Sourial, Nadia (2020). Primary care performance for persons with dementia in Ontario: the impact of interdisciplinary primary care on health service use. McGill Family Medicine Studies Online, 14:e14

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Abstract

BACKGROUND: Dementia has a high impact for patients, families and the health care system. Interdisciplinary primary care may be beneficial to provide timely access to care and manage the wide range of needs of this population. Ontario’s Family Health Teams offers one of the most comprehensive examples of interdisciplinary primary care; however, its potential impact on health service use in the dementia population is unclear. Whether the introduction of interdisciplinary primary care and other recent primary care reforms have influenced trends in the management of dementia in primary care and health service use in both men and women is unknown and subject to important methodological challenges for evaluation.

OBJECTIVES: This dissertation aimed to fill these gaps through four objectives: 1) to develop a framework of population-based, primary care performance and health service use indicators relevant to dementia and identify a subset of priority indicators; 2) to describe sex differences in these indicators over time in persons with dementia in Ontario; 3) to provide guidance on the use of causal inference methods for appropriate confounder selection and 4) to apply these methods to estimate the effect of interdisciplinary versus non-interdisciplinary primary care on health service use for persons with dementia in Ontario.

METHODS: 1) The framework was developed through the selection of an initial framework based on a literature review, identification of relevant indicators within the framework and enrichment based on existing dementia indicators and guidelines. Prioritization of indicators was carried out through a stakeholder survey. 2) Eighteen indicators from the framework were operationalized. Trends over time for men and women with dementia between 2002 and 2015 were assessed. 3) Recommendations for confounder selection in non-randomized studies were proposed based on recent advances in causal inference methods. 4) Using these methods, emergency department and hospital use in persons with dementia within an interdisciplinary versus non-interdisciplinary primary care setting were compared.

RESULTS: A framework of 37 indicators across eight domains of performance was developed. Continuity of care, early stage diagnosis and access to home care were consistently rated as priorities by stakeholders. Few differences between men and women were observed. Trends remained relatively stable over time (median relative change in men: 13.7%; interquartile range (IQR): 4.5% to 29.7%; median relative change in women: 15.7%; IQR: 5.9% to 31.5%). A practical example was used to demonstrate how methods in causal inference can be used to better inform confounding. Persons with dementia in an interdisciplinary primary care group were found to have a higher risk of having an emergency department visit (Relative risk (RR): 1.03; 95% CI:1.01-1.05) or non-urgent emergency department visit (RR:1.22; 95% CI:1.18-1.28) compared to those in a non-interdisciplinary primary care group. No meaningful differences in hospitalization outcomes were found.

CONCLUSION: This thesis created and operationalized a framework of indicators to support ongoing surveillance and evaluation for persons with dementia, raised awareness on the similarities and differences in management and health system use for men and women with dementia, demonstrated how causal inference methods may help strengthen evaluations and provided a reliable estimate of the impact of interdisciplinary on health service use in this population. Stable trends and lack of reduction in emergency department and hospital use may point to need for more targeted efforts, tailored to the needs of both men and women with dementia, to affect change and curb avoidable health service use