present a subset of indicators that we believe are robust indicators of PHC performance/outcome. We also relied on a previous Canadian Health Services Research Foundation (CHSRF) report, Quality of Healthcare in Canada: A Chartbook, to highlight differences in the PHC performance across provinces.19

Technical quality of care Commonly used indicators to measure the quality of care delivered include processes of care in the management of chronic diseases and in prevention. These are components of the PHC “Outputs” (Appendix A) and are predictive of health outcomes. Canada’s performance in these respects is relatively comparable to that of other developed countries. For example, Canadian women are as likely as those living in other OECD countries to have undergone breast and cervical cancer screening. Canada has somewhat poorer quality of diabetes management, but leads in medication review.

There is also considerable regional variation in PHC performance within Canada.19 For example, in 2007, 29% of all Canadians with diabetes had received all four recommended diabetes care processes, ranging from 21% in Newfoundland to 34% in both Alberta and British Columbia. Influenza vaccination coverage, recommended as preventive care for individuals 65 years of age and over, was 64% in Canada in 2007, but only 48% in Newfoundland and85% in Nunavut.


Figure 1: technical quality of care – Canada’s performance in relation to other oeCd countries

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MammogramPap Test

Cholesterol CheckBlood Pressure Monitoring

Diabetes Management

Medication Review

Hypertension

Asthma/COPD

Diabetes

% Positive Indicator

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Notes: Diabetes – Practice routinely uses written guidance to treat diabetes (% yes);15 Asthma/COPD – Practice routinely uses written guidance to treat asthma or COPD (% yes);15 Hypertension – Practice routinely uses written guidance to treat hypertension (% yes);15 Medication review – How often have any of your doctors or pharmacists reviewed and discussed all medications you are using [in patients with chronic conditions]? (% often, always);18 Diabetes management – Received all four: HbA1c checked in past six months: feet examined for sores or irritations in past year; eye exam for diabetes in past year; cholesterol checked in past year [in patients with diabetes]? (% yes);18 Blood pressure – Blood pressure checked in past year [in patients with chronic conditions]? (% yes of all respondents);18 Cholesterol check – Cholesterol checked in past year [in patients with chronic conditions]? (% yes of congestive heart failure, hypertension and diabetes patients);18 Pap test – Percent of women receiving Pap test at intervals recommended in each country for age group;12 Mammogram – Percent of women receiving mammogram test at intervals recommended in each country for age group.12

AccessibilityCanadians have problems accessing PHC services. While most Canadians (92% in 2009) can identify a family physician from whom they would seek care, Canada performs poorly with regards to all other indicators of accessibility.20 Canadians have inadequate after-hours access, have difficulty getting an appointment when needed and make inappropriate use of emergency room visits. Glazier et al. estimated that the limited availability of regular family physicians led to an estimated 17,741 excess emergency department visits, and 1,932 excess hospital admissions over two years among Ontario patients with chronic conditions.21 Accessibility is an important barometer of PHC quality. Poor accessibility in the PHC system has a significant impact on the overall healthcare system efficiency and sustainability, and on patient outcome.


Figure 2: accessibility – Canada’s PHC system performance in relation to other oeCd countries

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No ER use for non urgentSame/ next day apt

Regular doctor

After hours access


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Notes: After hours – After-hours arrangement to see doctor/nurse without going to ER;15 Regular doctor – Do you have a doctor or GP you regularly see [in patients with chronic conditions]? (% yes);18 Same/next day appt – Last time you were sick or needed medical attention, how quickly can you get an appointment to see a doctor [in patients with chronic conditions]? (% same or next day appointment);18 Off-hours care – How difficult is it to get care on nights, weekends, or holidays without going to the ER [in patients with chronic conditions]? (% very or somewhat easy);18 No ER use for non urgent – Did not go to ER for a condition that could have been treated by regular doctor or source of care if available [in patients with chronic conditions] (% yes).18

Quality-improvement initiativesHealth authorities can support quality care by shaping the context within which the practices operate. For example, they can aim to optimize care delivery by providing incentives for achieving target levels of quality (e.g. pay-for-performance initiatives), direct financial or in-kind support to enhance practice organization (e.g. implementation of electronic medical records (EMRs) or introduction of non-physician healthcare providers) or a mechanism for clinicians to monitor their performance level, all of which are measures aimed at optimizing care delivery. The logic model in Appendix A demonstrates the link between context, PHC performance and health outcomes.

Because the Canadian healthcare system is administered provincially, and because Canada lacks a coordinated national strategy for PHC, the Canadian PHC landscape is a patchy arrangement of reform initiatives with no nationwide adoption of strategies. As a result, quality improvement measures vary considerably across provinces. Figure 3, below, shows that, in contrast to many other OECD countries, Canadian health authorities are less likely to monitor or reward practices for patient satisfaction or achievement of clinical targets. The Canadian Working Group for Primary Healthcare Improvement is currently drafting a national strategy for PHC that is expected to support enhancements in primary care organization and harmonization of strategies across provinces.


Figure 3: Quality-improvement initiatives – Canada’s PHC system performance in relation to other oeCd count

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Clinical performancePatient satisfactionClinical outcomes

Multidisiplinarity

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Notes: Incentive/Support: Do you have the potential to receive or do you receive extra financial support or incentives based on any of the following? (This includes bonuses, special payments, higher fees, or reimbursements.): Patient satisfaction – High patient satisfaction ratings. (% yes);15 Clinical targets – Achieving certain clinical targets (% yes);15 Complex needs – Managing patients with chronic disease or complex needs (% yes);15 Preventive care – Enhanced preventive care activities, including patient counselling or group visits (% yes);15 Multidisciplinarity – Adding non-physician clinicians to your practice team (e.g., nurse for chronic disease management) (% yes).15

Feedback: Patient satisfaction – Does the place where you practice routinely receive and review data from surveys of patient satisfaction and experiences with care? (% yes);15 Clinical outcomes – Does the place where you practice routinely receive and review data on clinical outcomes (e.g., percent of diabetics or asthmatics with good control)? (% yes);15 Clinical performance – Are any areas of your own clinical performance reviewed against targets at least annually? (% yes).15

Practice organizationThe quality of the PHC system is also influenced by how it is organized to meet the needs of individuals and the population (depicted as “Inputs” in Appendix A). In a recent international comparison conducted by the Commonwealth Fund, Schoen ranks Canada and the United States lowest in terms of effective practice organization.13 The Commonwealth Fund studies use several indicators of organizational effectiveness. We chose to present three commonly agreed-upon important indicators: use of EMRs, information technology and multidisciplinarity.

Canada trails other countries in its adoption of information technology. In 2009, little more than one-third of Canadian family physicians reported using an EMR. In contrast, on average, four in five family physicians from the 11 surveyed countries reported having these electronic tools. Currently, approximately half of Canadian family physicians work in multidisciplinary practices, significantly fewer than in most other OECD countries. In a separate section of this report, we review the evidence supporting the use of non-physician health professionals in PHC practice.


Figure 4: Practice organization – Canada’s PHC system performance in relation to other oeCd countries

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e-information (high count=9-14)

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Notes: EMR – Use of EMRs in practice (% yes);15 e-information – Count of 14 functions such as electronic ordering of medications and tests, computer access to test results and medication lists, computer alerts/prompts and decision support;15 Multidisciplinary team – Practice uses non-physician staff to manage care (% yes).15

DiscussionThe Commonwealth data show that PHC services delivered in Canada (“Outputs” in Appendix A) are of moderate technical quality. Moreover, these services are poorly accessible in Canada. This hinders the PHC system’s ability to provide technically adequate care to patients and negatively affects the efficiency of the entire healthcare system, because it results in a deflection of care to other sectors. Improvement in both technical quality and accessibility of PHC services could be achieved if organizational and structural support were made available to Canadian PHC practices, yet Canada has fewer quality-improvement initiatives and poorer practice organization than other countries.

In the next section we demonstrate that addressing some of the system-level deficiencies, through better use of its resources (“Contexts” and “Inputs” in Appendix A), Canada can improve the quality of its PHC system.


INTERVENTIONS TO IMPROVE QUALITY IN PRIMARY HEALTHCAREThis section provides published evidence demonstrating that quality-improvement initiatives and practice organization can lead to improvements in the quality of care delivered. We performed a systematic literature search for evidence on feasible and effective strategies for enhancing PHC quality. The review included publications from multiple electronic databases for the years 2000 to 2010. With one exception (financial incentives), we focused exclusively on published systematic reviews or meta-analyses to ensure that the evidence presented is robust. Because pay-for-performance incentives are increasingly being adopted as a measure of quality improvement, we report on their impact, despite the lack of currently available systematic synthesis of the literature on the subject.

Medical Subject Headings (MeSH) and keywords, such as “primary care or primary healthcare or general practice or family practice or family medicine,” were used to identify the relevant literature. We focused on studies amenable to Canadian policy intervention or practice organization. These interventions fall into three categories: quality-improvement initiatives, information technology and human resources. The quality of the reviews were assessed using the AMSTAR scale, which evaluates systematic review quality, and only those with an AMSTAR score of 4 or higher (reviews of moderate to high quality) were retained for evidence synthesis.22 The full study protocol and a description of the included studies are presented in Appendices C and D. The results of the included reviews are synthesized under each intervention category.

Quality-improvement initiativesQuality-improvement initiatives are healthcare management-level or practice-level activities used to optimize care.

Financial incentives: Our summary of the impact of financial incentives on quality care in PHC is based on individual studies, as no systematic reviews are available on this topic. Many of these studies assessed the UK Quality of Care Framework (QOF), which contains financial incentives in PHC in concert with other PHC performance-enhancement interventions.23-29 These studies and others conducted with audit and feedback30 demonstrate some improvements in the indicators for which incentives were built. Since QOF was not studied under an experimental design, however, and since the program includes more than one intervention, it is difficult to attribute improvements strictly to the financial incentives themselves.31 There are also other concerns with pay-for-performance initiatives. These may have some unintended negative consequences, such as a decrease over time in quality indicators that are not covered under the incentive program.23 By their nature, these initiatives shift the care paradigm towards a more biomedical model of healthcare, rather than holistic and patient-centred.32 Also, most financial incentives are provided to the family physician and not the entire team, potentially having a negative impact on intra-practice relationships, causing resentments and lowering motivation.33

Audit and feedback: A meta-analysis of audit and feedback studies shows that this strategy is generally effective in improving practice outcomes such as appropriate care, procedures, screening, test ordering, referrals, health promotion, preventive services, diagnostics and record keeping.34 Across the 19 studies included in the meta-analysis, audit and feedback was found to have a medium-to-large effect (Cohen’s d = 0.40, 95% confidence interval = ±0.20). Similarly, most moderate-to high-quality reviews found evidence of a small to moderate effect size on practice outcomes,29;35;36 although one review did not find sufficient evidence to determine its effectiveness.37 In other reviews of more targeted outcomes, audit and feedback was found generally effective in improving cancer screening30

and immunization uptake,38;39 as well as appropriate antibiotic prescribing.40


Information technologyInformation technology (IT) interventions typically take place in the context of clinical practices with EMR systems. The use of these IT systems is considered a clinical activity (Appendix A). The implementation of different EMR-based IT functions has been measured in terms of their ability to affect PHC outcomes. Our review assessed the effectiveness of adopting EMR-based patient-recall systems and EMR-based provider reminders for processes of care, clinical decision making and drug order entry.

There is high-quality evidence from systematic reviews supporting the adoption of patient-recall systems for enhancing preventive care. Patient-recall systems improve immunization rates, both for influenza and other vaccine targets.41;42 These systems are also effective in improving levels of colon cancer,42 cervical cancer,42;43 and breast cancer screening,42;44 and in increasing the proportion of hypertensive patients who attended follow-up, which in two small trials led to improved blood pressure control.45

Standard reminder prompts to PHC practitioners are generally effective across many processes of care and outcomes,46 showing at least a moderate effect on processes such as prescription of vaccinations, tests and medication;45 administration of cancer screening; and adherence to recommended guidelines for chronic disease management.35;47

Provider reminders in the form of clinical decision support systems and/or computerized physician order entry were found to be effective in many areas of medication management,48 resulting in improved drug choices for outpatients,49;50 increased appropriate use and drug safety51;52 and reduced adverse drug events.53

Human resourcesPrimary care in Canada has traditionally been delivered by family physicians working in small, office-based practices. In many provinces, however, recent policy changes have encouraged a move to a multidisciplinary model of care. A number of reviews, including many systematic reviews, as well as one meta-analysis, have shown that nurses play an important role in PHC. They participate in patient education/management and facilitate compliance,54-58 improve the management of patients with major depression55;59 and improve clinical outcomes.60;61

The involvement of a pharmacist in a family practice has been associated with improved medication adherence, appropriate prescribing and disease-appropriate outcomes.60 In a few studies, higher survival among patients was documented in pharmacist-led interventions in PHC.62 Pharmacists can play a role in improving diabetes by increasing medication adherence, promoting patient education, and improving patient-healthcare provider communication.63 Pharmacist-led interventions in PHC have also been found effective in controlling blood pressure among hypertensive patients56 and improving prescribing of antidepressants for older patients.56;64-67

The implementation of collaborative care delivered by a multidisciplinary team has been associated with improvements in mental health and preventive care.56;67-69 However, there is little evidence that such improvements are sustainable or responsive to the degree of collaboration.42;66;68;69 Assigning a case manager has been identified as one of the key elements in improving clinical outcomes, even for complex interventions.19;30;35;61;63;70-72 Positive results were associated with case management when it was provided by nurses as well as many different types of PHC providers.61 One study found favourable effects on processes of care and patient outcomes when combining a multidisciplinary team with both case management and patient education.56


DiscussionThis section demonstrates that effective system-level quality-improvement initiatives and interventions aimed at optimizing practice organization can improve the quality of care delivered. Given that these are two areas in which Canada is deficient, we suggest that the performance of Canada’s PHC system can be enhanced through strategic national investments.

The purpose of this exercise was to demonstrate the evidence base for effective interventions. We did not attempt to identify all effective interventions. For that reason, with one exception, the evidence garnered in this section was restricted to systematic reviews or meta-analyses. We recognize that limiting the scope of the work that way will have inevitably resulted in overlooked effective interventions for which no systematic reviews exist. For example, there is considerable evidence that access greatly affects patient outcomes, but this evidence is not presented as these studies have not been synthesized.73-76


ECONOMIC IMPACT OF IMPROVEMENTS IN PHC In this section, we use four approaches to demonstrate the economic effect of PHC improvements. First, we synthesize the literature on the relationship between health and economics, with a focus on PHC. Second, we present the results of our systematic review designed to assess the economic consequences of adding a pharmacist to a PHC practice; a strategy that has been demonstrated to improve chronic disease management. Third, we report on a simulation exercise that we performed to evaluate the economic impact of enhancing influenza immunization in older adults. Finally, using published work, we work through a few examples that demonstrate how improvements in PHC can lead to cost savings.

The link between PHC services and economics: a review of the literatureThis section demonstrates that improvements in PHC can enhance the health and welfare of individuals. The literature suggests links between socioeconomic factors and health as well as employment and health. It shows that better health has positive effects on employment, thus improving the economic wellbeing of individuals and families. Increased health can also promote growth and productivity, which would lead to improved population health measures.The OECD framework (Appendix B) highlights the importance, among other things, of socio-economic conditions and environment on the health of individuals and populations. We synthesize these links between PHC, health and economic factors in Figure 5. While most of the literature linking health to economics refers to either measures of individual health from self-assessed health surveys, or measures of population health, typically derived from self-reported health, it is reasonable to link PHC to this literature via its impact on these measures of health as demonstrated in the logic model (Appendix A). Although there is a dearth of literature relating the economic impact of a well-functioning PHC system to the broader healthcare system, we argue that a number of the benefits from PHC lead naturally to a better-functioning overall healthcare system.

Figure 5: linking PHC to economics

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3

The link between PHC and health (arrow 1) There is strong support for a link between PHC and better health. One study found that people receiving good PHC (as characterized by accessibility, comprehensiveness, coordination, continuity and accountability) are 10-15% more likely to report being in good health in comparison to those receiving poorer PHC.77 Another study looked at the contribution of PHC to mortality in OECD countries.6 The study differentiated between three different measures of mortality: all-cause, all-cause premature and case-specific premature death from asthma and bronchitis, emphysema and pneumonia, cardiovascular disease and heart disease. For all three levels, there is strong evidence that better PHC care is associated with lower mortality. Even when controlling for important macro-economic influences (GDP per capita, number of physicians per 1,000 population, percent of elderly


in the population) and for micro-level effects (average number of ambulatory care visits, per capita income, alcohol and tobacco consumption), the relationship between PHC and health is positive and significant. Similarly, another study showed that the effect of adding one PHC physician per population of 10,000 people in the US is associated with an average improvement of 5.3% across a number of population based measures of health such as all-cause mortality, heart disease mortality, stroke mortality, infant mortality, low birth weight, life expectancy, and self-reported health.4

When discussing how to improve the performance of PHC, it is useful to distinguish between performance gains arising from increases (or decreases) in the inputs into the system (the extensive margin) – the most important being that of the number of family physicians – and those derived from the improved use of a given amount of inputs (the intensive margin). A number of papers have looked carefully at the intensive margin performance of family physicians. Some have looked at how measures such as patient-visits per week respond to changes in how physicians are remunerated,78;79 while others have focused on how different ways of organizing PHC can influence the quality of services or care provided.80-82

On the extensive margin, the literature suggests a strong link between family physician supply and health and the performance of the overall healthcare system. U.S. studies have shown larger family physician supply relative to population size to be associated with lower hospitalization for conditions that are ambulatory care sensitive,83 lower obesity,84 better self-reported health,85 earlier detection of cancer86 and better quality of care.87 Higher density of family physicians is also associated with reduced healthcare utilization, including hospital admissions, emergency department visits and surgeries.88

Canadian studies point in the same direction. Using random samples of the Ontario Cancer Registry, one study demonstrated that higher physician density is associated with earlier breast cancer detection and better survival outcomes.89 Using the Canadian National Population Health Survey, another showed that a higher supply of family physicians is associated with better health, whereas more specialists is associated with worse health.90

Overall, it seems clear that both quantity and quality of services matter for population health and for the functioning of the healthcare system in general. In a review of the literature, Starfield et al. conclude that “… primary care helps prevent illness and death, regardless of whether the care is characterized by supply of primary care physicians, a relationship with a source of primary care, or the receipt of important features of primary care.”4 p.457

Macro-economic factors and health (arrow 2)The most important link from macro-economics to health is via employment. Better employment means better financial resources for the family and, therefore, a healthier life.91 Unemployment is also associated with poorer health.92;93

More interesting, however, is the link between health and economic growth. The economic literature often uses life expectancy and mortality rate as measures of health. Growth is usually measured as the growth in gross domestic product (GDP), GDP per capita, or GDP per worker.

