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Hudon C.,Universite de Sherbrooke | Sanche S.,St Marys Research Center | Haggerty J.L.,McGill University
PLoS ONE | Year: 2016

Objective A small number of patients frequently using the emergency department (ED) account for a disproportionate amount of the total ED workload and are considered using this service inappropriately. The aim of this study was to identify prospectively personal characteristics and experience of organizational and relational dimensions of primary care that predict frequent use of ED. Methods This study was conducted among parallel cohorts of the general population and primary care patients (N = 1,769). The measures were at baseline (T1 ), 12 (T2 ) and 24 months (T3 ): self-administered questionnaire on current health, health behaviours and primary care experience in the previous year. Use of medical services was confirmed using administrative databases. Mixed effect logistic regression modeling identified characteristics predicting frequent ED utilization. Results A higher likelihood of frequent ED utilization was predicted by lower socioeconomic status, higher disease burden, lower perceived organizational accessibility, higher number of reported healthcare coordination problems and not having a complete annual check-up, above and beyond adjustment for all independent variables. Conclusions Personal characteristics such as low socioeconomic status and high disease burden as well as experience of organizational dimensions of primary care such as low accessibility, high healthcare coordination problems and low comprehensiveness of care are prospectively associated with frequent ED utilization. Interventions developed to prevent inappropriate ED visits, such as case management for example, should tailor low socioeconomic status and patients with high disease burden and should aim to improve experience of primary care regarding accessibility, coordination and comprehensiveness. © 2016 Hudon et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Source


Haggerty J.L.,McGill University | Bouharaoui F.,St Marys Research Center | Santor D.A.,University of Ottawa
Healthcare Policy | Year: 2011

Evaluating the extent to which groups or subgroups of individuals differ with respect to primary healthcare experience depends on first ruling out the possibility of bias. Objective: To determine whether item or subscale performance differs systematically between French/English, high/low education subgroups and urban/rural residency. Method: A sample of 645 adult users balanced by French/English language (in Quebec and Nova Scotia, respectively), high/low education and urban/rural residency responded to six validated instruments: the Primary Care Assessment Survey (PCAS); the Primary Care Assessment Tool - Short Form (PCAT-S); the Components of Primary Care Index (CPCI); the first version of the EUROPEP (EUROPEP-I); the Interpersonal Processes of Care Survey, version II (IPC-II); and part of the Veterans Affairs National Outpatient Customer Satisfaction Survey (VANOCSS). We normalized subscale scores to a 0-to-10 scale and tested for between-group differences using ANOVA tests. We used a parametric item response model to test for differences between subgroups in item discriminability and item difficulty. We re-examined group differences after removing items with differential item functioning. Results: Experience of care was assessed more positively in the English-speaking (Nova Scotia) than in the French-speaking (Quebec) respondents. We found differential English/French item functioning in 48% of the 153 items: discriminability in 20% and differential difficulty in 28%. English items were more discriminating generally than the French. Removing problematic items did not change the differences in French/English assessments. Differential item functioning by high/low education status affected 27% of items, with items being generally more discriminating in high-education groups. Between-group comparisons were unchanged. In contrast, only 9% of items showed differential item functioning by geography, affecting principally the accessibility attribute. Removing problematic items reversed a previously nonsignificant finding, revealing poorer first-contact access in rural than in urban areas. Conclusion: Differential item functioning does not bias or invalidate French/English comparisons on subscales, but additional development is required to make French and English items equivalent. These instruments are relatively robust by educational status and geography, but results suggest potential differences in the underlying construct in low-education and rural respondents. Source


Haggerty J.L.,McGill University | Beaulieu C.,St Marys Research Center | Lawson B.,Dalhousie University | Santor D.A.,University of Ottawa | Burge F.,Dalhousie University
Healthcare Policy | Year: 2011

