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

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  1. Michael E. Green, MD, MPH,
  2. Stewart B. Harris, MD, MPH,
  3. Susan Webster-Bogaert, MA,
  4. Han Han, PhD,
  5. Jyoti Kotecha, MPA, MRSC,
  6. Alexander Kopp, BA,
  7. Minnie M. Ho, MHSc,
  8. Richard V. Birtwhistle, MD, MSc,
  9. Richard H. Glazier, MD, MPH

+ Author Affiliations

  1. Affiliations: Departments of Family Medicine (Green, Han, Kotecha, Birtwhistle) and Public Health Sciences (Green, Birtwhistle), Centre for Health Services and Policy Research, Centre for Studies in Primary Care, Institute for Clinical Evaluative Sciences, Queen’s University, Kingston, Ont.; Department of Family Medicine (Harris); Centre for Studies in Family Medicine (Harris, Webster-Bogaert), Western University, London, Ont.; Institute for Clinical Evaluative Sciences (Kopp, Ho, Glazier); Department of Family and Community Medicine (Glazier), University of Toronto; St. Michael’s Hospital (Glazier), Toronto, Ont.
  1. Correspondence to:
    Michael Green, [email protected]


Background: In Ontario, a province-wide quality-improvement program (Quality Improvement and Innovation Partnership [QIIP]) was implemented between 2008 and 2010 to support improved outcomes in Family Health Teams, a care model that includes many features of the patient-centred medical home. We assessed the impact of this program on diabetes management, colorectal and cervical cancer screening and access to health care.

Methods: We used comprehensive linked administrative data sets to conduct a population-based controlled before-and-after study. Outcome measures included diabetes process-of-care measures (test ordering, retinal examination, medication prescribing and completion of billing items specific to diabetes management), colorectal and cervical cancer screening measures and use of health care services (emergency department visits, hospital admission for ambulatory-care-sensitive conditions and rates of readmission to hospital). The control group consisted of Family Health Team physicians with at least 100 assigned patients during the study follow-up period (November 2009-February 2013).

Results: There were 53 physicians in the intervention group and 1178 physicians in the control group. Diabetes process-of-care measures improved more in the intervention group than in the control group: hemoglobin A1c testing 4.3% (95% confidence interval [CI] 1.2-7.5) more, retinal examination 2.5% (95% CI 0.8-4.4) more and preventive care visits 8.9% (95% CI 2.9-14.9) more. Medication prescribing also improved for use of statins (3.4% [95% CI 0.8-6.0] more) and angiotensin-converting-enzyme inhibitors or angiotensin receptor blockers (4.1% [95% CI 1.8-6.4] more). Colorectal cancer screening improved 5.4% (95% CI 3.1-7.8) more in the intervention group than in the control group, and cervical cancer screening improved 2.7% (95% CI 0.9-4.6) more. There were no significant differences in any of the measures of use of health care services.

Interpretation: This large controlled evaluation of a broadly implemented quality-improvement initiative showed improvement for diabetes process of care and cancer screening outcomes, but not for proxy measures of access related to use of health care services.