One study examined the link between improvements in life expectancy and growth by summarizing many important papers.94 The review paper suggests that an improvement of five years in life expectancy would add to the GDP growth rate somewhere between 0 and 0.58 – with only one of the 13 papers summarized suggesting that the growth impact is zero.95-97 98-102 For instance, if the growth rate were, say, 3%, an increase of five years in life expectancy could increase this rate to as


much as 3.58%. There is, thus, the potential to have a significant impact on the economy derived from improvements in life expectancy. While the literature is not all in support of this link, population based studies suggest that that better health leads to GDP growth.103 Improvements in the performance of PHC lead to better health, which in turn leads to macro-economic growth.

Micro-economic factors and health (arrow 3)The link between socioeconomic status and health is generally recognized by economists – what is less clear, however, is the direction of causation. There is evidence showing that the socio-economic status of a household affects the health of its children.104-106 The inverse direction is also demonstrated, i.e. the health of the family impacts its socioeconomic status. A Canadian study demonstrated that females providing care to a family member in poor health (on average 4.6 hours weekly) worked 2.1 fewer hours weekly, which represents 6% of a normal working week, thus reducing the household potential for income.107 Improvements in the performance of PHC leads to better health, a higher earning capacity, and lower economic burden.

ConclusionsOverall, there is reason to believe that better primary care leads to better health outcomes, which themselves may lead to increased employment and increased growth and productivity. The literature underlying Figure 5 suggests that investments in PHC can have a direct impact on health and hence an indirect effect on employment and growth.


THE ECONOMIC IMPACT OF ADDING A PHARMACIST IN A PHC PRACTICE: A SYSTEMATIC REVIEWIntroductionEconomic evaluations can help inform health resource-allocation choices by comparing costs and consequences of interventions. In an earlier section we reported several interventions that have been shown to improve the quality of PHC. Of these, the integration of a pharmacist in a primary-care practice showed especially encouraging improvements in care delivery and in health benefits. For example, one randomized controlled trial reported that the intervention had increased the number of patients reaching goal blood pressure by 32%.108 We therefore chose to evaluate the economic consequences of adding a pharmacist to a primary healthcare practice as one example of the economic impact of improvement in PHC performance.

We undertook a systematic review of the evidence on the trade-offs between intervention costs, health benefits and direct and indirect cost savings of broad-scale implementation of pharmacist integration in PHC practices. We undertook a systematic review of the literature from the past 20 years on the health and economic impact of pharmacist integration in PHC practices.

MethodA systematic review was conducted of health economic studies published between 1990 and 2010 that evaluated the impact of multidisciplinary PHC teams on costs of any kind as well as health or clinical outcomes, and/or performance indicators. The full study protocol is found in Appendix E.

Search strategy: Studies were identified from databases (Cochrane Library/National Health Services Economic Evaluation Database, Medline and EconLit) using strict search criteria, and the grey literature (relevant websites and bibliographic references from relevant reviews). The citations in these articles were also reviewed to identify new relevant articles.

Eligibility criteria: Studies were included if they assessed the costs and health consequences of pharmacist integration in PHC practice.

Selection of studies: Identified studies were screened by two reviewers for eligibility using the inclusion and exclusion criteria outlined in the protocol in Appendix E.

Quality assessment: At least two reviewers were involved in the quality assessment of eligible studies by using the CHEC list (Appendix F) that assesses the quality of health economic evaluations based on a set of evaluation criteria.109 We retained studies with moderate-to-high quality (met more than 50% of the quality criteria).

Data abstraction: Two reviewers abstracted data from the retained studies using an established data extraction sheet capturing study design, population, time horizon, method used to measure costs and other health outcomes and the main results of the study, as well as any other comments that the reviewers found important in the overall assessment.

Analysis: The systematic review focused on the health economic impact of the addition of a pharmacist in a family practice. Due to the heterogeneity of approaches and outcomes, the results could not be combined to provide an overall estimate. The results are reported in narrative form. A flow diagram summarizing the flow of information through the different phases of the review is found in Appendix G.


ResultsDescriptions of the included studies can be found in Appendix H. A total of 1,787 articles were identified using broad search criteria to capture articles on the economic impact of multidisciplinary PHC teams, of which 249 related to a pharmacist intervention. After the first screen, 33 articles were identified according to article title and abstract, as potentially relevant articles. The 33 eligible articles were assessed for methodological quality and eight were retained because they were evaluated as being of moderate-to-high quality.

The majority of included studies assessed the costs and benefits of pharmacist integration in PHC in improving medication usage. Six studies involved an intervention where the pharmacist had direct contact with the patients, such as face-to-face consultation,110-115 and two involved an intervention whereby the pharmacist provided advice and recommendations to physicians after reviewing patient health records only.116;117

Three studies evaluated pharmacist integration in PHC in the control of blood pressure among hypertensive patients:

◥ In the study by Borenstein et al., the intervention group experienced a greater decrease in systolic blood pressure compared to the control group (usual care) by an average of 11 mmHg, and at a reduced cost. However, only drug costs and provider visit costs were assessed.115 This is a significant impact because a decrease in 10 mm Hg in the systolic blood pressure and 5 mmHg in the diastolic blood pressure reduces the risk of stroke by 38% and heart failure by 50%.19 The intervention achieved an estimated cost savings of $27.94 per mmHg decrease (USD) over one-year. Cost savings were attributable to lower average provider use (and therefore costs) in the intervention group compared to the usual care group (average cost of $160 vs. $195, p=0.04). Drug costs increased in the intervention group, but not statistically significantly (average monthly drug cost of $11.31 vs. $4.25, p=0.12). The study did not consider the cost of the pharmacist or cost consequences of better-controlled blood pressure such as hospitalization.

◥ Isetts et al.’s report focused on individuals with elevated blood pressure and cholesterol.111 One year after involving the pharmacist in their care, significant improvements in hypertension and cholesterol management compared to pre-intervention were observed, as well as a return on investment of $12.15 per $1 in intervention costs. Cost savings were attributable to decreased expenditures post-intervention by 57.9% for facilities (work and office space, including rent and utilities) and a decrease by 11.1% for professional claims. In contrast, drug costs increased by approximately 19.7%. The difference in total expenditures was found to be statistically significant (p<0.001).

◥ Forstrom et al. examined changes in medication use only, but did not report on clinical or health outcomes directly related to hypertension.116 They found that the average daily drug cost was significantly greater in the intervention group compared with the control group at baseline, but that over a six-month period the average daily drug cost decreased in the intervention group while it increased in the control group. By the end of the study (six months) the difference in drug cost was no longer significant. The average daily drug cost in the intervention group was reduced by 5.6 cents per patient day (16.8%) over the study period.


Two studies evaluated pharmacist integration in PHC in the control of haemoglobin A1C (HbA1C) levels in diabetic patients:

◥ Monte et al. found that 50% of patients had improvements in their HbA1C at six months, and the new levels were maintained relatively constantly until the end of the one-year study period.113 There was a significant decrease in costs associated with the intervention in terms of direct medical, and prescription costs by the end of the one-year period. It was not clear to which direct medical costs or cardiovascular outcomes the authors were referring.

◥ Ragucci et al. reported similar results. In that study, moderate improvement in HbA1C levels were observed in approximately 40% of intervention patients.114 They reported an estimated cost-avoidance of $59,040 for the year based on an estimated cost avoidance of $685–950 per year of mean total healthcare costs for every 1% reduction in HbA1C.

One study by Ramalho et al. examined the impact of medication therapy management (MTM) by pharmacists in PHC, over a 10-year period, on various clinical outcomes, economic impacts, and patient satisfaction for a variety of chronic diseases including, but not limited to, hypertension, hyperlipidaemia, diabetes and osteoporosis.110 They found that 80% of drug-therapy problems identified in the MTM program were resolved at study close. They also found an improvement for 55% of the conditions, 23% were unchanged, while 22% worsened during MTM services. The MTM program generated a cost savings of approximately $86.45 per encounter, with an average cost of $67.00 per MTM visit in last three months of 2008. The pharmacist-led intervention achieved an estimated cost savings to the health system over the 10-year period of $2,913,850 and the total cost of the intervention for the same period was estimated at $2,258,302. The estimated cost savings included medical services avoided, including office visits, long-term care stays and hospitalizations, as well as avoidance of lost work time. The overall return on investment was estimated at $1.29 per $1 in intervention costs, where cost savings were attributable to reduction in office visits, laboratory services, urgent care visits and emergency room visits, as well as lost work time avoided due to the intervention.

The studies by Malone et al. and Sellors et al. did not address the impact of pharmacist integration on any specific disease, but reported broadly on only either costs and/or some other outcome, such as quality of life or patient satisfaction:112;117

◥ Malone et al. looked at the impact of clinical pharmacist consultation with patients in PHC on medication usage, quality of life and patient satisfaction among patients at high risk for drug-related problems. Taking into account the cost of the pharmacist intervention, the overall healthcare expenditures, which included clinic costs, drug costs, laboratory costs and costs of hospitalizations, were not statistically significantly different in the intervention compared to the control group (p=0.06). Mean increases from baseline for the intervention group compared to the control group were $1,020 and $1,313, respectively. There was also no statistically significant difference in the health-related quality of life or patient satisfaction between the groups.


◥ Sellors et al. examined the impact of pharmacist integration in PHC within the context of a randomized controlled trial on process outcomes, including number of drug-related problems and proportion of recommendations implemented by the physician for an elderly population, as well as costs related to drug use.117 After five months, the patients in the intervention group were taking a mean 0.4 extra medication units (prescription and over the counter) compared to the control group (p=0.50). There was also no significant difference in the use of healthcare resources or in costs between the intervention group and the control group. The total daily medication costs for the intervention group was $5.01 vs. $4.82 for the control group (p=0.72). Costs to the Ontario Drug Benefit Program were also similar with $3.57 for the intervention group compared to $3.76 for the control group (p=0.78). Including the cost of the pharmacist intervention and only drug-related hospital stays, the mean cost of healthcare resources per senior in the intervention group was $1,281.27 versus $1,299.37 per senior in the control group. In terms of recommendation implementation, physicians fully implemented 46.4% of recommendations and partially implemented 9.3% of recommendations.

DisscussionThis systematic review synthesizes the existing health economic evidence surrounding one PHC intervention with the potential to improve PHC performance in Canada. Pharmacist integration has been shown to be effective in improving a number of clinical health outcomes. Unfortunately, this review could not make conclusions as to the economic impact of implementing a pharmacist in PHC due to the paucity of high-quality economic studies. Future investments should be made in high quality health economic research in this area that addresses the limitations of the current literature

Table 2 in Appendix F highlights the proportion of studies that meet each quality criteria evaluated in this review. More than half the studies (61%) did not measure costs appropriately. Studies often failed to describe the study population adequately (42%), select adequate horizons (39%), and measure outcomes appropriately (39%). Future investments should be made in high-quality health economic research in this area that addresses the limitations of the current literature.

Two studies looked specifically at return on investment, which may be considered a type of cost minimization analysis, where cost savings could be accrued from avoidance of healthcare use such as emergency room visits or hospitalizations.110;111 Other studies did not compare any corresponding clinical or health benefits to costs of the intervention when there was potential to report on these measures.110;111;116 Many studies were flawed in design, including lack of an adequate control group and short time horizons. Many also lacked transparency on methods used, the sources of data and how they were measured and analyzed, making it difficult to discern the validity and reliability of results. No study provided an actual incremental cost-effectiveness ratio. The return on investment studies by Isetts et al. and Ramalho et al. reported cost savings attributable to an intervention involving the integration of a pharmacist to a PHC practice in the context of direct, face-to-face consultation with patients.110;111 However, the lack of direct comparison of costs to health benefits in these studies impedes the ability to determine the actual cost-effectiveness of the intervention.


All included studies were of short time horizon. All but one study used a time horizon of one year or less. The use of intermediate health outcomes that can be captured within that time frame, such as blood pressure (mmHg) for hypertension, is considered a weak effectiveness measure in health economic evaluation. Stronger measures are clinical outcomes such as cardiovascular events. While these are understandably difficult to measure because of time horizons, no study attempted to model these outcomes. Longer study time horizons, such as life-time projection, are preferred as they can provide better estimates of costs and health or clinical benefits that change over time.

Only one article attempted to address uncertainty through a sensitivity analysis around particular cost parameters.112 In addition, most studies were unclear on their conceptual and decision-making context. It was also difficult to classify study design and to interpret study results due to lack of clarity in results reporting. The limitations of the included studies previously mentioned are common methodological flaws in economic evaluations, which Drummond and Sculpher have previously discussed.118

Based on the review findings, pharmacist integration in PHC practice has the potential to be cost effective based on the estimated return on investment, especially in the control of common chronic diseases, including blood pressure control among patients with hypertension and HbA1C levels among diabetics. However, stronger evidence and better quality studies are required to draw confident conclusions. The tradeoffs between costs and health benefits are unsatisfactorily addressed in the current literature. Although the intervention is considered effective, the question “what is the health economic impact of pharmacist integration in PHC practice?” cannot be answered by the current literature, nor can the question “is pharmacist integration in PHC practice cost-effective?” In order to answer these questions, investments need to be made in research with a focus on improving the body of high-quality health economic evidence. New evidence should employ more rigorous methods, taking into account long-term costs and direct clinical and health outcomes, as well as improved reporting to allow for evidence synthesis. Healthcare system-level decisions can be more confidently made when studies can provide results on the overall and long-term cost effectiveness of interventions in terms of, for example, costs per life years gained or cost per quality-adjusted life years gained. For example, one such study could employ a mathematical modeling approach using the reviewed studies’ intermediate outcomes and costs to project long-term health economic impact, similar to the exercise in the next section of this report.


A SIMULATION OF THE IMPACT OF IMPROVEMENTS IN INFLUENZA VACCINATION RATESWe conducted a simulation of the potential costs and benefits associated with an improvement in PHC performance by assessing the likely impact of increasing the rate of influenza vaccinations in the elderly population, brought about by a reminder system in the family physicians’ offices that is part of an EMR system.45 Uncertainty in the impact is addressed by providing different population/vaccination rate scenarios.

The benefits associated with an increase in vaccination rates are considered to be the cost savings arising from the reduction in services required by individuals with influenza-like conditions. The costs associated with increasing vaccination rates can be classified as direct and indirect. Direct costs include the cost of the vaccine and its administration and the costs of any incentive schemes in place to encourage vaccinations. Indirect costs refer to those associated with the implementation and usage of EMR systems in all Canadian family physician offices.

Model-based simulatorFor this model, we used a custom-designed program running on Stata©. This model is based on a simple one-period Markov chain process developed using the average likelihood of developing influenza-like symptoms, which may, in turn, trigger three events: a family physician visit, an Emergency Department (ED) visit, and/or hospitalization.119 First, the simulation hypothesizes a population of one million elderly people. The results from this simulated population are then adjusted to represent the elderly population numbers in different regions/time periods. Our population is assigned a vaccination status following a binomial distribution with a probability equal to the vaccination rate under study. For example, to simulate a population vaccinated at 64%, we use a binomial with p=0.64 where p is the probability that vaccination occurred. Second, the simulation program evaluates the probability that one of three events – family physician visit, ED visit or hospitalization – occurs. The assigned probability for each event uses a random sampling process based on a normal distribution whose mean is equal to the probability of the event occurring. These means are extracted from a review of the medical literature on influenza as explained in the data section of this report. After the Markov chain process is carried out on the population (i.e. run one million times), the simulation performs summaries of the events and calculates the costs associated with the adverse events. Finally, we ran the model over again with various incremental gains in vaccination rates in order to ascertain the possible savings associated with improving vaccinations among the elderly population.

ScenariosWe used four scenarios based on vaccination target rates of 66.5%, 69%, 74%, and 80%, representing an increase of 2.5, 5, 10 and 16 percentage points over the actual rate of 64%.19 We derived these values by stratifying the data from Jacobson and Silagyi (2005) to reflect low, medium and high effectiveness of the recall systems for the elderly.41 The 80% scenario represents an increase in the vaccination rate in all jurisdictions (except Nunavut) and hence could be considered as the highest achievable rate in Canadian provinces. We ran each scenario as a separate simulation.


DataPopulation: For the population, we downloaded population estimates from Statistics Canada.120 Statistics Canada also provides different projections to evaluate future population demographics (Appendix I). While they use many different population trends, we focus on the medium population growth scenario (M4 – increase based on 2001 to 2006 trends scenario) for our simulation. This scenario gives the population by age group on a yearly basis from 2010 to 2016, then by five years up to 2036. For our simulation, we find particularly interesting the projections for 2031 as during that year the seniors’ population peaks.

Influenza-specific statistics: The percentage of the population 65 and older vaccinated in Canada was taken from Leatherman and Sutherland (2010).19 We use the statistical mean at the provincial level and a weighted average for Canada. Currently, 64% of Canadians 65 and older are vaccinated, based on data gathered for year 2007. Appendix J presents the detailed data for all provinces.

Treatment events: Information was gathered on the vaccine effectiveness from different sources. Gross et al. found that individuals are about 50% less likely to develop an influenza-like illness (ILI) if vaccinated.121 We created three scenarios based on a lower bound, or “worse case” of 28%, an average value of 50% and an upper bound (or “best case”) of a 65% decrease in the likelihood of developing ILI.

Information on the likelihood that an ILI will result in three events – a visit to a family physician, an emergency department or a hospitalization – is found in a Canadian study by Kwong et al. (2008).119

However, the analysis in Kwong et al. is population-wide and does not distinguish between individuals who were vaccinated and those who were not. Thus, for the purposes of our simulation, we needed to calculate the probability of one of these three events occurring for the vaccinated group and for the non-vaccinated group separately. To do this, we start with noting that Kwong et al. finds that 7.492% of the elderly population (irrespective of vaccination status) will visit a family physician for influenza-like illnesses in a given year, 3.396% will visit an emergency department and 2.604% will be hospitalized. We know that 64% of the elderly population is vaccinated. Thus: 0.64*(probability of going to a family physician visit if vaccinated) + 0.36*(probability of going to a family physician visit if not vaccinated) = 0.07492. If we take the 35% number, (i.e. the likelihood of contracting an ILI is reduced by 35% if vaccinated), then we know that the probability of going to a family physician visit if vaccinated is (1 - 0.35) times the probability of going to a family physician if not vaccinated. So, letting x=the probability of going to a family physician if not vaccinated, we need to solve the following expression: 0.64*(0.65x) + 0.36x = 0.07492. In this case, x = 0.09655 or 9.655% and the probability of going to a family physician if vaccinated is 0.06276 or 6.276% (or 35% lower than the non-vaccinated case), corresponding to the highlighted numbers in table 1. We did this calculation for a 28%, 35%, 50% and 65% reduction in the likelihood of contracting an ILI if vaccinated.

table 1 – Calculated effectiveness rates for vaccinated (v) and non-vaccinated (nv) by event

28% 50% 60%

Event V NV V NV V NVGP Visit 0.06572 0.09128 0.05509 0.11018 0.04490 0.12829ED Visit 0.02979 0.04138 0.02497 0.04994 0.02035 0.05815Hosp 0.02284 0.03173 0.01915 0.03830 0.01561 0.04459


To help visualize what we have just described, Figure 6 presents the results from our simple algorithm based on 64% of the elderly population being vaccinated. The percentages at the end of each tree represent the probability that the particular event occurs (assumed to be 50%121) depending on whether the elderly person is vaccinated.

