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Canadian politicians, decision-makers, clinicians and researchers have come to agree that reforming primary care services is a key strategy for improving healthcare system performance. However, it is only more recently that real transformative initiatives have been undertaken in different Canadian provinces. One model that offers promise for improving primary care service delivery is the family medicine group (FMG) model developed in Quebec. A FMG is a group of physicians working closely with nurses in the provision of services to enrolled patients on a non-geographic basis. The objectives of this paper are to analyze the FMG's potential as a lever for improving healthcare system performance and to discuss how it could be improved. First, we briefly review the history of primary care in Quebec. Then we present the FMG model in relation to the four key healthcare system functions identified by the World Health Organization: (a) funding, (b) generating human and technological resources, (c) providing services to individuals and communities and (d) governance. Next, we discuss possible ways of advancing primary care reform, looking particularly at the family health team (FHT) model implemented in the province of Ontario. We conclude with recommendations to inspire other initiatives aimed at transforming primary care.

ABSTRACTObjectivesTo investigate variation across 78 New South Wales public hospitals, in mortality in the 30 days following admission and in returns to acute care (readmissions) in the 30 days following discharge for acute myocardial infarction, ischaemic stroke, heart failure, pneumonia, hip fracture surgery.
ApproachLinked data were used to (1) construct an analytic unit – an index period of care that comprised concatenated acute, contiguous hospitalisations with the principal diagnosis of interest; (2) to capture outcomes both within the index hospital and following discharge, wherever they occurred; (3) to enhance risk adjustment with one year look back for relevant comorbidities; (4) to assess fair attribution of outcomes. A risk-standardised mortality ratio (RSMR) and a risk standardised readmission ratio (RSRR) were calculated as the ratio of the observed to the expected number events at a given hospital, by developing and validating condition specific system-level prediction models. Funnel plots identified outliers. For the RSRR, the competing risk of death was considered.
ResultsFor both outcome indicators, sensitivity was enhanced by the use of linked data (33%-100% more deaths; 23%–32% more returns to acute care or readmissions). For mortality, RSMRs that only capture deaths in hospital, as opposed to deaths within 30 days of admission, were shown to be biased and change the outlier status of about 20% of hospitals. Including socioeconomic status in risk adjustment models altered the outlier status of about 10% of hospitals on the cusp of statistical significance but did not significantly alter the RSMRs. For returns to acute care, sensitivity analyses that included socioeconomic status in the models found there was no significant improvement in discriminatory power. For example, in the case of ischaemic stroke, the c-statistic for the model without inclusion of SES was 0.593 (0.578-0.610); inclusion of SES resulted in a c-statistic of 0.600 (0.583-0.616). There were some changes in hospital-level results but there was no clear evidence of a systematic effect on results.
ConclusionThe risk-standardised ratio method, based on linked data, compares a hospital's results given its case mix with an average New South Wales hospital with the same case mix. Ratio-based indicators have been reported publicly and have proven to be a valuable screening tool to identify hospitals where further investigation may be required locally.

The quest for greater efficiency in health systems encourages governments to bring together two fields of practice that have largely developed in parallel in industrialized countries: public health and healthcare. Current healthcare reform in the province of Quebec formally integrates these two fields within a common governance structure. The objective of this paper is to discuss the issues arising from the integration of public health services into the planning and delivery of local healthcare services, and its potential effect on the overall performance of the healthcare system. The authors begin by describing the characteristics of these two sectors; then, they discuss current reforms in Quebec and the impact of various transitions (epidemiological, technological and organizational) that bring the sectors into greater convergence. The paper concludes with a discussion of obstacles and potential opportunities at two levels: (a) the development of population-based planning of services within healthcare organizations, and (b) the articulation of public health and healthcare services concerns at the local level. The ongoing reform in Quebec is a unique opportunity to maximize outcomes from the resources invested in the healthcare system, based on a collective vision for improving health.

ABSTRACTObjectivesTo describe: (1) a stepwise guide to the use of linked data in the development of individual healthcare performance metrics; and (2) the application of these metrics in comprehensive performance assessment efforts at a system, regional and hospital level of analysis.ApproachA stepwise guide to the definition and validation of linked-data based indicators was developed following a rapid review of peer reviewed and grey literature and a series of semi-structured interviews with international subject experts. The review and interviews adopted a snowball approach to collect information on the ways in which linked data are currently used in performance measurement efforts. Data collection continued until indicator type saturation was reached. Details about existing applications of linked data in performance reporting were mapped, and used to inform the development of the guide. Indicators were aligned within a conceptual framework that is used to assess healthcare performance in New South Wales, on the basis of accessibility, appropriateness, effectiveness, efficiency, equity and sustainability. ResultsThe guide to indicator development considers the use and contribution of linked data in four stages: defining a cohort; capturing outcomes of interest; risk adjustment; and attribution. A series of vignettes illustrate the various contributions that linked data can make to performance measurement efforts – highlighting the ways in which those data can enhance understanding of complexity and dynamic relationships, and help build a comprehensive picture of performance.
ConclusionIn performance measurement efforts internationally, linked data are used to strengthen the reliability, accuracy and precision of individual metrics and to inform efforts to assess various dimensions of healthcare performance. In New South Wales, linked data underpin publicly reported performance measures and have the potential to provide in the future whole-of-government and whole-of-system perspectives on health.