Measurement and rural primary health care: a scoping review

Abstract

Introduction: Primary health care (PHC) is the foundation of healthcare systems around the world, recognized for its ability to deliver cost-effective, equitable, and high-quality care. Measuring and reporting on PHC performance allows decision-makers to ensure accountability and quality improvement. Rural areas, where residents are few and widely dispersed across vast areas, present special challenges for PHC delivery, and performance measurement systems need to acknowledge the ways rural PHC is unique. The objective of this scoping review is to establish the features of PHC that should be measured and reported in a rural versus a non-rural context.

Methods: The electronic databases PubMed, Scopus, and CINAHL, as well as grey literature in the form of government reports and research institute publications, were searched for relevant studies. Identified articles were eligible for inclusion if they reported or described (1) rural primary health care; (2) healthcare practice characteristics or structures, provider scope of practice, provider practice patterns, or patient patterns of health care use; and (3) one of four ‘pillars’ of quality PHC outlined in the College of Family Physicians of Canada’s ‘Patient’s Medical Home’ model: accessibility, continuity, comprehensiveness, or electronic health records. Articles were excluded if they reported or described (1) specific patient populations, health concerns, or health outcomes; or (2) patient preferences or experiences with PHC. Data were extracted and analyzed to determine unique aspects of rural PHC. Twenty-six articles met inclusion criteria.

Results: Results suggest important differences in aspects of rural PHC, particularly in how rural patients access such care and the types of services they receive from providers compared to non-rural patients.

Conclusion: These differences between rural and non-rural PHC will need to be considered in the design of performance measurement systems.

Key words: Canada, health reporting, performance measurement, primary health care.

Introduction

Primary health care (PHC) is the foundation of healthcare systems around the world, recognized for its ability to deliver efficient, equitable, high-quality, patient-centered care¹. Defined simply, PHC is ‘the broad range of primary prevention (including public health) and primary care services within the community, including health promotion and disease prevention; the diagnosis, treatment, and management of chronic and episodic illness; rehabilitation support; and end of life care'². In 2008, WHO called for the ‘renewal’ of PHC and, globally, many countries have undertaken major PHC reforms in the past 10–15 years^3,4.

In Canada, the College of Family Physicians envisioned a model of comprehensive PHC, the ‘Patient’s Medical Home’ (PMH), as the ‘central hub for the timely provision and coordination of a comprehensive menu of health and medical services patients need as well as a place where patients feel most comfortable discussing their health concerns'⁵. The PMH is supposed to be led by a team of clinicians (family physicians, nurses, and other health professionals) and patients who also hold some responsibility for taking an active role in their care. This model is an example of the kind of reimagining of PHC that has taken place in many jurisdictions over the past 15 years.

As innovative PHC models have developed, so has the need to evaluate their effectiveness. By measuring and reporting on PHC performance, decision-makers can ensure quality improvement and accountability at the practice, community, regional, and national levels¹. This is no easy task, since the ideal performance measurement framework has to align the needs of the various levels of the healthcare system with local and community priorities so that there is buy-in from stakeholders – patients and the public, as well as clinicians, administrators, and governments⁴.

Performance measurement and reporting in PHC need to ensure geographic context is taken into account. While the studies in this article’s results define rurality in a variety of ways, our conception of rurality is aligned with Statistics Canada’s ‘rural and small town’ designation: the areas including small towns and municipalities outside the commuting area of large urban centers (centers with populations exceeding 10 000⁶). These rural areas, where residents are fewer and widely dispersed across vast areas, present challenges for PHC delivery. For example, rural PHC clinicians offer care in their clinics during the day but may staff the emergency department (ED) during the evening and overnight, and may in fact tell their patients to come to the ED if they need care during these times. In more urban areas, not only do patients have other options (eg a walk-in clinic) for care, but they are unlikely to see their clinician if they were to go to the ED after hours. Understanding the ways in which rural PHC differs from non-rural PHC is therefore a crucial step in developing accurate performance systems for the rural setting.