Vaccination costs: The direct cost included in our simulation is the actual cost of the vaccine and its administration to the patient and the cost associated with any bonus paid to the family physician office. The cost of the vaccine was taken from Sander et al. (2010) and is $7.50.122 Administering costs were found in the Family Health Organization Agreement (2007). In the context of influenza vaccinations, two scenarios are possible. In the first scenario, the patient receives the flu shot when coming for a family physician visit concerning another matter. In this case, the cost for the shot would be $8.15 (intervention G538). In the second scenario, the patient comes solely for the flu shot, which incurs a cost of $17.85 (intervention G539). More research is required to know the percentage of individuals who fall into these two cases, but a conservative estimate would be 25% and 75% respectively. We use this estimation in our simulation. The indirect costs associated with the different events, which include the administration costs of visits to clinics and hospitals were taken from Sander et al. (2010).122 It is important to clarify that these costs are lower bound values and the actual cost could be higher. For example, the $35 cost associated with a family physician visit only captures the actual consultation and does not include costs for any additional treatments such as x-rays or blood tests.

Figure 6: algorithm tree for determining the probability of an influenza-like illness-related event in the elderly, assuming a 50% vaccination effectiveness rate

ElderlyPopulation

Not Vaccinated(36%)

Vaccinated(64%)

GP Visit (5.509%)

ED Visit (2.497%)

Hospitalization (1.915%)

GP Visit (11.018%)

ED Visit (4.994%)

Hospitalization (3.830%)

EMR system and reminder: The actual cost of the installation of an EMR system and its maintenance is not accounted for in our simulation. The main reason is that these systems include many more functions than a reminder system for vaccinations. Given that an EMR system is in place, the marginal cost associated with reminding elderly patients to have a vaccination is likely to be very small. Because evidence shows that phone call-based reminder systems perform better than other forms of reminders such as mailings,41 we estimate the cost for a staff member to call patients under the indirect costs.


ResultsBenefits: In this section, we present the simulation results for the year 2010 for Canada assuming 50% effectiveness. The individual province results for the projected years 2010 and 2031 are presented in Appendix K.

table 2: reductions in the number of adverse events and the dollar savings associated with these reductions for 2010 by target vaccination rate

target vaccination rate

Events 66.5% 69.0% 74.0% 80.0%

Number of Adverse Events (Reductions)

GP 6,591 13,209 26,333 42,559ED 2,811 5,848 11,913 19,298

Hosp. 2,201 4,696 9,130 14,722

Cost Savings (Dollars)

GP $230,716 $462,259 $921,648 $1,489,550

ED $618,478 $1,286,656 $2,620,882 $4,245,488Hosp. $14,123,431 $30,138,489 $58,596,134 $94,491,255

Total Cost Saved $14,972,625 $31,887,404 $62,138,664 $100,226,293

The top half of Table 2 presents the reduction in the number of adverse events arising from an increase in the vaccination rate from the actual rate of 64% to the indicated rate in the column. For example, the first column shows the reduction in the number of family physician (GP) visits, ED visits and hospitalizations resulting from a 2.5 percentage point increase in the vaccination rate from 64% to 66.5%. The simulation indicates that the resulting decrease in GP visits would be 6,591. The second section, called Costs Savings, represents the reduction in costs associated with the decrease in adverse events (a measure of the “benefits” associated with the decrease in adverse events): the 2.5% vaccination rate increase would thus result in a savings of $230,716 from the reduction in GP visits. The bottom row represents the total cost saved from increasing the vaccination rate by 2.5, 5, 10 and 16 percentage points. According to our simulation, a 2.5 percentage point increase in the vaccination rate of the elderly will result in a savings of almost $15 million. This savings increases to more than $100 million should the vaccination rate increase to 80%.

Direct costs: Table 3 presents estimates of the increase in direct costs associated with the given increase in the vaccination rate. For example, if we increased the vaccination rate from 64% to 66.5%, the cost for the additional vaccines required would be $958,532 and its administration would be $1,859,792 for a total cost of $2,818,324.

table 3: direct costs associated with increasing the vaccination rate

targeted vaccination rate

66.5% 69.0% 74.0% 80.0%Vaccination Cost $958,532 $1,917,063 $3,834,126 $6,134,602

Visit Cost $1,859,792 $3,719,585 $7,439,169 $11,902,670Total Direct Cost $2,818,324 $5,636,648 $11,273,295 $18,037,272


Indirect Costs (Patient reminder): We used an hourly wage rate of $20 for a staff member calling patients with reminders. Assuming that 20 calls could be made per hour, and assuming that these calls go out to the entire elderly population, this would then result in an indirect cost of $4,822,800.

Benefits minus costs: Table 4 presents the net benefits resulting from our simulation with a vaccination effective rate of 50%.

table 4: net benefit calculations by target vaccination rate for 2010 and 2031 (projected)


Year 2010 population profile 66.5% 69.0% 74.0% 80.0%Benefit $16,357,073 $31,744,056 $63,626,889 $101,247,194Direct Cost $2,818,324 $5,636,648 $11,273,295 $18,037,272Benefit before EMR Cost $13,538,749 $26,107,408 $52,353,594 $83,209,922

Patient Reminder Cost $4,822,800 $4,822,800 $4,822,800 $4,822,800Net Benefit $8,715,949 $21,283,608 $47,530,794 $78,387,122


Year 2031 popuation profile 66.5% 69.0% 74.0% 80.0%Benefit $32,596,116 $63,259,058 $126,794,665 $201,763,817Direct Cost $5,616,312 $11,232,623 $22,465,245 $35,944,392Benefit before EMR Cost $26,979,804 $52,026,435 $104,329,420 $165,819,425Patient Reminder Cost $9,610,800 $9,610,800 $9,610,800 $9,610,800Net Benefit $17,369,004 $42,415,635 $94,718,620 $156,208,625

The net benefit of increasing the vaccinated population from 64% to 66.5% (a 2.5 percentage point increase) using a reminder system would result in a potential savings of about $8.7 million. By the year 2031 all of the “baby boomer” part of the population will have reached 65 years of age or older. We can use the projected population for the year 2031 to estimate what the potential benefits may be of increasing the elderly vaccination rate with the projected demographics at that time. These figures are presented in the bottom half of table 4. Using the 2031 demographics, the potential savings from increasing the vaccination rate of the elderly population would range from more than $17 million to more than $156 million, depending on the vaccination rate achieved.

Sesitivity analysisThe largest uncertainty in this simulation exercise is the vaccine effectiveness rate. We thus performed a sensitivity analysis. We used the confidence interval of 28%–65%, from Gross et al. (1995), and ran two different scenarios: one for the “worse case” of a very low vaccination effectiveness rate of 28% and one for the “best case” of 65%.121 Table 5 presents these results. With the worse-case scenario, increasing the vaccination rate of the elderly by 2.5 percentage points would not be cost effective as it results in a net loss of about $200,000. However, if we were to push up the vaccination rate to 69% of the elderly population, then the net benefits would be more than $4 million, even with the very low vaccination effectiveness rate of 28%. Of course, if the effectiveness rate were high (i.e. 65%), then the net benefits of even a modest increase in the vaccination rate of the elderly would be large – more than $15 million for a 2.5 percentage point increase.


table 5: net benefit calculations using best- and worst-case scenarios regarding vaccination effectiveness (costs in $millions)


Year 2010 Population profile 66.5% 69.0% 74.0% 80.0%Effectiveness 28% 65% 28% 65% 28% 65% 28% 65%Benefit $7.4 $22.9 $14.7 $49.1 $29.4 $94.8 $46.9 $151.7Direct Cost $2.8 $2.8 $5.6 $5.6 $11.3 $11.3 $18.0 $18.0Gross Benefit $4.6 $20.1 $9.1 $43.5 $18.1 $83.5 $28.9 $133.7EMR Cost $4.8 $4.8 $4.8 $4.8 $4.8 $4.8 $4.8 $4.8Net Benefit $-0.2 $15.3 $4.3 $38.7 $13.3 $78.7 $24.1 $128.9


Year 2031 Population profile 66.5% 69.0% 74.0% 80.0%Effectiveness 28% 65% 28% 65% 28% 65% 28% 65%Benefit $14.8 $45.6 $29.3 $97.8 $58.7 $189.0 $93.4 $302.4Direct Cost $5.6 $5.6 $11.2 $11..2 $22.5 $22.5 $36.0 $36.0Gross Benefit $9.2 $40.0 $18.1 $86.6 $36.2 $167.5 $57.4 $266.4EMR Cost $9.6 $9.6 $9.6 $9.6 $9.6 $9.6 $9.6 $9.6Net Benefit $-0.4 $30.4 $8.5 $77.0 $26.6 $157.9 $47.8 $256.8

ConclusionsIf an increase in the influenza vaccination rate of 2.5 percentage points for the elderly were achieved, our analysis indicates that healthcare costs could fall by more than $16 million. Once the costs of effecting this increase were taken into account, net benefits are still $8.7 million. In most scenarios, several millions of dollars can be saved annually by reducing the need to treat elderly people with ILIs. One way to bring about increases in influenza vaccinations would be through the use of telephone reminder systems. Investments in such systems at the PHC level may make a lot of economic sense and certainly bear further investigation.

The estimates derived in this section do not take into account the benefits that may arise from additional contact with a healthcare professional in order to get vaccinated. An additional visit to a PHC physician may strengthen the patient-physician relationship and foster better continuity of care, factors that could improve care at future encounters.

The strength of the simulation approach is that it provides estimates of the potential impact of an increase in immunization rates of the targeted population. The main weakness of this approach is that it is based on average outcomes for the targeted population, as well as average costs and benefits. We have tried to be conservative in our estimates and have provided ranges based on best- and worst-case scenarios with respect to vaccination effectiveness.

This simulation exercise clearly demonstrates that an increase in the performance of PHC (as measured by increased immunization rates) would confer a significant economic benefit in cost savings associated with reduced healthcare utilization.


ECONOMIC IMPACT OF IMPROVEMENTS IN SELECTED INDICATORSIntroduction

This section uses the existing literature to demonstrate the link between primary healthcare improvements and economic benefits. It is important to note that the discussion focuses on the potential economic gains of improving health and does not include the costs of interventions that are required to achieve these improvements. We represent the economic impact of improvements in a set of health conditions using an economic burden of illness approach, and one indicator of service delivery, continuity of care. For the health outcomes, we chose to focus on three common chronic conditions where the potential for improvement in care has been clearly established in the section “Interventions to improve quality in PHC,” focusing on hypertension, diabetes and cancer.

Hypertension is a serious risk factor for many other health problems, such as stroke or myocardial infarction.123 As a result of the associated risk of these events, the economic burden of hypertension is very large,124 as poor blood pressure control extends its hazards to these other health conditions. Type 2 diabetes is another prevalent disease in Canada. The economic burden of Type 2 diabetes could be reduced through the implementation of preventive interventions and improved management of diabetic patients.125 The high costs of treating various cancers can be reduced through early screening and detection. Cancer screening can result in cost minimization by shifting the stage at diagnosis to an earlier stage which incurs lower treatment costs compared to later stage cancer and confers better health outcomes.126 Improvements in the management of hypertension, diabetes and cancer have potential to reduce mortality, improve life expectancy, thereby improving productivity, which can, in turn, provide further economic benefits. This section reviews the estimated impact of these conditions based on available literature, and how improvements in the quality of care can produce economic benefits. Unfortunately, there is a lack of independent evidence, so that the estimates provided here may not be fully accurate.

Continuity of care, also referred to as relational continuity or longitudinality is defined as “a therapeutic relationship between a patient and one or more clinicians that spans various health care events and results in accumulated knowledge of the patient and care consistent with the patient’s needs.”127

Continuity of care is improved by accessing care from the same provider, good patient-provider communication and, ultimately, better knowledge of the patient.

HyptertensionThe Conference Board of Canada estimates the 2005 total costs for cardiovascular disease to be more than $20 billion, nearly half of which is from income loss due to premature mortality.128 Hypertension is a leading cause of cardiovascular disease (as well as stroke and renal disease129). It has been estimated that the prevalence of hypertension in Canada increased by approximately 60% from 1995 to 2005.129 Approximately six million adult Canadians have been diagnosed with hypertension in 2007, a number expected to grow to 7.3 million in 2012.130 Because age increases the risk of hypertension, an aging population means that nearly 10 million individuals will be living with hypertension by 2030.

Currently, one-third of adult Canadians diagnosed with hypertension have uncontrolled blood pressure levels, which worsens the risks of hypertension.124 Blood pressure control can be effectively improved through PHC interventions. For instance, a Cochrane systematic review by Glynn et al. showed that reminder systems for blood pressure monitoring can improve the odds of blood pressure control (OR=1.85, 95% CI: 1.37 – 2.44), potentially improving control from 66% to 78%.71Another meta-analysis by Carter et al. found that integrating pharmacists in PHC clinics improves systolic blood pressure control in hypertensive patients (OR=2.17, 95% CI: 1.75 – 2.68), potentially improving control from 66% to 81%.63


Uncontrolled hypertension leads to significant resource use and is a significant economic burden. In 2004–05, the total acute care inpatient costs in Canada for hypertensive-related conditions was an estimated $74 million.131 Patients with uncontrolled blood pressure have follow-up office visits with a family physician about 13 days earlier than patients with controlled blood pressure.132 In 2004, the cost of heart failure was estimated to be $425 million in Canada, 50% of which is attributable to poor blood pressure control.131;133 According to a study by Moffatt et al., the total costs attributable to hypertension among Albertans in 2005 were estimated at $125.5 million.134 Direct and indirect costs were estimated using the Public Health Agency of Canada’s Economic Burden of Illness Report 2000. A more recent study by Anis et al. estimated that the current total health expenditures in Canada related to hypertension were $3,459 million (CAD 2006 dollars).135 The total direct costs (expenditures on hospital care, physician services, services provided by other health professionals, drugs, health research and other healthcare) were extracted from the National Health Expenditure Database (NHEX) projections for 2006. Indirect costs included morbidity costs due to long-term and short-term disability.

The potential cost minimization associated with improved blood pressure control in PHC is substantial. Controlling blood pressure can also improve life expectancy. For instance, a 10 mmHg reduction in systolic blood pressure can reduce all-cause mortality by 26% and extend life by at least 17 years.136;137 Using a population-based simulation approach, one study estimated the cost consequences of a 2 mmHg reduction in systolic blood pressure to result in a savings of more than $38 million through reduction in risk of stroke and myocardial infarction.138 A pharmacist intervention that has the potential to reduce blood pressure by 10 mmHg can therefore result in savings of more than $190 million via stroke and myocardial infarction prevention alone.

DiabetesThe prevalence of diabetes mellitus in Canada increased by 69% from 1995 to 2005, with the 2005 prevalence estimate exceeding the World Health Organization’s projected global rate for 2030.139 Diabetes is considered one of the most expensive medical conditions in terms of acute care inpatient costs, estimated at $284 million in Canada in 2005.131

Moffatt et al. reported an estimated $161.5 million attributable to Type 2 diabetes in Alberta alone in 2005.134 Current total health expenditures in Canada related to Type 2 diabetes are estimated at $1.4 billion (CAD 2006 dollars).135

Hemoglobin A1C (HbA1C) is an indicator of glucose control in patients with diabetes.140 A variety of PHC interventions have been shown to improve HbA1C levels among diabetic patients. For example, multidisciplinary PHC teams with case management and patient education can effectively reduce HbA1C. These interventions can improve HbA1C

control by 1.5%, a relative improvement of 15%, as well as reduce the number of hospital admissions.61;141 A study by Grimshaw et al. showed that continuity of care in diabetes has the potential to improve HbA1C by as much as 2.1%.35

Uncontrolled diabetes can also have a substantial impact on resource use, including hospitalizations from a variety of health problems, including ischemic heart disease, heart attack, heart failure, chronic kidney disease, stroke and lower limb amputations.142 It has been estimated that diabetic patients aged 20-49 visit family physicians two times more and specialists three to four times more than the general population.142


CancerIn 2010 there were an estimated 173,800 new cases of cancer and 76,000 deaths due to cancer in Canada.126 Screening has been shown to improve survival for a number of cancers, including breast, cervical and colorectal cancer.19 There are few peer-reviewed estimates of the impact of cancer in Canada, although the Canadian Cancer Society estimates 1,026,700 potential years of life lost (PYLL) as a result of cancer in 2004, representing 32% of the PYLL resulting from all causes of death.143 One study estimated current total health expenditures in Canada related to post-menopausal breast cancer and colorectal cancer at $351.1 million and $978.8 million (CAD 2006 dollars), respectively.135 The Public Health Agency of Canada estimates the economic burden of malignant neoplasms at upwards of $20 billion in 2000, the great majority of which is due to morbidity and mortality.144

Screening can improve cancer survival by detecting cancers at an earlier stage, when treatment is usually more effective. Between 1992 and 2004, mortality rates in Canada fell by approximately 25% and the number of years of life lost to breast cancer decreased by about 29%, in part due to increased screening uptake and improvements in treatment.19 A recent study found that mammography screening resulted in a relative risk reduction in breast cancer mortality by 10% compared to no screening.145 A Swedish study found that cervical cancer screening with Pap smear resulted in a 53% reduction in cervical cancer mortality (95% CI: 23–72%).146 In Canada, biennial colorectal cancer screening with fecal occult blood testing (FOBT) of 67% of the population aged 50-74 in the year 2000 resulted in an estimated 10-year colorectal cancer mortality reduction of 16.7%.147 Colorectal cancer screening was reported to contribute 194–203 life-years gained, depending on the screening tool, per 1,000 persons screened.148 The effects of cervical cancer screening were estimated at 640–1,110 life years gained for every 1,000,000 women in the general population, which corresponds to 5 and 40 Pap smear tests over an individual’s lifetime.149

PHC interventions have been shown to improve cancer screening uptake. One review reported that provider assessment and feedback interventions are effective in increasing screening rates for certain cancers by about 13%.30 These interventions were found to increase the uptake of breast cancer screening (mammography) by 3%–21%, cervical cancer screening (Pap test) by 4%–30%, and colorectal cancer screening (FOBT) by 4%–30%. Another review also found improvements in screening attributable to various organizational and practice-level interventions in PHC.42 For instance, it found that organizational change could improve cervical and colorectal cancer screening by an odds ratio of 3.03 (95% CI 2.56-3.58) and 17.6 (95% CI 12.3-25.2), respectively. Financial incentives for patient care were found to improve mammography and cervical cancer screening by odds ratio of 2.74 (95% CI 1.78-4.24) and 2.82 (95% CI 2.35-3.38), respectively. Patient reminder systems and provider education were found to improve colorectal screening uptake by an odds ratio of 2.75 (95% CI 1.90-3.97) and 3.01 (95% CI 1.98-4.56), respectively. Collaboration and teamwork were found to improve cervical and colorectal cancer screening uptake by an odds ratio of 5.55 (95% CI 4.54-6.80) and 9.21 (5.46-15.5), for cervical and colorectal cancer, respectively.42

Improvements in cancer screening can affect costs at the healthcare-system and societal levels. It has been reported that screening 1,000 women every year for breast cancer, starting at age 40 and continuing until age 84, would result in 177 to 227 life-years gained compared with no screening.150 Increases in cancer screening uptake can result in significant economic gains achieved from reduced healthcare utilization and prolonged life.


