Views of family physicians in southwestern Ontario on preventive care services and performance incentives

Although the Canadian Task Force on Preventive Health Care recommends that several preventive care services be routinely provided to eligible patients in primary care settings, 1 the delivery rate for these services continues to be suboptimal. 2 A recent meta-analysis found evidence to support the use of several strategies to improve preventive care delivery rates, 3 yet many practitioners still rely primarily on an opportunistic approach for delivering preventive care services. Primary care networks (PCN) and family health networks (FHN) are two new models of primary health care delivery in Ontario, characterized by patient rostering and a capitation payment structure with added incentives. One such incentive is the preventive care management program, offering annual preventive care performance bonuses that are calculated from the delivery rate of biennial Papanicolaou smear screening (age 35–69 years) and mammography screening (age 50–69 years), annual influenza vaccination (age 65 years or over), and a series of five childhood immunizations by 2 years of age. The annual bonus payments increase incrementally to a maximum of $CAN 2200 for delivery rates ranging from 75% for mammography screening to 95% for childhood immunizations. Each physician is also eligible to claim a management fee of $CAN 6.86 per service for each overdue patient contacted by reminder letter and telephone call. The ‘Provider and Patient Reminders in Ontario: Multi-strategy Prevention Tools’ (P-PROMPT) demonstration project is currently implementing a reminder and recall strategy in participating PCN and FHN practices across southwestern Ontario to increase the delivery of the four targeted preventive care services. The purpose of the current report was to explore the views of family physicians enrolled in the P-PROMPT project on preventive care in general and of the preventive care management program in particular, and to gather information on their current preventive care delivery strategies. Seventy-three percent of invited physicians in PCN/FHN networks (246 of 335 physicians in 30 networks) in southwestern Ontario, Canada agreed to participate in the P-PROMPT project: 90 physicians in 8 PCN practices and 156 physicians in 16 FHN practices. A baseline questionnaire was mailed to each participating physician, with one follow-up reminder at 3 weeks. The cross-sectional survey consisted of 18 items assessed on a 7-point Likert scale, and sought information on preventive care strategies and physicians' opinions on prevention and the current program. Respondent characteristics (gender, graduation year, and urban versus rural practice) were compared with those of non-respondents and with the profile of Canadian physicians from the 2001 National Family Physician Workforce Survey. 4 Likert scale ratings were grouped to determine physician agreement (5–7 = agreement, 1–4 = disagreement or neutral). Percent agreement, frequency distributions and descriptive statistics were calculated for each item. Multivariable logistic regression analyses were also used to explore correlates of physician and practice characteristics [physician gender, year of graduation, urban versus rural practice, academic versus non-academic practice, certification with the College of Family Physicians of Canada (CFPC), total roster size] and agreement with the following questionnaire items: use of an opportunistic approach for preventive care delivery, satisfaction with the effectiveness of current delivery strategies and with the financial incentives for each of the four services, and endorsement of program expansion to include additional preventive care services and management of selected chronic diseases. In total, 212 of the 246 physicians responded to the survey (86.2%). Of the responding physicians, 60.8% were male, the mean year of graduation from medical school was 1982 (SD = 9.28), and 85.8% practiced in an urban setting. Survey respondents were similar to both non-respondents and to the Canadian family physician profile for these characteristics. Additionally, 10.4% of respondents held an academic appointment, 68.4% were CFPC certified, and the mean practice roster size was 1498 patients (SD = 652). A breakdown of selected questionnaire response frequencies is presented in Table A1. In addition, agreement with the importance of the services targeted by the preventive care management program was high, ranging from 93.9% for Pap smear screening to 99.1% for childhood immunizations (data not shown). Also, the majority of respondents agreed with the statement that the financial bonuses were an incentive to increase the delivery of the target services, with agreement ranging from 52.4% for Pap screening to 64.6% for childhood immunizations (data not shown). The multivariable logistic regression models indicated that larger roster size was significantly and negatively correlated with agreement that the Pap smear and mammography bonuses provide an incentive to increase service delivery (both 6% less likely to agree for each additional 100 patients on the roster), and that urban-based physicians were three times more likely to endorse program expansion to include additional preventive care services. No other physician- or practice-level correlates were statistically significant at the 0.05 level (data not shown). One limitation to our survey is that all respondents are currently participating in the P-PROMPT project, designed to improve preventive care delivery, and thus may be more likely to have positive attitudes towards the importance of preventive care. Similarly, respondents have volunteered to participate in implementing strategies to increase delivery of preventive care services, indicating that these physicians may have been more likely to be using an opportunistic strategy for providing preventive care and to be dissatisfied with their approach. Therefore, the results of this survey may not represent the views of all physicians in PCN and FHN practices in Ontario. Overall, the PCN and FHN physicians strongly endorsed the importance of delivering preventive care services, but were also dissatisfied with the effectiveness of their opportunistic approach to delivery. The majority of participating physicians considered the preventive care management program to be an appropriate incentive to maximizing the delivery of the four target services; however, physicians with larger rosters were less likely to be satisfied with the financial bonuses, and many physicians considered the administration of the program to be burdensome and time-consuming. This indicates that support tools may be required by physicians to facilitate their optimal participation in the preventive care management program. This work was supported by the Ontario Ministry of Health and Long Term Care (Primary Health Care Transition Fund G03-02757). Ethics approval was obtained from the McMaster University Research Ethics Board prior to the start of the P-PROMPT project. Survey results showing percent physician agreement and mean rating on a 7-point Likert scale a Rated on a 7-point Likert scale from ‘1 = Strongly Disagree’ to ‘7 = Strongly Agree’. Survey results showing percent physician agreement and mean rating on a 7-point Likert scale a Rated on a 7-point Likert scale from ‘1 = Strongly Disagree’ to ‘7 = Strongly Agree’.

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