שנת סיום: 2018

כותרת עבודת הדוקטורט: The Association between Different Primary Care Models and Patients' Health Outcomes

מנחה: פרופ' אורנה בראון אפל

Abstract

Scientific Background

Various types of primary care models are implemented in order to provide effective ways of coping with the rising burden of chronic illnesses worldwide. It is commonly accepted today that the use of multidisciplinary teams and patient empowerment lead to better treatment processes and health outcomes. However, true teamwork is challenging and patients' adherence remains un-satisfactory. Since healthcare services have limited resources, it is imperative to identify the effect the type of primary care models may have on patients' outcomes, thus contributing to the population's health.

Objective To examine the association between type of primary care model and health outcomes achieved.

Methodology

A quazi-experimental study compared an Independent Physician Model with two multidisciplinary models: Teamwork (physicians, nurses, dietitians and social workers) and Collaboration (nurses and physicians), implemented by Maccabi Health Services (MHS). The study implemented a mixed method approach and consisted of two phases: The first phase explored how clinics' and health professionals' characteristics effect multi-disciplinary work and health education implementation in the clinics. This phase included a qualitative and quantitive assessments. In-depth interviews were conducted with 33 health professionals, representing all primary models from large and small clinics. Computerized questionnaires were sent to all health professionals affiliated with this study's clinics.

The second phase of our study examined the association between the type of primary care model and patients' health outcomes. All patients over eighteen years old, affiliated with a clinic for a minimum of twelve months prior to the data mining date (December 31st 2015) were included in this study (n=1,064,608). Independent variables included the type of primary care model and the size of clinic. The dependent variables included vaccinations, periodic check-ups, medical adherence, risk-factor control and health education activities.

Data were extracted from MHS computerized health records and multi-leveled statistical analysis was performed. Clinical health outcomes were defined according to the Israeli National Program for Quality Indicators. The significance for all the statistical tests was set to 0.05.

Conclusions

Multidisciplinary models were associated with better health outcomes, especially among the chronically ill and the Collaboration Model, a downsized multidisciplinary model, presented health outcomes resembling those of the traditional Teamwork Model. However, differences were minor and all three types of primary care models produced adequate health outcomes. This leaves MHS and other HMOs that implement similar primary care models with the challenge of identifying which model would best suit specific conditions.

The effect Multidisciplinary treatment had on low socioeconomic status and morbidity levels may help minimize health inequalities.

Additional personal and organizational factors, such as professional perceptions and resources allocated to the clinic, should be further explored in order to evaluate its effect on health outcomes.

Policy Implications and Recommendation

The implementation of various types of primary care models seem to be justified, as all three types examined in this study produced adequate results.

Considering factors such as health professionals' skills, populations' characteristics and resources available is key to successful implementation of a chosen primary care model.

In light of this study's results, multidisciplinary models should be implemented primarily among low SES, chronically ill populations and downsized collaborations may enable health services to better cope with limited resources while achieving adequate health outcomes.

Organizational support of multidisciplinary work expressed by health professionals' training alongside relevant fee policies, may help promote collaboration implementation in multidisciplinary primary care models, among health professionals as well as with patients.