ContinuityContinuity of care is often measured as the proportion of visits to the usual provider relative to all primary care visits. Taking into account socio-demographic factors and severity of health conditions, a higher proportion of visits to the usual provider (compared to the low continuity group) is associated with a lower risk of hospitalization for any cause, in the general population (odds ratio (OR) (95% confidence interval (CI)) of 0.75 (0.66, 0.87) in one study151 and 0.48 (0.45-0.51) in another.152 It is also associated with a lower risk of avoidable hospitalization in individuals of all age groups (for people aged 19-64: OR 0.41 (0.35, 0.48)), children with diabetes (OR 0.14 (0.03-0.67))153 and elderly people with diabetes (rate ratio 0.82 (0.69, 0.97).154

A higher proportion of visits to the usual provider is also associated with a lower risk of emergency room visit in all individuals (OR 0.82 (0.70, 0.95)),155 and a lower risk of making multiple emergency room visits in all individuals (OR 0.65 (0.56, 0.76)).155 One study randomly assigned individuals to high versus low continuity of care, and found that those randomized to better continuity had fewer hospital admissions (20% vs. 39%) and shorter duration of hospital stay (15.5 vs. 25.5 days).156

A systematic review of continuity of care found 20 studies addressing its impact on resource utilization, only one of which found no association. In total, the studies assessed 41 resource variables, 35 of which were lower in higher continuity contexts.157

Findings from Canadian studies are in keeping with these studies. Controlling for socio-demographic and health conditions, having low continuity of care is associated with a much greater risk of making emergency room visits in end-of-life cancer patients (relative risk 3.93 (3.57, 4.34))158 and in individuals aged 65 and over (relative risk 1.46 (1.44, 1.48).159 A higher continuity of care score is linked to a lower risk of avoidable hospitalization in older adults (OR 0.67 (0.51, 0.90)),160 a lower risk of making an emergency room visit in individuals 15 years and older (OR 0.90 (0.87, 0.92)), and a lower risk of making three or more such visits (OR 0.78 (0.73, 0.83)).161

Three studies quantified the costs associated with different levels of continuity. One U.S. study found that African or Latino Americans with low provider continuity (as measured by usual provider continuity score) incurred significantly higher healthcare costs ($3,565/year) compared to those with high continuity ($2,279/year). These costs were largely driven by hospital costs.162 That study is flawed in that it did not account for differences in patients characteristics between the two groups. Another U.S. study assessed continuity by asking individuals 65 years and older how long they had been seeing their usual provider and categorized their answers into five groups ranging from less than one year to more than 10 years. Adjusting for potential confounders, the study found that, compared to individuals with the shorter relationship, those with the longest relationship had lower hospital costs ($496 ($81, $910)), and lower medical costs (e.g. outpatient visits, tests) ($317 ($117, $516)).163

A dose-response relationship across length of relationship categories was observed. The third study assessing costs is a Canadian study by Hollander et al. that evaluated the extent to which the patients used the same practice (rather than same provider) for their visits. That study found a dose-response relationship between the extent of attachment to a practice and the costs of hospital and medical services for patients with diabetes. For example, among the high resource users (Resource Utilization Band of 5), the hospitalization cost was $16,988 and $5,909 for those with lowest and highest continuity levels. Similarly, for individuals with congestive heart failure with high resource use, the hospitalization cost was $21,293 and $7,507 for those with lowest and highest continuity levels.72

These studies suggest that improvement in the continuity of primary care services can result in considerable cost savings in various sectors of the healthcare system.


DiscussionThis section uses an economic burden of illness approach by compiling evidence from the literature to report on the potential economic impact of improvements in health for common chronic diseases in Canada. We focus on hypertension, diabetes and cancer, for which there is evidence that improvements can be made through PHC interventions. Due to the paucity of available evidence, some of the data relating the current costs of illness was derived from literature that may be considered more advocacy than scientific. Non-governmental organizations often use research to help define their advocacy positions and to provide additional arguments to support their advocacy activities, which may result in biased methodology and results.164 For that reason, some of the projections about gains may not be accurate. Despite these limitations, this section demonstrates a clear potential for economic gains with improvements in PHC performance.

This section only considered the impact of improvements in PHC and did not consider the cost of interventions required to achieve these gains. PHC interventions can offer high economic value from the health service payers’ perspective when the value of health system resources avoided exceeds the value of resources required to implement the intervention.165 It has also been suggested that through aggregation of micro-economic contributions, including labour productivity, labour supply, education and savings and investment, a healthier population may generate greater rates of macro-economic growth than would a less healthy population.166;167

This section also provides strong evidence of the economic benefit of high continuity of care in family practice. Better continuity allows a better knowledge of the patient, produces more appropriate care and results in significantly lower healthcare costs. It is necessary to note that much of the available literature has been published in the form of cost-of-illness studies and by disease-focused organizations and could contain some biases toward such matters. A study by Larg and Moss suggests there are often inconsistencies in the way in which cost of illness studies are conducted and there is a lack of transparency in reporting.168 These limitations have impeded the interpretation of study results and have, therefore, limited their usefulness.


RECOMMENDATIONS AND EXPERT COMMENTARIESFindingsThis report finds that significant gaps in Canada’s PHC performance exist, and that several PHC interventions offer the possibility of improving its current status. We used four strategies to assess the economic impact of improvements in PHC. Three of these, the macro- and micro-economic effects of good health derived from PHC performance, the vaccination simulation exercise and the cost consequences of four specific improvements in PHC based on currently published literature, demonstrated that improvements in PHC’s performance would yield economic benefits. The systematic review on the economic impact of integrating a pharmacist into practice was inconclusive. While all studies suggested a cost saving, none have adequately considered all facets of costs, and most were deemed only of moderate reporting quality.

In the course of producing this report, we identified gaps in knowledge and weaknesses in the current structure of the Canadian PHC system. These are discussed below.

National coordination bodyThere is inadequate inter-jurisdictional dialogue and coordination of effort on the direction of PHC investments in Canada, largely because in Canada, the healthcare system is governed at the provincial level. Canada’s systems for delivering primary care services vary substantially, providing ample opportunities for cross-jurisdictional learning. The Canadian PHC sector needs a national coordination body to facilitate this dialogue and planning efforts across jurisdictions. We recommend that a national coordination body be established. We recommend that the national body be responsible for facilitating the following activities in order to inform investments in PHC:

◥ Conduct a scoping exercise to understand the variability in PHC structure across Canada and assess the strengths, weaknesses, barriers and facilitators of the various PHC reform strategies.

◥ Conduct a systematic review of the scientific literature and jurisdictional reports to assess the effectiveness of various potential investments in PHC and assess the transferability of these finding to the Canadian context.

◥ Coordinate a cross-jurisdictional dialogue of the findings and facilitate the discussion of investments in PHC appropriate for the various jurisdictions.

◥ Identify gaps in knowledge, develop a research agenda for Canada and coordinate research efforts to address these gaps.

Investments in primary healthcareThe international comparison conducted by the Commonwealth Fund demonstrates that Canada’s performance in several indicators of the strength of its PHC sector is poor. These deficiencies create inefficiencies in care delivery. Canada’s performance on accessibility, for instance, is dismal. The quality of PHC significantly influences outcomes and, as such, will have a significant impact on other healthcare sectors. A poor PHC system reduces the effectiveness of other healthcare sectors. Strengthening primary care can significantly alleviate pressures in other parts of the healthcare system.

This report demonstrated that there are several interventions for which strong evidence of effectiveness exists. For example, the use of information technology can improve preventive care, as exemplified in our stimulation of an EMR-facilitated increase in influenza vaccination uptake. It was not the purpose of this report to perform a comprehensive assessment of potential strategies for PHC, only to demonstrate that


effective interventions exist that can address the current deficiencies and evaluate their economic impacts. To guide future investments, we recommend that a comprehensive and systematic review be conducted to assess the strength of the evidence supporting different strategies. Decisions about the optimal investment areas within primary care is best determined by combining information about each intervention’s effectiveness, acceptability to the user and estimated economic impact.

Investing in high-quality PHC research/evaluationThere is currently insufficient information about the estimated economic impact of PHC investment strategies to inform further investments. Most current economic evaluations are far too narrow in scope, poorly reported and suffer from too short a time horizon. More rigorous economic evaluation (such as cost-effectiveness or cost-benefit research) that considers all costs and includes an assessment of longer-term impacts on costs and health benefits is required. Where long-term study designs are not feasible, the use of modeling (simulations) can predict long-term effects.Canada requires an ongoing monitoring strategy that would allow continuous assessment of its performance and permit researchers to evaluate the impact of various reform strategies on the quality of care delivered, the efficiency of the system and the economic burden of primary care-sensitive illnesses. For this to be feasible, a common reporting structure of indicators, with standardized data, is required across Canadian jurisdictions. Such a strategy can be facilitated by a National Coordination Body.

In addition, Canada has a tremendous opportunity to learn from the natural experiment currently in place across its jurisdictions, as well as from a better understanding of the policies, practices and organizational structure of successful PHC in OECD countries, through a similar scoping exercise to that conducted last year by the Commonwealth Fund Commission in its report “The Path to a High Performance U.S. Health System – A 2020 Vision and the Policies to Pave the Way.”169

LimitationsWhile this report largely demonstrates that investing in PHC would reap economic benefits, it did not aim to address which interventions would yield the best economic value. We have shown that many effective interventions exist but, with the exception of the systematic review of the pharmacist integration we performed, we did not assess the economic viability of the different interventions.

Because of the complex nature of PHC, the impact of an investment in PHC to achieve one endpoint is likely to have a much broader effect. For example, achieving higher vaccination rates involves a contact with the family practice and could have additional benefits such as improving continuity and the patient-provider relationship. Similarly, the integration of a pharmacist focused on addressing hypertension is likely to have a broader reach than merely improving patient blood pressure control. Medication reviews are likely to identify other areas of deficiency and the presence of the pharmacist in the practice can be expected to result in acquired knowledge among other practitioners. The broad-reaching impact of PHC is well illustrated by the multifactorial effect of enhanced continuity. However, because most research relied on for this report focused on specific outcomes, the resulting discussion follows a reductionist approach. The true potential impact across the entire healthcare system is likely underestimated in the report.

ConclusionsThe economic burden of illnesses which are sensitive to the quality of primary care is great. Canada’s PHC system performance lags behind that of other industrialized countries. Well-targeted investments in PHC can achieve considerable benefits. Better data on the economic impact of individual investments are required to make informed decisions about the direction of future investments.


APP

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IX A

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APPENDIX B: OECD FRAMEWORK

Health Status How Healthy are the citizens of the oeCd member countries?

Health Conditions Human Function and Quality of Life

Life Expectancy and Well-being

Mortality

non-Healthcare deterninants of Health are the non-healthcare factors that also determine health as well as how healthcare is used changing across and within oeCd member countries?

Healthcare System Perfomance How does the healthcare system perform? What is the level of care across the range of patient needs?

What does this performance cost?

Dimensions of Healthcare Performance

Healthcare Needs

eFFiCienCY

(MaCro- and MiCro-eConoMiC eFFiCienCY)

HealtH SYSteM deSiGn and ConteXt

What are the important design and contextual aspects that may be specific to each health system and which may be useful for interpreting the quality of it’s healthcare?

Other country-related determinants of performance (e.g capacity, societal values/ preferences, policy)

Health System Delivery Features

eQu

itY

Staying Healthy

Getting Better

Living with illness or disability

Coping with end of life

AccessibilitySafetyEffectiveness Responsiveness/ Patient-

centeredness

AccessQuality Cost/Expenditure

Physical Environment

Socio-economic Conditions & Environment

Perssonal or Host Resources

Health Behaviours and Lifestyle


APPENDIX C: SYNTHESIS OF REVIEW LITERATURE – STUDY PROTOCOLProject title: Economic analysis of the consequences of achieving a high-quality primary healthcare system in Canada

Study title: Assessing and Projecting the Health Impact of Improvements in PHC Performance – A Synthesis of the Review Literature

1. 0 IntroductionBackground

There is now good evidence demonstrating the substantive contributions of PHC services to health and equity of health within populations.4 Concerns remain, however, that changes at the system level have not kept pace with available evidence. It has been suggested that health services researchers internationally should more closely examine the impact that PHC has on health services, patients, providers, and the system as a whole.170 The development and performance of the Canadian primary healthcare (PHC) sector have lagged in comparison to other wealthy industrialized countries,13;14 despite the $800 million investment made by Health Canada between 2000 and 2006 through the Primary Health Care Transition Fund (PHCTF)171 to support reform initiatives within the provinces and territories. Sixty-eight projects and project envelopes were resourced through the PHCTF, but more work is needed to disseminate the knowledge arising from these initiatives and to bring a national focus to primary healthcare in Canada, particularly with respect to defining priorities for research and stimulating evidence-informed policy and practice that will strengthen the healthcare system and improve the health of Canadians. In her recent commentary on the state of PHC in Canada, Barbara Starfield noted that “Canada seems to have stalled in its commitment to strengthening PHC. One reason for this lack of movement may be the poor investment in PHC research and evaluation. In this regard, Canada is probably at least 10 years behind.”172

An analysis of the health and economic consequences of closing the gap in access and quality between evidence-based practice and current PHC performance will provide a better understanding of the opportunities for improvement in Canada. CHSRF recently commissioned two reports173;174

that examined important elements of primary healthcare related to improving quality and research capacity. In Mapping the Future of Primary Healthcare Research in Canada the authors presented case studies of system-level structures that support and sustain PHC research and practice change.174

Initiatives in the UK and Australia provide examples that could be considered for application in Canada to enhance the profile of and system-level support for PHC research and reform in policy and practice. Recently CHSRF funded the project “Economic analysis of the consequences of achieving a high-quality primary healthcare system in Canada,” of which one component was to assess the current evidence of how PHC performance can be enhanced.

objectives

The objective of this project component (deliverable #3) is to identify review studies that have demonstrated that PHC performance can be enhanced and summarize the evidence in a qualitative synthesis format.


Hypothesis

From our experience, we anticipate that the examples will be provided from the following six areas where sufficient evidence exists to allow conclusions to be made: accessibility, relational continuity, prevention/screening, immunization, diabetes, and/or cardiovascular disease. We anticipate covering multidisciplinary collaboration in primary-care practices, remuneration strategies, including capitation and pay-for-performance initiatives, and the organization of primary-care practices, including the use of information technology.

2.0 Key questions1. What is the evidence that PHC performance can be enhanced?2. What is the evidence on the effectiveness of specific PHC interventions or improvements?

3.0 Method 3.1 Study designA literature review and synthesis will be used to answer the project key questions.

include:

◥ Published reviews, systematic reviews or meta-analyses ◥ Published articles in English or French ◥ Work published between 2000 and 2010 ◥ Studies with content relating to interventions that are amenable to policy intervention or practice

organization and/or focused on a common condition

exclude:

◥ Non-review articles ◥ Content not related to quality (e.g. provider satisfaction) ◥ Studies that cannot be generalizable to the Canadian setting ◥ Studies that are not focused on general practice (i.e. special population) ◥ Interventions focused on a rare condition

3.2 Searching for the evidence: Literature search strategies for identification of relevant studies to answer the key questions

ovid

OVID Medline and OVID Healthstar will be used to search for published literature to identify relevant articles pertaining to categories identified in the inclusion and exclusion criteria.

Search terms used included: “primary care or family practice or general practice or family medicine or family physician or primary healthcare” in Title, Abstract or Key words.

Limits used for the search were: Full articles, English language and Publication year 2000–Current.

The initial OVID search produced a total of 6,842 articles.


Cochrane library

Potentially relevant reviews were identified in the Cochrane Library including CENTRAL Cochrane Central Register of Controlled Trials.

Search terms used included: “primary care or primary healthcare or general practice or family practice or family medicine” in Title, Abstract or Key words.

The Cochrane Library search produced a total of 455 articles.

Health technology assessment (Hta) database

Potentially relevant reviews were identified in the Health Technology Assessment (HTA) Database, produced by the Centre for Reviews and Dissemination (CRD).


Studies that were recorded as being “Brief record” or “Project record” did not contain data and were excluded.

The HTA database search produced a total of 802 articles.

database of abstracts of reviews of effectives (dare)

Potentially relevant reviews were identified in the Database of Abstracts of Reviews of Effectives (DARE), produced by the Centre for Reviews and Dissemination (CRD).


The DARE search produced a total of 218 articles.

nHS economic evaluation database (nHSeed)

Potentially relevant reviews were identified in the NHS Economic Evaluation Database (NHSEED).


The NHSEED search produced a total of 150 articles.

Campbell library

Potentially relevant reviews were identified in the Campbell Library.


The Campbell Library search produced a total of 7 articles.


3.3 ScreeningIn total, 8,474 articles were identified in the preliminary databases search. The article screening process further assessed via scan of article title and abstract, relevance based on both general inclusion and exclusion criteria outlined in section 3.1 as well as specific inclusion and exclusion criteria relating to specific conditions/outcomes/populations or interventions of interest.

Articles will be screened by one reviewer (SD). Articles identified as being potentially relevant after the screening process will be retrieved and coded by a different reviewer (KM or MP). Newest versions available for each article will be retrieved.

Database-specific exclusions included the HTA database, where some studies that were recorded as a “Brief record” or “Project record” did not contain data and were excluded right away. Also the NHSEED had many articles that were not reviews. The reviewer SD used the “find” function to locate the word “review” to identify potential reviews to screen.

