Age equity in different models of primary care practice in Ontario

#Editor's Key Points

• Canada has restructured its primary care models of service delivery, shifting from traditional fee-for-service models to salaried community health centres, and to models in which remuneration is largely based on capitation (ie, health service organizations and family health networks). This is the first study to assess disparities among age groups across several dimensions of primary care performance in primary care models.
• Oder individuals reported substantially better health service delivery in all models and this was not explained by their poorer health status or greater needs. 
• Age was a significant determinant (P<.05) of the likelihood of receiving chronic disease management according to recommended guidelines in all models of care except community health centres.

#Abstract

Objective: To assess whether the model of service delivery affects the equity of the care provided across age groups.

Design: Cross-sectional study.

Setting: Ontario.

Participants: One hundred thirty-seven practices, including traditional fee-for-service practices, salaried community health centres (CHCs), and capitation-based family health networks and health service organizations.

Main outcome measures: To compare the quality of care across age groups using multilevel linear or logistic regressions. Health service delivery measures and health promotion were assessed through patient surveys (N=5111), which were based on the Primary Care Assessment Tool, and prevention and chronic disease management were assessed, based on Canadian recommendations for care, through chart abstraction (N=4108).

Results: Older individuals reported better health service delivery in all models. This age effect ranged from 1.9% to 5.7%, and was larger in the 2 capitation-based models. Individuals aged younger than 30 years attending CHCs had more features of disadvantage (ie, living below the poverty line and without high school education) and were more likely than older individuals to report discussing at least 1 health promotion subject at the index visit. These differences were deemed an appropriate response to greater needs in these younger individuals. The prevention score showed an age-sex interaction in all models, with adherence to recommended care dropping with age for women. These results are largely attributable to the fact that maneuvers recommended for younger women are considerably more likely to be performed than other maneuvers. Chronic disease management scores showed an inverted U relationship with age in fee-for-service practices, family health networks, and health service organizations but not in CHCs.

Conclusion: The salaried model might have an organizational structure that is more conducive to providing appropriate care across age groups. The thrust toward adopting capitation-based payment is unlikely to have an effect on age disparities.