Instruments have been developed that measure consumer evaluations of primary healthcare using different approaches, formats and questions to measure similar attributes. In 2004 we concurrently administered six validated instruments to adults and conducted discussion groups to explore how well the instruments allowed patients to express their healthcare experience and to get their feedback about questions and formats. Method: We held 13 discussion groups (n=110 participants): nine in metropolitan, rural and remote areas of Quebec; four in metropolitan and rural Nova Scotia. Participants noted critical incidents in their healthcare experience over the previous year, then responded to all six instruments under direct observation and finally participated in guided discussions for 30 to 40 minutes. The instruments were: the Primary Care Assessment Survey; the Primary Care Assessment Tool; the Components of Primary Care Index; the EUROPEP; the Interpersonal Processes of Care Survey; and part of the Veterans Affairs National Outpatient Customer Satisfaction Survey. Two team members analyzed discussion transcripts for content. Results: While respondents appreciated consistency in response options, they preferred options that vary to fit the question. Likert response scales functioned best; agreement scales were least appreciated. Questions that average experience over various providers or over many events diluted the capacity to detect critical negative or positive incidents. Respondents tried to answer all questions but stressed that they were not able to report accurately on elements outside their direct experience or in the provider's world. They liked short questions and instruments, except where these compromise clarity or result in crowded formatting. All the instruments were limited in their capacity to report on the interface with other levels of care. Conclusion: Each instrument has strengths and weaknesses and could be marginally improved, but respondents accurately detected their intent and use. Their feedback offers insight for instrument development. Source


Jang Y.,McGill University | Lortie M.A.,St Marys Research Center | Sanche S.,St Marys Research Center
Journal of Medical Internet Research | Year: 2014

Background: The use of electronic health records (EHR) in clinical settings is considered pivotal to a patient-centered health care delivery system. However, uncertainty in cost recovery from EHR investments remains a significant concern in primary care practices. Objective: Guided by the question of "When implemented in primary care practices, what will be the return on investment (ROI) from an EHR implementation?", the objectives of this study are two-fold: (1) to assess ROI from EHR in primary care practices and (2) to identify principal factors affecting the realization of positive ROI from EHR. We used a break-even point, that is, the time required to achieve cost recovery from an EHR investment, as an ROI indicator of an EHR investment. Methods: Given the complexity exhibited by most EHR implementation projects, this study adopted a retrospective mixed-method research approach, particularly a multiphase study design approach. For this study, data were collected from community-based primary care clinics using EHR systems. Results: We collected data from 17 primary care clinics using EHR systems. Our data show that the sampled primary care clinics recovered their EHR investments within an average period of 10 months (95% CI 6.2-17.4 months), seeing more patients with an average increase of 27% in the active-patients-to-clinician-FTE (full time equivalent) ratio and an average increase of 10% in the active-patients-to-clinical-support-staff-FTE ratio after an EHR implementation. Our analysis suggests, with a 95% confidence level, that the increase in the number of active patients (P=.006), the increase in the active-patients-to-clinician-FTE ratio (P<.001), and the increase in the clinic net revenue (P<.001) are positively associated with the EHR implementation, likely contributing substantially to an average break-even point of 10 months. Conclusions: We found that primary care clinics can realize a positive ROI with EHR. Our analysis of the variances in the time required to achieve cost recovery from EHR investments suggests that a positive ROI does not appear automatically upon implementing an EHR and that a clinic's ability to leverage EHR for process changes seems to play a role. Policies that provide support to help primary care practices successfully make EHR-enabled changes, such as support of clinic workflow optimization with an EHR system, could facilitate the realization of positive ROI from EHR in primary care practices. Source


McCusker J.,McGill University | McCusker J.,St Marys Research Center | Verdon J.,McGill University | Vadeboncoeur A.,Montreal Institute of Cardiology | And 5 more authors.
Journal of the American Geriatrics Society | Year: 2012

Objectives To develop and conduct a preliminary validation of selected subscales of an elder-friendly emergency department (ED) assessment tool. Design Content validation of tool by an international panel. Construct validation using care ratings of ED lead physicians and nurses. Setting Quebec, Canada. Participants The international panel comprised 34 clinicians, administrators, and researchers. The construct validation was based on a 2006 survey of ED lead physicians and nurses at all 103 EDs in the province, of whom 68 (66%) supplied complete data. Measurements The initial tool included five subscales: ED staffing, screening and assessment, discharge planning, community services, and care philosophy. Differences in subscale scores were examined according to ED size, and of these scores were correlated with care ratings made by lead physicians and nurses. Results The average scores for three subscales (ED staffing, discharge planning, and community services) varied according to ED size. After adjustment for ED size, three subscales (screening and assessment, discharge planning, and community services) were correlated with ED nurse or physician care ratings. A preliminary tool, taking into account all factors, is proposed. Conclusion This study provides preliminary evidence of the validity of three subscales of the proposed elder-friendly ED assessment tool. Results suggest that ED size should be considered in interpreting these subscales. Further evaluation and validation of the proposed tool will be needed to further its utility in helping to focus the quality improvement efforts of clinicians, managers, and administrators related to the care they provide older adults. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society. Source

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