The following table outlines specific inclusion and exclusion criteria used in the screening process.

Condition/outCoMe/PoPulation

Include ExcludeObesity Complementart medicineDiabetes Breast FeedingCardiac condition Children and adolescentsDepression Specific cardiac condition (e.g. left ventricular dysfunction)

Primary vs secondary care Drinking/ addictionsFrequent attenders STD (e.g. Chlamydia and HIV)Physical activity AsthmaDrug prescription AutismPrevention (Breast cancer) Abuse

Healthcare workersBladderProstateCancer managementScreening for rare condition (e.g. oral cancer, micro-albuminuria, ocular hypertension)Vulnerable populationPrenatal careEating disordersDementiaDeveloping countriesDentalcare


intervention

Include ExcludeAudit and feedback (knowledge transfer) Communication/patient-centered/family-centered careElectronic tools Alternative and complementary interventionsMultidisciplinarity/NP/managed care/midwife TelemedicineSelf care/management PharmacotherapyConsultation lengthDifferent models of care (e.g. after hours)Continuity of care

3.4 Data abstraction and data managementData extraction of included studies will be undertaken by one reviewer (KM/MP/TD) and checked by a second reviewer (SD). A data extraction form (Excel workbook) will be used to record information on relevant key information that can be used for the synthesis.

The data abstraction form includes the following headings: Author and Year, Title, Source, Search Method, Document Type and Notes.

3.5 Quality assessmentWe seek to identify and include only those reviews that meet a minimum standard of quality as a systematic review. This required that the review had to have used and described adequate methods to search for, appraise and describe included studies. Narrative reviews, in which the inclusion of studies may have been subject to a high level of bias, would be included as low quality. The quality of each review identified will be assessed within the following domains:

◥ description of study selection and inclusion criteria ◥ comparability of included studies ◥ assessment of publication bias ◥ assessment of heterogeneity ◥ generalizability to the Canadian context

Review articles that were screened into the data abstraction phase will be reviewed for quality of the reporting and methods using the AMSTAR checklist (‘assessment of multiple systematic reviews) (Shea et al. 2007) and Cochrane Handbook for Systematic Reviews of Interventions.175 Review articles that were deemed “moderate quality” or “high quality” will be included.

Currently, there exists a paucity of systematic reviews of incentives as a quality-improvement initiative in PHC. In order to provide a more complete picture of this intervention, data from the few identified review articles was supplemented by evidence from primary studies. These studies were not assessed for quality.

Evidence summaries will be created for each intervention based on the evidence from the review studies included. Evidence summaries can be produced in a similar format as those produced by the Ontario Health Research Institute – Knowledge to Action group.176


4.0 Results reporting4.1 Identified studiesThe identified studies were maintained in a database using Microsoft Excel. Studies were categorized according to interventions, target outcomes and quality scores. Those reviews that did not target policy-relevant outcomes or had low quality scores were separated into a list of excluded studies.

4.2 Data synthesisTables will be used to present included studies and their findings in a systematic and clear format. A ‘Summary of findings’ table provides key information concerning the quality of evidence, and the sum of available effectiveness data on all important outcomes for a given comparison. This table can help inform the main results of the synthesis of reviews, which, in turn, will help address the project objectives and key questions and provide key recommendations on priorities for PHC system improvement in terms identifying specific interventions to enhance the PHC system.


APPENDIX D: DESCRIPTION OF STUDIES INCLUDED IN THE SECTION ON “INTERVENTIONS TO IMPROVE PHC PERFORMANCE”Quality assurance - incentives

Authors, Year Title Article Type Effects Quality Score

Campbell et al., 2007

Quality of primary care in England with the introduction of pay-for-performance

Primary Study Primary Study Pay-for-performance schemes have been mostly found to be effective in improving practice level quality scores in the area of care they reward.

CHD: ~+11.5% ; Diabetes: ~+15.6%; Asthma: ~+19.9%;

N/A


Effects of Pay-for-performance on the Quality of Primary Care in England

Primary Study Pay-for-performance schemes have been mostly found to be effective in improving clinical quality scores in disease-specific processes:

(Asthma: +0.83% on clinical quality score; Diabetes: + 2.83% on clinical quality score);

Health outcomes not related to the incentives decrease over time and those that were rewarded reached a peak shortly after being implemented.

N/A


The Experience of Pay-for-performance in English Family Practice: A Qualitative Study

Primary Study (Qualitative)

It is difficult to attribute improvements in clinical outcomes to incentives. The tendency away from collaborative care and towards delegation causes physicians to lose skills in the areas they have reassigned to others

N/A

Checkland et al., 2008

Biomedicine, holism and general medical practice: responses to the 2004 General Practitioner contract

Primary study (Qualitative)

Quality and Outcomes Framework (QOF) was implemented and impacts were assessed by collecting qualitative information on the viewpoints of practitioners and staff. The quality of care in pay-for-performance shifts towards a biomedical model of healthcare and away from a holistic model. GP respondents generally failed to consider the overall experience of a patient attending the practice and were more concerned with the measurable (within QOF) outcomes as definable entities of “what went wrong” in their offices.

N/A

Doran and Roland, 2010

Lessons from Major Initiatives to Improve Primary Care in the United Kingdom

Commentary The U.K.’s comprehensive physician practice incentive program improved physician morale, helped address a shortage of FPs, and improved chronic disease care. But the longer-term effects on the physician–patient relationship cannot yet be assessed.

N/A


Gravelle et al., 2007

Doctor Behaviour Under a Pay-for-performance Contract: Evidence from the Quality and Outcomes Framework

Primary Study Pay-for-performance may have led to above trend increases in quality. Ninety-one percent of practices achieved above quality thresholds.

N/A

Lee et al., 2009

Linking families and facilities for care at birth: What works to avert intrapartum-related deaths?

Systematic Review

Pay-for-performance schemes have been mostly found to be effective in improving the area of care they reward Institutionalized births: +41%Primary care centre births: +4%

6

Naccarella et al, 2009

Final report: Narrative Literature Review on Incentives for Primary Healthcare Team Services Provision: Learning and Working Together in Primary Healthcare

Narrative Review

Pay-for-performance schemes have been mostly found to be effective in improving the area of care they reward, but reinforce hierarchies, therefore disempowering nurses.

3

Oluwatowoju et al., 2010

Organisation and Delivery of Care- Improvements in glycaemic control and cholesterol concentrations associated with the Quality and Outcomes Framework: a regional 2-year audit of diabetes care in the UK

Primary Study Pay-for-performance schemes have been mostly found to be effective in improving the area of care they reward: Glycemic control: +12.4% of patients

Achieving HbA1c and cholesterol targets: +13.5% of patients.

N/A

Petersen L, 2006

Does Pay-for-Performance Improve the Quality of Healthcare?

Review Provider group-level incentive resulted in a statistically significant improvement in the measure of quality of care in two studies. In five other studies the financial incentive had a partial effect. One study found a small improvement in rates of cervical cancer screening between the intervention and comparison groups after the quality incentive program (difference, 3.6%; P=0.02). Improvements in mammography screening rates and hemoglobin A1c testing were not statistically significant.

8

Sabatino et al., 2008

Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers systematic reviews of provider assessment and feedback and provider incentives

Systematic Review

Financial incentives may be effective when coupled with audit and feedback interventions. There is insufficient evidence to determine the effectiveness of provider incentives in increasing screening for breast, cervical or colorectal cancers. Evidence is insufficient because of too few qualifying studies and inconsistent results.

4

Schatz et al., 2008

Does pay-for-performance influence the quality of care?

Systematic Review

Pay-for-performance programs that reward physician groups or individual physicians can improve markers of quality, but not always. Of the studies included, even when studies suggest positive effects, the designs often do not permit assurance that the effects are due to the incentives compared with other factors.

4


Strong et al., 2009

The UK Quality and Outcomes Framework pay-for-performance scheme and spirometry: rewarding quality or just quantity? A cross-sectional study in Rotherham, UK

Primary Study Pay-for-performance may only increase the quantity and not the quality of care provided.

There was an approximately 95 % mean achievement for COPD indicators.

N/A

Sturam et al., 2007

Pharmaceutical policies: effects of financial incentives for prescribers

Systematic Review

Due to methodological limitations, overall the evidence is weak. It supports the conclusion that drug budgets can decrease prescribed drug volume and drug expenditure. Results on healthcare utilization and quality of care were inconclusive. Approximately 10% difference between fundholders and non-fundholders in terms of increase in prescribing costs.

9

Quality assurance - Feedback

Authors Title Article Type Effects Quality Score

Jamtvedt et al. 2006

Audit and feedback: effects on professional practice and healthcare outcomes.

Review A&F had a small effect on professional practice outcomes: median adjusted risk difference: 4% (-16 to 32%)

8

Grimshaw et al. 2004

Audit and feedback: effects on professional practice and healthcare outcomes.

Review A&F had a medium effect on professional practice outcomes: median risk difference: 7% (1.3-16%)

7

Hysong 2009 Meta-analysis audit and feedback features impact effectiveness on care quality.

Meta-analysis A&F was generally effective in improving professional practice outcomes.

5

Marinopoulos et al. 2007

Effectiveness of continuing medical education.

Review Insufficient evidence for the effect of A&F on professional practice outcomes.

7

Baskerville 2010

Systematic Review of Practice Facilitation and Evaluation of a Chronic Illness Care Managment Tailored Outreach Facilitation Intervention for Rural Primary Care Physicians.

Systematic Review

EOV had a medium effect on professional practice outcomes: odds ratio: 0.54 (0.43-0.65).

10

Shaw et al. 2005

Tailored interventions to overcome identified barriers to change: effects on professional practice and healthcare outcomes.

Review EOV was generally effective in improving professional practice outcomes.

7

Qureshi et al. 2002

A systematic review of educational outreach visits for a non-prescribing interventions in general practice.

Systematic Review

EOV was generally effective in improving professional practice outcomes.

7

O’Brien et al. 2007

Educational outreach visits: effects on professional practice and healthcare outcomes.

Review Insufficient evidence for the effect of EOV on professsssional practice outcomes.

8

Forsetlund et al. 2009

Continuing education meetings and workshops: effects on professional practice and healthcare outcomes.


8


Thomas et al. 2000

Guidelines in professions allied to medicine.


8

Légaré et al. 2010

Interventions for improving the adoption of shared decision making by healthcare professionals.


9

Faulkner et al. 2003

A systematic review of the effect of primary care-based service innovations on quality and patterns of referral to specialist secondary care.

Systematic Review

Insufficient evidence to draw any conclusions regarding the effects of A&F on interprofessional collaboration.

8

Akbari et al. 2008

Interventions to improve outpatient referrals from primary care to secondary care.

Review Insufficient evidence to draw any conclusions regarding the effects of A&F on interprofessional collaboration.

7

Zwarenstein et al. 2008

Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes.

Review Insufficient evidence to draw any conclusions regarding the effects of EOV on interprofessional collaboration.

7

Smolders et al. 2008

Knowledge transfer and improvement of primary and ambulatory care for patients with anxiety.

Review Insufficient evidence to draw any conclusions regarding the effects of EOV on interprofessional collaboration or on managing anxiety.

7

Sabatino et al. 2008

Task Force on Community Preventive Services. Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers systematic reviews of provider assessment and feedback and provider incentives.

Systematic Review

A&F is generally effective for improving cancer screening.

4

Bordley et al. 2000

The effect of audit and feedback on immunization delivery.

Review A&F is generally effective for immunization rates.

5

Ryman et al. 2008

The effect of audit and feedback on immunization delivery.

Review A&F is generally effective for immunization rates.

5

Safdar and Abad 2008

Educational interventions for prevention of healthcare-associated infection: a systematic review.

Systematic Review

Insufficient evidence for the effect of A&F on reducing infections.

5

Glynn et al. 2010

Interventions used to improve control of blood pressure in patients with hypertension.

Review Insufficient evidence for the effect of A&F on managing hypertension.

10

Flodgren et al. 2010

Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people.

Review Insufficient evidence for the effect of A&F on managing obesity.

8

Renders et al. 2000 (Published as up to date in 2009)

Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings.

Review Insufficient evidence for the effect of A&F on managing diabetes.

7

Guldberg et al. 2009

The effect of feedback to general practitioners on quality of care for people with type 2 diabetes.

Review Insufficient evidence for the effect of A&F on managing diabetes.

4


Gilbody et al. 2003

Educational and organisational interventions to improve the management of depression in primary care.A systematic review.

Systematic Review

EOV is generally effective for managing depression medication.

6

Arnold and Straus 2005

Interventions to improve antibiotic prescribing practices in ambulatory care.

Review EOV has small effect on improving appropriate antibiotic prescription (5.1% (-6.5 to 9.5%).

A&F has a small effect (5.8% (-0.4-14.5%) on improving antibiotic prescription.

7

Steinmann et al. 2006

Improving antibiotic selection: a systematic review and quantitative analysis of quality improvement strategies.

Systematic Review

EOV is generally effective for improving antibiotic prescription

Insufficient evidence for the effectiveness of A&F for improving appropriate antibiotic prescription.

5

Bennett and Glasziou 2003

Computerised reminders and feedback in medication management: a systematic review of randomized controlled trials.

Systematic Review

A&F was generally effective for improving appropriate prescriptions of medication: Risk Difference: 2% (0-8%).

4

Chaudhry et al. 2006

Systematic review: Impact of health information technology on quality, efficiency, and costs of medical care.

Systematic Review

Insufficient evidence for the effectiveness of A&F in improving appropriate prescription of medication.

4

Figueiras et al. 2001

Effectiveness of educational interventions on the improvement of drug prescription in primary care: a critical literature review.

Review Insufficient evidence for the effectiveness of A&F in improving appropriate prescription of medication.

4

information technology - Patient recall


Jacobson Vann and Szilagyi 2005

Patient reminder and recall systems to improve immunization rates.

Review Improved immunization rates: Influenza: absolute risk difference (ARD) = 12 more people out of 100 (95% CI: 6, 18); all other vaccines: ARD = 18 more people out of 100 (95% CI: 4, 33).

10

Stone and Morton 2002

Interventions that increase use of adult immunization and cancer screening services: a meta-analysis.

Meta-analysis Improved immunization rates:All vaccines: Odds Ratio (OR) = 2.52 (95% CI: 2.24, 2.82)Improved cancer screening:Colon cancer: adjusted OR= 2.75 (1.90–3.97) Cervical cytology: adjusted OR= 1.74 (1.58–1.92) Mammography: adjusted OR = 2.31 (1.97–2.70)

9

Forbes et al. 2002

Interventions targeted at women to encourage the uptake of cervical screening.

Review Improved cancer screening:Cervical cytology: generally effective.

10


Bonfill Cosp et al. 2001

Strategies for increasing the participation of women in community breast cancer screening.

Review Improved cancer screening:Mammography: letter of invitation (OR 1.66, 95% CI 1.43 to 1.92); letter of invitation plus phone call (OR 2.53, 95% CI 2.02 to 3.18); phone call (OR 1.94, 95% CI 1.70 to 2.23.

9

Glynn et al. 2010


Review Improved proportion of hypertensive patients who attended follow-up.In two small trials also led to improved blood pressure control, odds ratio favouring intervention 0.54 (95% CI 0.41 to 0.73).

10

Renders et al. 2000 (Published as up to date in 2009)

Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings.

Review Improved follow-up in diabetic patients. 7

information technology - Provider reminders


Shojania et al. 2009

The effects of on-screen, point of care computer reminders on processes and outcomes of care.

Review Small effects on clinical processes and outcomes:-prescription of vaccinations (3.8%, IQR: 0.5 to 6.6%)-test ordering (3.8%, IQR: 0.4 to 16.3%) -all measure of medication ordering (6.2%, IQR: 3.0% to 28.0%).Median improvement across all process measures (5.6% (IQR: 2.0% to 19.2%)) with a process adherence of 4.2% (interquartile range (IQR): 0.8% to 18.8%) across all reported process outcomes.Intervention patients experienced a median absolute improvement of 2.5% (IQR: 1.3% to 4.2%); systolic blood pressure (-1 mm Hg; (IQR: 2.3 mmHg reduction to 2.0 mmHg increase)).

8

Grimshaw et al. 2004

Effectiveness and efficiency of guideline dissemination and implementation strategies.

Review Medium effects on adherence to guidelines (cancer screening, blood pressure monitoring, diabetes care, immunizations, etc.): median risk difference: 11.6% (-1% to 40%).

7

Balas et al. 2000

Improving preventive care by prompting physicians.

Review Medium effects on adherence to guidelines (cancer screening, blood pressure monitoring, diabetes care, immunizations, etc.): cumulative rate difference: 13.1% (10.5-15.6%).

4

Chaurhry et al. 2006

Systematic review: Impact of health information technology on quality, efficiencey, and costs of medical care.

Systematic Review

Provider reminders were generally effective in improving quality of care.

4


Thomas et al. 2000

Guidelines in professions allied to medicine.

Review Insufficient evidence for the effect of provider reminders on process outcomes.

7

Zwarenstein et al. 2009

Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes.

Review Insufficient evidence to draw any conclusions regarding the effects of provider reminders on interprofessional collaboration.

7

Akbari et al. 2008

Interventions to improve outpatient referrals from primary care to secondary care.

Review Insufficient evidence to draw any conclusions regarding the effects of provider reminders on interprofessional collaboration.

7

Stone and Morton 2002


Meta-Analysis Provider reminders increased immunization uptake: OR = 3.80 (95% CI: 3.31. 4.37).

9

Glynn et al. 2010


Review Provider reminders alone were unlikely to be effective in the management of hypertension.

10

Flodgren et al. 2010

Interventions to change the behaviour of health professionals and the organisation of care to promote weight reduction in overweight and obese people.

Review Insufficient evidence to draw conclusions about provider reminders in the management of obesity.

9

Gilbody et al. 2003

Educational and organisational interventions to improve the management of depression in primary care.

Review Insufficient evidence to draw conclusions about provider reminders in the management of depression.

6

de Belvis et al. 2009

Can primary care professionals’ adherence to Evidence Based Medicine tools improve quality of care in Type 2 diabetes mellitus? A systematic review.

Systematic Review

Insufficient evidence to draw conclusions about provider reminders in the management of diabetes.

7

Kawamoto et al. 2005

Improving clinical practice using clinical decision support systems: a systematic review of trials to identify features critical to success.

Systematic Review

After meta-regression, 94% of studies where CDSS incorporated the following components (based on univariate analyses) found CDSS to be effective for general disease management: 1) automatic provision of decision support; 2) provided at point of care; 3) recommendations provided; 4) computer generated

5

Lu et al. 2008 Interventions designed to improve the quality and efficiency of medication use in managed care: a critical review of the literature 2001-2007 (Provisional abstract).

Review Insufficient evidence for the effectiveness of reminders in disease management.

4


Durieux et al. 2008

Computerized advice on drug dosage to improve prescribing practice.

Review Improved initial dose (standardized mean difference 1.12, 95% CI 0.33 to 1.92), serum concentrations (standardized mean difference 1.12, 95% CI 0.43 to 1.82), time to therapeutic stabilization (standardized mean difference -0.55, 95%CI -1.03 to -0.08), risk of toxic drug level (rate ratio 0.45, 95% CI 0.30 to 0.70) and length of hospital stay (standardized mean difference -0.35, 95% CI -0.52 to -0.17).

7

Bennett and Glasziou 2003

Computerised reminders and feedback in medication management: a systematic review of randomized controlled trials.

Systematic Review

Improved drug choices for outpatients (RD: 22% (10.7% and 34%).

4

Yourman et al.

Use of computer decision support interventions to improve medication prescribing in older adults: a systematic review.

Systematic Review

Improved drug choices for outpatients. 5

Ioannidis and Lau 2001

Evidence on interventions to reduce medical errors: an overview and recommendations for future research.

Review Improved drug choices for outpatients. 4

Ammenwerth et al. 2008

The Effect of Electronic Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review.

Systematic Review

Increased appropriate use and drug safety.

5

Kaushal et al. 2003

Effects of computerized physician order entry and clinical decision support systems on medication safety: a systematic review.

Systematic Review

Increased appropriate use and drug safety. 5

Pearson et al. 2009

Do computerised clinical decision support systems for prescribing change practice? A systematic review of the literature (1990-2007).

Systematic Review

Combining CPOE + CDSS best reduced adverse drug events.

5

Garg et al. 2005

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.

Systematic Review

Mixed results on effectiveness of CDSS. 5

Arnold and Straus 2005

Interventions to improve antibiotic prescribing practices in ambulatory care.

Systematic Review

Mixed results on effectiveness of CDSS. 7

Randell et al. 2007

Effects of computerized decision support systems on nursing performance and patient outcomes: a systematic review.

Systematic Review

Insufficient evidence to draw conclusions on the effectiveness of CDSS.

6


team Structure


Boult et al., 2009

Successful models of comprehensive care for older adults with chronic conditions: evidence for the Institute of Medicine’s “retooling for an aging America” report.

Systematic Review

(Narrative) A team composed of a primary care physician and one or more allied health professionals has improved several indices of the quality of multimorbid patients’ PHC, and many have improved patients’ quality of life and functional autonomy. For most of the different team structures, available evidence of success is limited to a single randomized trial. Only teams focused on heart failure have improved patients’ survival and have been evaluated in enough studies to allow a meta-analysis, which reported significant reductions in hospital admissions and total costs (actual estimates not provided).

7

Bower et al., 2006

Collaborative care for depression in primary care. Making sense of a complex intervention: systematic review and meta-regression

Meta-Analysis Using collaborative care in depression management OR 1.92, 95% CI 1.54-2.39 I2 80% = improved antidepressant use and SMD 0.24, 95% CI 0.17 - 0.32, I2 54% = better depressive outcomes.

4

Bower and Rowland, 2009

Effectiveness and cost effectiveness of counseling in primary care.

Systematic Review

Greater clinical effectiveness in the counseling group compared with usual care in the short term (standardized mean difference -0.28, 95% CI -0.43 to -0.13) but not in the long term (standardized mean difference -0.09, 95% CI -0.27 to 0.10).

8

Carter et al., 2009

The potency of team-based care interventions for hypertension: a meta-analysis.

Meta-Analysis Adding a pharmacist to primary practice improves blood pressure control: OR 2.17 95% 1.75 - 2.68; adding a nurse improves blood pressure control: OR 1.69 95% 1.48 - 1.93. There were no significant differences between the nursing and pharmacy studies (P=0.19).

4

Chang-Quan et al., 2009

Collaborative care interventions for depression in the elderly: a systematic review of randomized controlled trials.

Systematic Review

Using a collaborative care intervention (care systems integrated mental health providers and primary care) was more effective in improving depression symptoms than usual care during each follow-up period. Compared with baseline, thoughts of suicide in subjects receiving intervention significantly decreased (OR= 0.52; 95% CI 0.35- 0.77), but not that in those receiving usual care (OR=0.85; 95% CI, 0.50-1.43).

8


Chapman et al., 2004

Systematic review of recent innovations in service provision to improve access to primary care.

Systematic Review

(Narrative) Lack of rigorous evidence. Substituting nurses for GPs or the telephone for face-to-face consultations may be effective in improving access where GP recruitment and retention is a challenge, however may infringe on equality of access for some, including people who do not speak English or who have hearing impairments. Weak evidence that patients can be safely managed by pharmacists’ advice and treatment.

4

Craven and Bland, 2006

Better practices in collaborative mental healthcare: an analysis of the evidence base

Systematic Review

(Narrative) A trend towards positive outcomes in studies with collaboration. Using collaborative care improves mental healthcare outcome.

4

Gensichen et al., 2006

Case management to improve major depression in primary healthcare: a systematic review

Meta-Analysis Standard mean difference/effect size on symptom severity after 6–12 months of -0.40 (95% CI -0.60 to –0.20). Patients in case management group more likely to achieve remission after 6-12 months compared to control group: RR 1.39, 95% 1.30-1.48. Intervention group more likely to achieve better medication adherence compared to control: RR=1.5, 95% 1.28-1.86.

8

Gilbody et al., 2003

Educational and organizational interventions to improve the management of depression in primary care: a systematic review

Systematic Review

(Narrative) Adding a pharmacist improved antidepressant prescribing in patients 60 years and older: RR 0.55, 95% 0.33-0.92. Adding a nurse/coordination improved adherence to medication: OR 2.7, 95% 1.6-4.8 (individual study). Adding a nurse practitioner improved medication adherence: OR 1.99, 95% 1.23-3.22 (individual study), and improved clinical response: OR 2.22, 95% 1.31-3.75 (individual study).

6

Glynn et al., 2010

Interventions used to improve control of blood pressure in patients with hypertension

Systematic Review

(Narrative) Nurse- or pharmacist-led care may be a promising way forward, with the majority of RCTs being associated with improved blood pressure control and mean systolic blood pressure and diastolic blood pressure, but these interventions require further evaluation.

9

Hudon et al., 2008

Single risk factor interventions to promote physical activity among patients with chronic diseases: systematic review

Systematic Review

(Narrative)Insufficient evidence for the effects of collaborative care. One study showed a positive trend from the least intensive intervention (usual care) to the more intensive interventions (prescription by a FP and counseling by a nurse) toward increased physical activity at one month. Another study found no significant effect. Suggests that face-to-face consultation with a counselor is more effective than over-the-phone consultation.

7


Laurant et al., 2005

Substitution of doctors by nurses in primary care

Systematic Review

(Narrative) In general, no appreciable differences were found between doctors and nurses in health outcomes for patients, process of care, resource use or cost. Patient health outcomes were similar for nurses and doctors but patient satisfaction was higher with nurse-led care.

8

Lindenmeyer et al., 2006

Interventions to improve adherence to medication in people with type 2 diabetes mellitus: a review of the literature on the role of pharmacists.

Systematic Review

(Narrative) Three studies evaluated pharmacist-led integrated management and education programs designed to improve glycaemic control for under-served patient populations. They all succeeded in lowering glycated haemoglobin, but it remains unclear whether this resulted from improved patient adherence. One included study reported a decrease of HbA1c by 2.2% in the intervention group compared to usual care.

7

Loveman et al., 2003

Specialist nurses in diabetes mellitus Systematic Review

(Narrative) One study demonstrated a significant reduction in HbA1c in the presence of the diabetes specialist nurse/nurse case manager at six months. Significant differences in episodes of hypoglycaemia and hyperglycaemia between intervention and control groups were found in one trial.

9

McAlister et al., 2004

Multidisciplinary strategies for the management of heart failure patients at high risk for admission: a systematic review of randomized trials.

Systematic Review

(Narrative) One study found that collaborative care reduced mortality compared to usual care: RR 0.75, 95% 0.59-0, reduced heart failure hospitalizations: RR 0.74, 95% CI 0.63 - 0.87 and reduced all-cause hospitalizations: RR 0.81, 95% CI 0.71 - 0.92.

7

Renders et al., 2000 (Published as up to date in 2009)

Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings

Systematic Review

Nurse partly replaced physician with positive impacts on glycaemic control. More evidence needed for pharmacist replacing physician for diabetes care; using a nurse practitioner to increase patient education or facilitate adherence to treatment. Using case management and multidisciplinary teams showed favorable effects on process and patient outcomes. One of the included studies found improvements in HbA1c: absolute difference of 0.6 and relative improvement of 8%. Baseline: 7.4±1.6 vs 7.4±1.9; post intervention: 7.0±1.3 vs 7.6±1.5

7


Rice and Stead, 2009

Nursing interventions for smoking cessation

Meta-Analysis Adding a pharmacist: (OR 0.92, 95% 0.81-1.05) RCTs only but (OR 0.64, 95% 0.43-0.96) = for all pharm-led interv effective in reducing hospital admissions; adding a nurse/coordinator: (RR 1. 28, 95% 1.18-1.38) nursing interv to help patients quit smoking.

9

Stone et al. 2002


Meta-Analysis Organizational change results in a significant increase in immunization uptake; OR = 16.0 (95% CI: 11.2, 22.8).

9

Tsai and Wadden, 2009

Treatment of obesity in primary care practice in the United States: a systematic review.

Systematic Review

dding a counselor: positive results for multidisciplinary model with physical activity counselors. For 1) PHC counseling alone, (2) PHC counseling + pharmacotherapy, and (3) “collaborative” obesity care (treatment delivered by a non-physician provider), weight losses in the active treatment arms of these categories of studies ranged from 0.1 to 2.3 kg, 1.7 to 7.5 kg, and 0.4 to 7.7 kg, respectively.

9


APPENDIX E: SYSTEMATIC REVIEW – STUDY PROTOCOLProject Title: Economic analysis of the consequences of achieving a high-quality PHC system in CanadaStudy title: Systematic review of the cost-effectiveness of multidisciplinary PHC teams in improving PHC (PHC) performanceFocused review title: Systematic review of the economic impact of adding a pharmacist to PHC team

1.0 Introduction1.1 BackgroundThere is now good evidence demonstrating the substantive contributions of primary care services to health and equity of health within populations.4 Concerns remain, however, that changes at the system level have not kept pace with available evidence. It has been suggested that scientists conducting international research on health services should more closely examine the impact that primary care has on health services, patients, providers and the system as a whole.170 The development and performance of the Canadian PHC sector have lagged in comparison to other wealthy industrialized countries,13;14 despite the $800 million investment made by Health Canada between 2000 and 2006 through the PHC Transition Fund (PHCTF)171 to support reform initiatives within the provinces and territories. Sixty-eight projects and project envelopes were resourced through the PHCTF, but more work is needed to disseminate the knowledge arising from these initiatives and to bring a national focus to PHC in Canada,– particularly with respect to defining priorities for research and stimulating evidence-informed policy and practice that will strengthen the healthcare system and improve the health of Canadians. In her recent commentary on the state of PHC in Canada, Barbara Starfield noted that “Canada seems to have stalled in its commitment to strengthening primary care. One reason for this lack of movement may be the poor investment in primary care research and evaluation. In this regard, Canada is probably at least 10 years behind.”172

An analysis of the health and economic consequences of closing the gap in access and quality between evidence-based practice and current PHC performance will provide a better understanding of the opportunities for improvement in Canada. Multidisciplinary primary care teams have been suggested as one PHC intervention that has potential to improve access and quality, at a reduced cost to the healthcare system. The proposed study aims to review and integrate the current literature on the health and economic impact of multidisciplinary care teams as they relate to the addition of allied health professionals to the primary-care practice. For the purposes of the report to the Canadian Health Services Research Foundation, the health and economic impact of adding or integrating a pharmacist to a primary-care practice will be evaluated and presented.

1.2 ObjectivesTo systematically review the literature and provide a narrative analysis of the potential health and economic impact of pharmacist-physician collaborative care within the primary-care practice setting.

1.3 Project time lineProject Start Date: August 6, 2010Anticipated Draft Report Due Date: November 15, 2010


2.0 Key questions 2.1 Questions that the review will address

Principal Questions:

1. What economic outcomes can be attributed to multidisciplinary primary care teams, and in particular the contribution of pharmacist-physician collaborative care?

2. Is pharmacist-physician collaboration in primary care cost effective? 3. For which diseases is pharmacist-physician collaborative care in PHC cost effective?

additional Questions:

◥ What methods have been used to assess the economic impacts of multidisciplinary teams? ◥ When have the economic benefits of multidisciplinary primary care teams been evaluated? ◥ How can international approaches and findings be applied to the Canadian context (generalizability)?

2.2 Population(s)

include:

PHC practice and professionals providing PHC within the primary practice setting (i.e. involving healthcare providers as the first point of consultation for patients, or any kind of healthcare providers acting as first points of consultation for patients).177 Include healthcare providers within the settings of family practice, general practice and family medicine, including FPs or other PHC workers (e.g. nurses, physicians’ assistants, pharmacists, etc.) For the CHSRF report, results will be reported for the inclusion of pharmacists in primary-care practices.

exclude:

Institutions and persons providing solely secondary and/or tertiary healthcare; private institutions providing PHC; and traditional healthcare not locally recognized as being part of official healthcare system. For the CHSRF report, those studies that assess the health economic impact of multidisciplinary teams that include other non-pharmacist allied health professionals will be excluded. Assessment of other types of multidisciplinary care teams will be conducted and reported on at a later time.

2.3 Interventions

include:

To improve/affect: accessibility, relational continuity, prevention/screening, immunization, diabetes and/or cardiovascular disease within the PHC context. Examples of multidisciplinary primary care include the addition within a primary-care practice of an allied health professional to a FP, such as a nurse practitioner, registered nurse, pharmacist and/or mental health counselor, psychotherapist or social worker. For the purposes of the CHSRF report, results will be reported for the intervention of pharmacist-physician collaborative care in primary-care practices.

exclude:

Studies with no active intervention, any multidisciplinary care provided outside the primary practice setting including outpatient care, home care or care provided in a nursing home/long-term care facility. Exclude evaluations of allied health professionals as substitutes for the primary care physician or those working in collaboration but who work outside the practice, such as community-based care. Exclude studies that assess the impact of multidisciplinary teams for less-significant diseases, for example


headache, dermatological issues, etc. For the purposes of the CHSRF report, the review will exclude findings for all non-pharmacist interventions. The health economic impact of multidisciplinary primary care teams that include other allied health professionals will be evaluated and reported on at a later time.

2.4 ComparatorsCurrent standard of care and/or other intervention

For the purposes of the CHSRF report, the comparators of interest include pharmacist integration in primary-care practice versus usual care within a PHC setting (i.e. family/general practice).

2.5 OutcomesAt least one economic outcome measure reported, including costs related to the PHC intervention, health resource use, medication usage, etc. Effectiveness outcomes are any improvements in care or clinical outcomes, including improvements in accessibility, relational continuity, health resource use and/or other chronic diseases including hypertension, diabetes and overweight/obesity. Other cost-effectiveness outcomes including cost-effectiveness ratios or incremental cost-effectiveness ratios i.e. cost per effect or cost per benefit gained when evaluating comparators.

3.0 Method 3.1 Study design

include:

◥ Published literature and grey literature from January 1990 to August 2010 ◥ English language ◥ Full economic evaluation studies (i.e. cost-effectiveness analyses, cost-utility analyses, cost-benefit

analyses) of [intervention(s) versus comparator(s)] ◥ Partial economic evaluations (i.e. cost analyses, cost-description studies, cost-outcome

descriptions) of [intervention(s) and comparator(s)]; and randomized trials reporting more limited information, such as estimates of resource use or costs associated with [intervention(s) and comparator(s)].

◥ Primary studies that assess the cost and effectiveness of pharmacist-physician collaborative care within primary-care practice

exclude:

◥ Studies that specifically refer to cost-effectiveness of treatment interventions (i.e., micro-economic studies)

◥ Methodology studies ◥ Non-primary studies, reviews, commentaries and editorials.


3.2 Searching for the evidence: Literature search strategies for identification of relevant studies to answer the key questions

3.2.1 Grey literature

The search of grey literature was performed for a previous component of the broader project (deliverable 2). The following search strategy was employed to identify the relevant grey literature:

◥ a search of web pages of international organizations, bilateral agencies and nongovernmental organizations (NGOs) involved in PHC research

◥ a search for primary studies referred to in bibliographies of reviews and other articles ◥ reports and articles in press that were recommended by experts in the field ◥ documents that refer to economic evaluations of multidisciplinary primary care and, in particular pharmacist-

physician collaborative care in primary-care practice will be included

Websites studied included:

◥ CHSRF (www.chsrf.ca/) ◥ Commonwealth Fund organization (www.commonwealthfund.org/) ◥ Health Canada (http://www.hc-sc.gc.ca/index-eng.php) ◥ RAND corporation (www.rand.org) ◥ Canadian Nurses Association (www.cna-nurses.ca/cna/) ◥ College of Family Physicians of Canada (www.cfpc.ca/) ◥ Provincial college of family physician and nurses (www.ocfp.on.ca/ and www.cno.org) ◥ OECD (www.oecd.org) ◥ World Health Organization (www.who.int/en/) ◥ Australian PHC Research Institute (www.anu.edu.au/aphcri/) ◥ Department of Health – Primary Care (UK) (www.dh.gov.uk/en/index.htm), National ◥ Primary Care Research and Development Centre (www.npcrdc.ac.uk/About_NPCRDC.cfm) ◥ The European Observatory on Health Systems and Policies (www.euro.who.int/observatory) ◥ Provincial health quality councils (e.g. for Ontario http://www.ohqc.ca/en/index.php) ◥ Health Quality Council of Canada (http://www.healthcouncilcanada.ca/en/) ◥ NIH (http://health.nih.gov/) ◥ Institute for Health Improvement (http://www.ihi.org/ihi)

3.2.2 Databases

The following databases will be used to identify published relevant studies:

◥ Cochrane library, specifically the NHS Economic Evaluation Database (NHSEED) ◥ OVID Medline ◥ Econlit


3.3 Search strategy

Cochrane library

A broader search was conducted using the Cochrane library in order to ensure large capture. The MeSH trees were used, specifically the exploded term “PHC.” Selected databases: Economic Evaluations

Search Strategy #identified studies

1 (“PHC” or “primary care” or “family practice” or “general practice” or “family medicine” or “general practitioner”) and (mutlidisciplin* or nurse* or pharmacist* or counsel* or psychotherap* or “allied health”) restrict to years 1990–2010

571

ovid Medline(r)1950 to august Week 1 2010


1 PHC/ 42,6152 (Primary care or family practice or general practice or family medicine or general

practitioner or PHC).mp.143,747

3 1 or 2 143,7474 multidisciplin$.mp. 28,2585 nurse$.mp. 222,2316 pharmacist$.mp. 17,8447 counsel$.mp. 17,8448 pssycotherap$.mp. 58,0309 Allied Health Personnel/ 9,24810 social work$.mp. 17,86311 or/4-10 401,71412 3 and 11 19,07513 Economics, Dental/ or Economics, Nursing/ or Economics/ or Economics, Medical/ or

Economics, Hospital/ or Economics, Pharmaceutical/50,282

14 exp “costs and cost analysis”/ 151,68215 (economic$ or cost or costs or costly or costing or price or prices or pricing or

pharmacoeconomic$).ti,ab.317,081

16 (expenditure$ not energy).ti,ab. 13,55017 (value adjl money).ti,ab. 1518 Budget&.ti,ab. 13,78719 or/13-18 426,270

20 ((energy or oxygen) adj cost).ti,ab. 2,21321 (metabolic adj cost).ti,ab. 56222 ((energy or oxygen) adj expenditure).ti,ab. 12,48423 or/20-22 14,67024 19 not 23 422,91525 letter.pt. 686,35226 editorial.pt. 260,53827 Historical article.pt. 266,86228 or/25-27 1,201,751



29 12 and 24 2,37729 29 not 28 2,33931 Animals/ 4,626,40032 Humans/ 11,364,78633 32 not 31 10,172,71434 30 and 33 2,05135 limit 34 to yr=”1990 -Current” 1,850

econlit

Restricted to years 1990 to 2011


1 KW=(“PHC” or “primary care” or “family practice” or “general practice” or “family medicine” or “general practitioner”) and (mutlidisciplin* or nurse* or pharmacist* or counsel* or psychotherap* or “allied health”)

24

3.3.1 Screening

Total number of articles for screening = 2,445

Documents identified by the preliminary grey literature and database search will be screened twice for potential relevance based on title and a rapid content scan through the grey literature and title and abstract scan through the database articles. Two reviewers (TD and LZ) will each screen titles and abstracts of all identified articles separately. All articles identified by each reviewer will be included for the second screening process. For the second screening process, documents and articles that are identified as being potentially relevant to the study will be retrieved for confirmation of relevance and, if eligible, for data abstraction. Discordance will be resolved through a consensus process between the two reviewers. If there is lack of consensus, a third person (DC) will be used to resolve any discordance in selected included studies at the end of the second screening process. For the purposes of the final report to CHSRF, only economic evaluations looking at the cost effectiveness of including a pharmacist within a PHC setting, specifically within a family or general practice, at second screening, will be included for quality assessment and data extraction. Final recommendations will be made in the context of including pharmacist(s) within PHC.

3.3.2 Assessment of methodological quality of individual studies

Those studies that are identified as relevant after the second screening process will undergo a methodological quality assessment. The methodological quality of included studies will be evaluated using the CHEC list, consisting of 19 items for assessment of the quality of economic evaluations.109 The list was developed through a Delphi procedure involving 23 international experts in the field of health economics. Data will be abstracted from only those studies rated moderate-to-high quality. Moderate quality would be rated as 50%–75% met criteria and high quality would be rated as >75% met criteria. High-quality studies must meet criteria #1 through #15. Quality assessment will be performed by two reviewers and discordance of ratings will be resolved via consensus. Any rating disagreements will be resolved by the third person.


3.3.3 Data abstraction and data management

Data extraction of moderate-to-high quality studies will be undertaken by one reviewer and checked by a second reviewer. A standard data extraction form will be used to record information on pre-determined items for each included study. The data extraction form will allow for the recording of information pertaining to the evaluation of methodological quality elements used by Polisena et al. (2009).178 Abstracted data will include information pertaining to the research question posed, the study’s perspective, the methodology used, the comparators, and the quality of evidence, the costs outcomes considered, discounting, marginal analysis and sensitivity analysis.

4.0 Results reporting4.1 Identified studiesA flow diagram will summarize the flow of information through the different phases of the systematic review as outlined in the PRISMA Statement.179

4.2 Data synthesisFor each included economic evaluation study, information on outcomes, demographics, settings and study quality will be summarized in text and tables/figures. Also, evidence summaries will be used to qualitatively synthesize the evidence for each intervention.

4.3 RecommendationsThe results of the systematic review of evaluations will provide narrative information on the cost effectiveness of multidisciplinary PHC teams and provide an evidence base for adoption of the intervention in primary care in Canada.

APPENDIX F: QUALITY ASSESSMENT CHECKLIST AND QUALITY ASSESSMENT RESULTSitem Yes no

1. Is the study population clearly described?2. Are competing alternatives clearly described?3. Is a well-defined research question posed in answerable form?4. Is the economic study design appropriate to the stated objective?5. Is the chosen time horizon appropriate to include relevant costs and consequences?6. Is the actual perspective chosen appropriate?7. Are all important and relevant costs for each alternative identified?8. Are all costs measured appropriately in physical units?9. Are costs valued appropriately?10. Are all important and relevant outcomes for each alternative identified?11. Are all outcomes measured appropriately?12. Are outcomes valued appropriately?13. Is an incremental analysis of costs and outcomes of alternatives performed?14. Are all future costs and outcomes discounted appropriately?15. Are all important variables, whose values are uncertain, appropriately subjected to sensitivity analysis?


16. Do the conclusions follow from the data reported?17. Does the study discuss the generalizability of the results to other settings?18. Does the article indicate that there is no potential conflict of interest of study researcher(s) and funder(s)?19. Are ethical and distributional issues discussed appropriately?

Source: Evers S, Goossens M, Vet H, van Tulder M, Ament A: Criteria list for assessment of methodological quality of economic evaluations: Consensus on Health Economic Criteria. International Journal of Technology Assessment in Healthcare 2005, 21(2):240-245

Quality assessment Criteria % studies that meet criteria (n=33)

1. Is the study population clearly described? 42%

2. Are competing alternatives clearly described? 39%

3. Is a well-defined research question posed in answerable form? 33%

4. Is the economic study design appropriate to the stated objective? 36%

5. Is the chosen time horizon appropriate to include relevant costs and consequences?

39%

6. Is the actual perspective chosen appropriate? 12%

7. Are all important and relevant costs for each alternative identified? 24%

8. Are all costs measured appropriately in physical units? 61%

9. Are costs valued appropriately? 33%

10. Are all important and relevant outcomes for each alternative identified? 18%

11. Are all outcomes measured appropriately? 39%

12. Are outcomes valued appropriately? 24%

13. Is an incremental analysis of costs and outcomes of alternatives performed? 3%

14. Are all future costs and outcomes discounted appropriately? 48%

15. Are all important variables, whose values are uncertain, appropriately subjected to sensitivity analysis?

6%

16. Do the conclusions follow from the data reported? 58%

17. Does the study discuss the generalizability of the results to other settings? 21%

18. Does the article indicate that there is no potential conflict of interest of study researcher(s) and funder(s)?

15%

19. Are ethical and distributional issues discussed appropriately? 9%


APPENDIX G: FLOW DIAGRAM SUMMARIZING THE FLOW OF INFORMATION THROUGH THE DIFFERENT PHASES OF THE SYSTEMATIC REVIEW.

Identification

Screening

Eligibility

Included

# of records identified through database searching (published

journal articles)2,445

# of additional records identified through other sources (grey literature)

6

# of records after duplicates removed1787

Keep only pharmacist related studies

# of records screened249

# of full-text documents assessed for eligibility

33

# of documents included in qualitative synthesis

8

# of records exluded215

# of full-text documents excluded, with reasons

25


APP

END

IX H

: IN

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f pat

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met

from

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end

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terv

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ia

vs c

ompa

riso

n gr

oup.

Cho

lest

erol

: Si

gnifi

cant

, 22%

mor

e pa

tient

s in

inte

rven

tion

grou

p m

et H

EDIS

crit

eria

vs

com

pari

son

grou

p.

Econ

omic

out

com

es:

Dec

reas

e in

ann

ual h

ealth

exp

endi

ture

s pe

r per

son

per y

ear a

mon

g 18

6 M

TM

inte

rven

tion

grou

p pa

tient

s - a

redu

ctio

n of

31.

5% fr

om p

re-in

terv

entio

n to

pos

t-in

terv

entio

n (p

<0.0

01).

Dec

reas

e of

57.

9%

in fa

cilit

ies c

laim

s exp

endi

ture

s and

de

crea

se o

f 11.

1% fo

r pro

fess

iona

l cla

ims

in in

terv

entio

n gr

oup.

Dru

g ex

pend

iture

s in

inte

rven

tion

grou

p in

crea

sed

by 1

9.7%

. Re

duct

ion

in to

tal e

xpen

ditu

res f

or

inte

rven

tion

grou

p =

$3,6

78 p

er p

erso

n pe

r yea

r. RO

I = $

12.1

5 pe

r $1

in M

TM

cost

Mal

one

(200

0)11

2A

n ec

onom

ic a

naly

sis

of a

rand

omiz

ed,

cont

rolle

d,

mul

ticen

ter s

tudy

of

clin

ical

pha

rmac

ist

inte

rven

tions

for

high

-risk

vet

eran

s: th

e IM

PRO

VE

stud

y

Wha

t is e

cono

mic

and

hu

man

istic

impa

ct o

f cl

inic

al p

harm

acis

ts in

an

am

bula

tory

, hig

h-ri

sk p

opul

atio

n?

US

Nin

e Vet

eran

s A

ffairs

med

ical

ce

ntre

s and

th

eir p

atie

nts

iden

tified

as h

igh

risk

to e

xper

ienc

e a

med

icat

ion-

rela

ted

prob

lem

Non

e sp

ecifi

ed

Pros

pect

ive,

mul

tisite

, ra

ndom

ized

con

trol

led

tria

l TH

: one

yea

r bef

ore,

one

year

aft

er

Res

ourc

e us

e:

Sign

ifica

ntly

mor

e pr

ovid

er v

isits

in

inte

rven

tion

grou

p. S

igni

fican

tly m

ore

lab

test

s in

usua

l car

e gr

oup

com

pare

d to

in

terv

entio

n.

Econ

omic

: M

ean

annu

al d

rug

cost

s not

sign

ifica

ntly

di

ffere

nt (p

=0.0

7). M

edia

n la

b co

sts h

ighe

r in

con

trol

gro

up v

s int

erve

ntio

n gr

oup

(p=0

.05)

. Hos

pita

l cos

ts n

ot si

gnifi

cant

ly

diffe

rent

bet

wee

n in

terv

entio

n an

d co

ntro

l gr

oup

(p=0

.21)

. No

signi

fican

t diff

eren

ce

for a

ll co

sts c

ombi

ned

(p=0

.06)

.


aut

hor (

Year

)ti

tler

esea

rch

Que

stio

n(s)

Set

ting

and

Pop

ulat

ion

dis

ease

focu

sS

tudy

des

ign

tim

e H

oriz

on (t

H)

res

ults

Mon

te

(200

9)11

3C

linic

al a

nd e

cono

mic

im

pact

of a

dia

bete

s cl

inic

al p

harm

acy

serv

ice

prog

ram

in

a u

nive

rsity

and

pr

imar

y ca

re-b

ased

co

llabo

ratio

n m

odel

Wha

t is t

he im

pact

of

clin

ical

pha

rmac

y se

rvic

es (C

PS) i

n pa

tient

s with

type

2

diab

etes

?

US

Regi

onal

pr

imar

y ca

re

grou

p in

Buff

alo,

N

Y\Pa

tient

s with

ty

pe 2

dia

bete

s id

entifi

ed b

y FP

, ref

erre

d to

Med

Sens

e pr

ogra

m.

Dia

bete

sLo

ngitu

dina

l pre

-pos

t coh

ort

stud

y. TH

: one

yea

rC

linic

al o

utco

mes

: A

t 6 m

os, i

mpr

ovem

ents

seen

in e

very

m

etab

olic

par

amet

er, e

xcep

t HD

L.

Hem

oglo

bin

A1C

dec

reas

ed b

y 1.

1%

(p<0

.000

1), F

PG d

ecre

ased

by

39 m

g/dL

(P

=-0.

003)

. LD

L, T

G, B

P, an

d ov

erw

eigh

t/ob

esity

redu

ced

but n

ot si

gnifi

cant

ly fr

om

base

line.

At 1

2 m

os, m

etab

olic

par

amet

ers

rela

tivel

y co

nsta

nt.

Econ

omic

out

com

es:

Mea

n co

sts p

er p

atie

nt a

t 6 a

nd 1

2 m

os

inte

rval

s pos

t-in

terv

entio

n de

crea

sed

for c

ardi

ovas

cula

r-re

late

d m

edic

al c

osts

by

$11

2 (p

=0.2

23) a

nd $

295

(p=0

.007

). N

on-c

ardi

ovas

cula

r rel

ated

cos

ts m

odes

tly

incr

ease

d by

$53

and

$15

at 6

and

12

mos

re

spec

tivel

y (n

on-s

igni

fican

t diff

eren

ces)

. C

osts

of m

edic

al c

are

decr

ease

d at

6 m

os

by $

73 (p

=0.7

99) a

nd a

t 12

mos

by

$331

(p

=0.2

54).

Med

icat

ion

cost

s inc

reas

ed a

t 6

and

12 m

os, b

ut n

ot st

atist

ical

ly. T

otal

di

rect

med

ical

cos

ts re

duce

d by

$84

and

by

$21

6 at

6 a

nd 1

2 m

os (n

on-s

igni

fican

t di

ffere

nces

)

Rag

ucci

(2

005)

114

Effec

tiven

ess

of p

harm

acist

-ad

min

ister

ed d

iabe

tes

mel

litus

edu

catio

n an

d m

anag

emen

t ser

vice

s

Wha

t is t

he e

ffect

iven

ess

of p

harm

acist

-ad

min

ister

ed d

iabe

tes

mel

litus

edu

catio

n an

d m

anag

emen

t ser

vice

s on

sele

cted

dia

bete

s pe

rfor

man

ce m

easu

res?

Thre

e un

iver

sity-

base

d pr

imar

y ca

re c

linic

s and

th

eir p

atie

nts.

Dia

bete

sO

bser

vatio

nal s

tudy

C

ost a

void

ance

TH

: one

yea

r

Clin

ical

out

com

es:

Mor

e offi

ce v

isits

ass

ocia

ted

with

im

prov

ed A

1C va

lues

(OR=

1.31

, p<0

.05)

w

hen

com

pari

ng b

asel

ine

to e

nd o

f stu

dy.

Sign

ifica

nt im

prov

emen

t in

aver

age

bloo

d pr

essu

re (d

ecre

ase)

and

asp

irin

use

(in

crea

se) f

rom

bas

elin

e to

end

of s

tudy

. Th

erap

eutic

goa

ls fo

r A1C

valu

es a

nd L

DL

leve

ls m

et, b

ut n

ot fo

r blo

od p

ress

ure.

40%

of p

atie

nts r

each

ed A

1C g

oals

at 1

ye

ar c

ompa

red

to 1

2% a

t bas

elin

e (2

8%

abso

lute

impr

ovem

ent)

. 42%

reac

hed

LDL

goal

at 1

yea

r, bu

t non

-sig

nific

ant c

hang

e fr

om b

asel

ine.

Econ

omic

out

com

es:

Base

d on

est

imat

ed sa

ving

s of $

820

for

each

1%

dec

reas

e in

A1C

, cos

t avo

idan

ce

was

cal

cula

ted

as $

59,0

40.

aut

hor (

Year

)ti

tler

esea

rch

Que

stio

n(s)

Set

ting

and

Pop

ulat

ion

dis

ease

focu

sS

tudy

des

ign

tim

e H

oriz

on (t

H)

res

ults

Isse

tts.

(200

3)11

1C

linic

al a

nd

econ

omic

out

com

es

of m

edic

atio

n th

erap

y m

anag

emen

t ser

vice

s: Th

e M

inne

sota

ex

peri

ence

1. W

hat a

re th

e clin

ical

eff

ects

ass

ocia

ted

with

the

prov

ision

of m

edic

atio

n th

erap

y m

anag

emen

t (M

TM) s

ervi

ces

2. W

hat i

s the

pe

rcen

tage

of p

atie

nts

achi

evin

g H

ealth

care

Ef

fect

iven

ess D

ata

and

Info

rmat

ion

Set

(HED

IS) g

oals

for

hype

rten

sion

and

hy

perl

ipid

emia

in

the

MTM

ser

vice

s in

terv

entio

n gr

oup

com

pare

d to

the

cont

rol

grou

p

3. W

hat a

re th

e to

tal

heal

th e

xpen

ditu

res f

or

the

year

bef

ore

and

after

re

ceiv

ing

MTM

serv

ices

? U

S (M

inne

sota

)

US

(Min

neso

ta)

Blue

cros

s Bl

uesh

ield

hea

lth

plan

ben

efici

arie

s w

ith o

ne o

r m

ore

of 1

2 st

udy

med

ical

co

nditi

ons

Hyp

erte

nsio

n

Hyp

erlip

idem

ia

Pros

pect

ive

Befo

re a

nd

after

- hi

stor

ical

con

trol

C

ost a

naly

sis a

nd c

linic

al

outc

omes

(hyp

erte

nsio

n/

hype

rlipi

dem

ia)

Q

uasi-

cos

t-be

nefit

ana

lysis

Re

turn

on

inve

stm

ent (

ROI)

TH: 6

mon

ths

Clin

ical

out

com

es:

4% o

f pat

ient

s’ go

als o

f the

rapy

wer

e be

ing

met

from

bas

elin

e to

end

of s

tudy

.

Hyp

erte

nsio

n:

Sign

ifica

nt, 1

2% m

ore

patie

nts i

n in

terv

entio

n gr

oup

met

HED

IS c

riter

ia

vs c

ompa

riso

n gr

oup.

Cho

lest

erol

: Si

gnifi

cant

, 22%

mor

e pa

tient

s in

inte

rven

tion

grou

p m

et H

EDIS

crit

eria

vs

com

pari

son

grou

p.

Econ

omic

out

com

es:

Dec

reas

e in

ann

ual h

ealth

exp

endi

ture

s pe

r per

son

per y

ear a

mon

g 18

6 M

TM

inte

rven

tion

grou

p pa

tient

s - a

redu

ctio

n of

31.

5% fr

om p

re-in

terv

entio

n to

pos

t-in

terv

entio

n (p

<0.0

01).

Dec

reas

e of

57.

9%

in fa

cilit

ies c

laim

s exp

endi

ture

s and

de

crea

se o

f 11.

1% fo

r pro

fess

iona

l cla

ims

in in

terv

entio

n gr

oup.

Dru

g ex

pend

iture

s in

inte

rven

tion

grou

p in

crea

sed

by 1

9.7%

. Re

duct

ion

in to

tal e

xpen

ditu

res f

or

inte

rven

tion

grou

p =

$3,6

78 p

er p

erso

n pe

r yea

r. RO

I = $

12.1

5 pe

r $1

in M

TM

cost

Mal

one

(200

0)11

2A

n ec

onom

ic a

naly

sis

of a

rand

omiz

ed,

cont

rolle

d,

mul

ticen

ter s

tudy

of

clin

ical

pha

rmac

ist

inte

rven

tions

for

high

-risk

vet

eran

s: th

e IM

PRO

VE

stud

y

Wha

t is e

cono

mic

and

hu

man

istic

impa

ct o

f cl

inic

al p

harm

acis

ts in

an

am

bula

tory

, hig

h-ri

sk p

opul

atio

n?

US

Nin

e Vet

eran

s A

ffairs

med

ical

ce

ntre

s and

th

eir p

atie

nts

iden

tified

as h

igh

risk

to e

xper

ienc

e a

med

icat

ion-

rela

ted

prob

lem

Non

e sp

ecifi

ed

Pros

pect

ive,

mul

tisite

, ra

ndom

ized

con

trol

led

tria

l TH

: one

yea

r bef

ore,

one

year

aft

er

Res

ourc

e us

e:

Sign

ifica

ntly

mor

e pr

ovid

er v

isits

in

inte

rven

tion

grou

p. S

igni

fican

tly m

ore

lab

test

s in

usua

l car

e gr

oup

com

pare

d to

in

terv

entio

n.

Econ

omic

: M

ean

annu

al d

rug

cost

s not

sign

ifica

ntly

di

ffere

nt (p

=0.0

7). M

edia

n la

b co

sts h

ighe

r in

con

trol

gro

up v

s int

erve

ntio

n gr

oup

(p=0

.05)

. Hos

pita

l cos

ts n

ot si

gnifi

cant

ly

diffe

rent

bet

wee

n in

terv

entio

n an

d co

ntro

l gr

oup

(p=0

.21)

. No

signi

fican

t diff

eren

ce

for a

ll co

sts c

ombi

ned

(p=0

.06)

.


aut

hor (

Year

)ti

tler

esea

rch

Que

stio

n(s)

Set

ting

and

Pop

ulat

ion

dis

ease

focu

sS

tudy

des

ign

tim

e H

oriz

on (t

H)

res

ults

Ram

alho

(2

010)

110

Med

icat

ion

ther

apy

man

agem

ent:

10

year

s of e

xper

ienc

e in

a la

rge

inte

grat

ed

heal

thca

re sy

stem

Wha

t are

the

clin

ical

, ec

onom

ic, a

nd

hum

anist

ic o

utco

mes

of

10

year

s of d

eliv

erin

g m

edic

atio

n th

erap

y m

anag

emen

t (M

TM)

serv

ices

to p

atie

nts i

n a

heal

thca

re d

eliv

ery

syst

em?

US

(Min

neso

ta)

Patie

nts a

ged

21 a

nd o

ver

who

eith

er m

et

heal

thca

re p

ayer

’s re

imbu

rsem

ent

crite

ria

for

inte

rven

tion

or p

aid

for

inte

rven

tion

out

of p

ocke

t. U

nder

Fa

irvi

ew H

ealth

Se

rvic

es.

Dia

bete

sRe

tros

pect

ive

coho

rt

Cos

t-av

oida

nce

(sav

ings

) an

alys

is TH

: 10

year

s

Hea

lth o

utco

mes

: 80

% o

f dru

g th

erap

y pr

oble

ms i

dent

ified

in

MTM

pro

gram

wer

e re

solv

ed w

ith

dire

ct in

volv

emen

t of p

hysic

ians

. 55%

of

con

ditio

ns im

prov

ed, 2

3% w

ere

unch

ange

d, a

nd 2

2% w

orse

ned

duri

ng

MTM

serv

ices

. Am

ong

Dia

bete

s pat

ient

s-

abso

lute

cha

nge

of 2

5.4%

; mor

e pa

tient

s ac

hiev

ed D

5 go

als f

rom

bas

elin

e to

end

of

stud

y

Econ

omic

out

com

es:

MTM

cos

t sav

ings

= $

86.4

5 pe

r enc

ount

er.

Aver

age

cost

of M

TM v

isit w

as $

67.0

0 in

la

st 3

mon

ths o

f 200

8. R

OI =

$1.

29 p

er $

1 in

MTM

cos

ts.

Sello

rs

(200

3)11

7A

rand

omiz

ed

cont

rolle

d tr

ial

of a

pha

rmac

ist

cons

ulta

tion

prog

ram

fo

r FPs

and

thei

r el

derly

pat

ient

.

Can

an

inte

rven

tion

by a

spec

ially

trai

ned

phar

mac

ist re

duce

th

e nu

mbe

r of d

aily

m

edic

atio

n un

its ta

ken

by e

lder

ly p

atie

nts,

as w

ell a

s cos

ts a

nd

heal

thca

re u

se?

Can

ada

Twen

ty-f

our

fam

ily p

ract

ices

in

Ont

ario

. Pa

tient

s age

d 65

an

d ol

der t

akin

g fiv

e or

mor

e m

edic

atio

ns, a

nd

who

had

visi

ted

thei

r phy

sicia

n w

ithin

the

past

12

mon

ths

Non

e sp

ecifi

edR

ando

miz

ed c

ontr

olle

d tr

ial

Cos

ting

Hea

lthca

re u

sage

TH

: five

mon

ths

Med

icat

ion

adhe

renc

e an

d qu

ality

of l

ife:

Inte

rven

tion

was

sim

ilar t

o co

ntro

l in

mea

n nu

mbe

r of d

aily

med

icat

ion

units

us

ed (p

=0.5

0) a

nd n

umbe

r of m

edic

atio

ns

take

n pe

r day

(p=0

.87)

. Afte

r five

mon

ths,

phys

icia

ns su

cces

sful

ly im

plem

ente

d 46

.4%

of r

ecom

men

datio

ns a

nd p

artia

lly

fulfi

lled

9.3%

of r

ecom

men

datio

ns. N

o sig

nific

ant d

iffer

ence

in Q

OL

scor

es

betw

een

inte

rven

tion

and

cont

rol g

roup

.

Econ

omic

out

com

es:

Inte

rven

tion

Tota

l cos

t of i

nter

vent

ion

vs c

ontr

ol: $

5.01

vs $

4.82

, p=0

.72,

and

in

OD

BP c

osts

: $3.

57 v

s $3.

76, p

= 0.

78.

Incl

udin

g co

st o

f pha

rmac

ist in

terv

entio

n an

d on

ly d

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rela

ted

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ital s

tays

, mea

n co

st o

f hea

lthca

re re

sour

ces p

er p

erso

n =

$128

1.27

in in

terv

entio

n gr

oup

vs

$129

9.37

in c

ontr

ol g

roup

(p=0

.45)

.


APPENDIX I: ELDERLY POPULATION PROjECTIONS FROM 2010 TO 2036 (NUMBER OF INDIVIDUALS ×1000)

Province/Year 2010 2011 2012 2013 2014 2015 2016 2021 2026 2031 2036

Newfoundland and Labrador

77.9 81.2 85.1 88.6 92.4 96.0 99.8 118.5 135.2 148.5 154.3

Prince Edward Island

22.1 23.0 24.2 24.2 26.1 27.1 28.2 33.1 38.5 43.2 45.5

Nova Scotia 151.4 155.8 161.9 168.2 173.6 179.2 184.7 214.9 247.6 275.4 285.6

New Brunswick 119.6 123.2 128.6 133.8 139.1 143.9 149.0 175.6 202.3 224.5 232.9

Quebec 1209.7 1,251.5 1,297.6 1,342.2 1,388.1 1,434.2 1,481.5 1,739.9 2,20.7 2,256.0 2,357.3

Ontario 1,836.1 1,890.6 1,968.4 2,042.6 2,113.3 2,184.6 2,257.8 2,676.1 3,177.5 3,694.4 4,040.6

Manitoba 171.6 175.3 180.9 186.2 191.3 196.8 202.6 236.6 276.0 311.7 332.7

Saskatchewan 153.5 156.1 159.9 164.0 168.0 172.5 177.2 209.7 247.6 283.0 3322.7

Alberta 399.0 414.0 434.2 455.0 475.1 496.2 518.2 653.0 810.6 958.6 1,070.3

British Colombia 675.6 696.4 726.7 756.4 785.4 816.2 846.9 1,18.6 1,209.1 1,394.4 1532.8

Yukon 2.8 3.1 3.5 3.7 4.1 4.3 4.8 6.3 8.0 9.3 10.0

NWT 2.4 2.6 3.0 3.2 3.5 3.8 3.9 5.6 7.4 8.7 9.5

Nunavut 1.1 1.1 1.2 1.3 1.4 1.6. 1.7 2.0 2.7 3.1 3.4

Canada 4,822.8 4.973.9 5,175.2 5,370.4 5,561.4 5.756.4 5,956.3 7,090.8 8,383.2 9,610.8 10,378.7

APPENDIX j: POPULATION VACCINATION RATES FOR ELDERLY POPULATION IN 2007

Province/Year Pct

Newfoundland and Labrador 48%

Prince Edward Island 62%

Nova Scotia 71%

New Brunswick 57%

Quebec 70%

Ontario 57%

Manitoba 70%

Saskatchewan 60%

61% 56%

British Colombia 61%

Yukon 74%

NWT 71%

Nunavut 85%

Canada 64%

aut

hor (

Year

)ti

tler

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rch

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and

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on (t

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(2

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ent:

10

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s of e

xper

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Wha

t are

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, ec

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s $3.

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in c

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ol g

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APPENDIX K: SIMULATION RESULTS BY PROVINCE: PROjECTED YEARS 2010 AND 2031

Projected Year 2010: target vaccination rate

66.5% 69.0% 74.0% 80.0%

alberta

EventsGP Visits 545 1,093 2,179 3,5211ED Visits 233 484 986 1,597Hosp. 182 389 755 1,218

CostsGP Visits 19,088 38,244 76,250 123,233ED Visits 51,168 106,448 216,831 351,238Hosp. 1,168,460 2,493,418 4,847,777 7,817,453

Total Cost 1,238,716 2,638,109 5,149,857 8,291,924

British Colombia

EventsGP Visits 923 1,850 3,689 5,962

ED Visits 394 819 1,669 2,703Hosp. 308 819 1,669 2,703

CostsGP Visits 32,320 64,755 129,109 208,663ED Visits 86,639 180,241 367,145 594,727Hosp. 1,978,475 4,22,938 8,208,416 13,236,769

Total Cost 2,097,434 4,466,934 8,704,669 14,040,159

Manitoba

EventsGP Visits 235 470 937 1,514ED Visits 100 208 424 687Hosp. 78 167 325 524

CostsGP Visits 8,209 16,448 32,7993 53,00ED Visits 22,006 45,780 93.254 151,059

Hosp. 502,526 1,072,357 2,084,090 3,362.093Total Cost 532,742 1,134,585 2,210,955 3566,151

new Brunswick


CostsGP Visits 5,721 11,464 22,856 36,939ED Visits 15,338 31,908 64,995 105,283Hosp. 350,245 747,401 1,453,118 2,343,277

Total Cost 371,304 790,772 1,540,969 2,485,499

newfoundland & labrador

EventsGP Visits 106 213 425 687ED Visits 45 94 192 312Hosp. 36 76 147 238

CostsGP Visits 3,272 7,467 14,887 24,060ED Visits 9,990 20,783 42,334 68,575Hosp. 228,844 486,810 946,471 1,526,265

Total Cost 241,844 515,059 1,003,691 1,618,899



66.5% 69.0% 74.0% 80.0%

nova Scotia


CostsGP Visits 7,243 14,511 28,933 46,761ED Visits 19,416 40,391 82,276 133,277Hosp. 443,371 946,124 1,839,482 2,966,322

Total Costs 470,029 1,001,027 1,950,691 3,156,359

nunavut


CostsGP Visits 53 105 210 340ED Visits 141 293 598 968Hosp. 3,221 6,874 13,365 21,552

Total Costs 3,415 7,273 14,173 22,860

northwest territories


CostsGP Visits 115 230 459 741ED Visits 308 640 1,304 2,113Hosp. 7,028 14,998 29,160 47,022

Total Costs 7,451 15,868 30,922 49,876

ontario

EventsGP Visits 2,510 5,028 10,025 16,203ED Visits 1,070 2,227 4,535 7,347Hosp. 838 1,788 3,476 5,605

CostsGP Visits 87,836 175,988 350,883 567,090ED Visits 235,462 489,846 997,802 1,616,310Hosp. 5,376,966 11,474,098 22,308,277 35,973,997

Total Costs 5,700,265 12,139,931 23,656,962 38,157,396

Prince edward island


CostsGP Visits 1,057 2,118 4,223 6,826ED Visits 2.834 5,896 12,010 19,455Hosp. 64,719 138,107 268,511 432,997

Total Costs 68,611 146,121 285,744 459,277



66.5% 69.0% 74.0% 80.0%

Quebec

EventsGP Visits 1,653 3,313, 6,605 10,675ED Visits 705 1,467 2,988 4,840Hosp. 552 1,178 2,290 3,693

CostsGP Visits 57,870 115,948 231,176 373,623ED Visits 155,132 322,731 657,394 1,064,893Hosp. 3,542,572 7,559,619 14,697,,632 23,701,183

Total Costs 3,755,574 7,998,298 15,586,202 25,139,699

Saskatchewan


CostsGP Visits 7,343 14,713 29,334 47,409ED Visits 19,685 40,,9952 83,417 135,125Hosp. 449,520 959,247 1,864,997 3,007,466

Total Costs 476,548 1,014,912 1,977,748 3,190,001

Yukon


CostsGP Visits 134 268 535 865ED Visits 359 474 1,522 2.465Hosp. 8,200 17,498 34,019 54,859

Total Costs 8,693 18,513 36,076 58,189



66.5% 69.0% 74.0% 80.0%

alberta

EventsGP Visits 1,310 2,625 5,234 8,459ED Visits 559 1,162 2,368 3,836Hosp. 437 933 1,815 2,926

CostsGP Visits 45,858 91,881 183,191 296,069ED Visits 122,931 255,741 520,937 843.851Hosp. 2,807,233 5,990,453 11,646,814 18,718,479

Total Cost 2,975,022 6,338,074 12,350,942 12,921,398

British Colombia

EventsGP Visits 1,906 3,819 7,614 12,305

ED Visits 813 1,691 3,444 5,579Hosp. 636 1,358 2,640 4,257

CostsGP Visits 66,706 133,651 266,473 430,668ED Visits 178,818 372,007 757,767 1,227,484Hosp. 4,083,460 8,713,840 16,941,704 27,319,940

Total Cost 4,3228,985 9,219,498 17,965,944 28,978,092

Manitoba

EventsGP Visits 426 854 1,702 2.751ED Visits 182 378 770 1,247Hosp. 142 304 590 952

CostsGP Visits 14,911 29,876 59,576 96,270ED Visits 182 378 770 1,247

Hosp. 142 304 590 952Total Cost 967,688 2,060,899 4,016,053 6,477,676

new Brunswick

EventsGP Visits 307 615 1,226 19,81ED Visits 131 272 555 898Hosp. 102 219 425 685

CostsGP Visits 10,740 21,518 42,902 69,338ED Visits 28,790 59,8993 122,001 197,626Hosp. 657,442 1,402,938 2,727,634 4,398,542

Total Cost 696,972 1,484,350 2,892,537 4,667,506

newfoundland & labrador


CostsGP Visits 7.10004 14,234 28,379 45,865ED Visits 19,044 39,618 80,700 130,724Hosp. 434.878 928,001 1,804,428 2,909,503

Total Cost 461,0226 981,853 1,913,327 3,086,0922



66.5% 69.0% 74.0% 80.0%

nova Scotia

EventsGP Visits 376 754 1,504 2,430ED Visits 161 334 680 1,102Hosp. 126 268 521 841

CostsGP Visits 13,175 26,397 52,630 85,059ED Visits 35,175 26,397 52,630 85,059Hosp. 806,501 1.721,021 3,346,059 5,395,806

Total Costs 854,993 1,820,891 3,548,351 5,723,298

nunavut


CostsGP Visits 416 834 1,663 2,687ED Visits 1,116 2,321 4,728 7,659Hosp. 25,478 54,368 105,703 170,456

Total Costs 27,010 57,523 112,09994 180,801

northwest territories


CostsGP Visits 148 297 592 957ED Visits 398 827 1,685 4,398,542Hosp. 9,078 19,372 37,664 60,737

Total Costs 9,624 20,497 39,941 64,423

ontario

EventsGP Visits 5,050 10,117 20,172 32,601ED Visits 2,154 4,480 9,126 14,783Hosp. 1,686 3,597 6,994 11,278

CostsGP Visits 176,735 354,104 706,008 1,141,036ED Visits 473,771 985,614 2,007,668 3,252,162Hosp. 10,818,944 23,086,927 44,886,2280 72,382,948

Total Costs 11,469,450 24,426,645 47,599,956 76,776,147

Prince edward island


CostsGP Visits 2,067 4,141 8,256 13,343ED Visits 5,540 11,525 23,476 38,029Hosp. 126,510 269,964 524,872 846,4001

Total Costs 134,117 285,630 556,604 897,772



66.5% 69.0% 74.0% 80.0%

Quebec

EventsGP Visits 3,084 6,178 12,318 19,908ED Visits 1,315 2,736 5,573 9,027Hosp. 1,029 2,197 4,271 6,887

CostsGP Visits 107,924 216,235 431,126 626,778ED Visits 289,310 601,869 1,225,991 1,985,946Hosp. 6,606,631 14,098,124 27,409,986 44,200,935

Total Costs 7,0030,865 14,916,228 29,067,103 46,883,659

Saskatchewan

EventsGP Visits 387 775 1,545 2,497ED Visits 165 343 699 1,132Hosp. 129 276 536 864

CostsGP Visits 13,538 27,125 54,082 87,406ED Visits 36,292 75,500 1,685 4,398,542Hosp. 828,757 1,768,515 3,438,398 5,544,710

Total Costs 878,588 1871,140 3,646,272 5,881,239

Yukon


CostsGP Visits 445 891 1,777 2,872ED Visits 1,193 2,481 5,054 8,187Hosp. 227,235 58,117 112,993 182,211

Total Costs 28,827 61,490 119,824 193,270


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