This scoping review aims to answer the following question: ‘What structural and organizational factors of primary healthcare performance should be measured and taken into account in a rural context?’ Because PHC performance measurement and reporting for the rural context has not been well studied, a scoping review is a particularly appropriate research method. This review maps the existing literature and helps guide further research, a crucial next step to advancing PHC outcomes in rural communities.

Methods

This scoping review follows Arksey and O’Malley’s⁷ general five-stage approach and is informed by Levac et al’s suggested refinements: (1) identify the research question;( 2) identify relevant studies; (3) select studies for data extraction; (4) extract and chart data; and (5) summarize and report results⁸.

Searches were limited to articles comparing rural with non-rural aspects of PHC, written in the English p, and published between 2003 and 2017. The year 2003 was chosen as a start date as this coincides with Canada’s First Ministers’ Accord on Health Care Renewal, a document that set out a new vision for a sustainable and accessible healthcare system⁹.

All searches were conducted in June 2017. Initial limited searches in PubMed were conducted to identify relevant key words and medical subject headings (MeSH), and were used to identify appropriate measures of quality PHC (described below). Full searches were then conducted in the electronic databases PubMed, CINAHL, and Scopus. The grey literature was also searched, including Australian, Canadian, US, and UK government websites and research institutes, as well as the databases Canadian Electronic Library, OpenGrey, and Grey Literature Report. In PubMed, search terms included both key word and MeSH, while key words alone were used for searches in the other databases and websites (Table 1). Search strategies were left deliberately broad to ensure capture of relevant articles. Any published or unpublished literature (whether peer-reviewed or other) was considered.

Identified articles were eligible for inclusion if they reported or described (1) practice characteristics or structures, physician scope of practice, physician practice patterns, or patient patterns of health care use. Articles were excluded if they reported or described (1) specific patient populations, health concerns, or health outcomes; or (2) patient/clinician preferences or experiences with PHC. This second criterion was indicated in order to narrow the focus of selected studies to more structural and organizational level concerns. It was determined from initial, preliminary searches that studies focusing on patient and clinician preferences and experiences mostly included practice-level concerns (eg quality improvement measures, such as specific testing capabilities). This review was concerned first and foremost with what structural and organizational factors ought to be considered in performance measurement.

Database searches generated 7413 citations (t1). Reviewing titles and abstracts of these citations for relevancy and eliminating duplicates yielded 72 articles for further analysis. Grey literature searches resulted in two additional articles, and hand-searching the reference lists of these 74 articles generated another five articles, for a total of 79. As described above, date limitations were originally set at 2000–2017, but this was changed to 2003–2017, which excluded 10 further articles, leaving 69 for full-text review. Applying the preset inclusion and exclusion criteria to these 69 articles yielded 26 studies for full review, and it was these studies from which a data extraction table was generated.

Table 1: Database search results

Figure 1: Flow diagram of included studies.

Analysis

Data extracted from all articles included title, authors, publication date, date of study, demographic characteristics of the study sample, as well as primary objectives. The main results and their implication for rural PHC performance measurement were also extracted. All data were entered in a Microsoft Excel spreadsheet (Table 2). From thematic grouping of the resulting studies found in the literature, the articles were organized into four of the nine pillars of the PMH model. The four were access, continuity, comprehensiveness, and EMR use. They are defined in the model as follows. ‘Access’ means timely access to appointments in the practice as well as ensuring/advocating for timely access for other specialist appointments. ‘Continuity’ means continuity of care, relationships, and information for all patients, including when being delivered in different settings (long-term care, office, hospital, etc.). The model defines ‘comprehensiveness’ as the full scope of family practice services, delivered in conjunction with other team members, as necessary, for patients of all ages. Finally, the ‘EMR’ pillar refers to full EMR functionality, including e-prescribing, clinical decision support, and e-referral functions.

Table 2: Full results of data extraction

Results

Twenty-six studies were identified for analysis. Table 3 provides an overview of the search results. In brief, 10 of the studies were from Canada, eight from the USA, four from Australia, and three from the UK. The studies’ publication dates ranged from 2003 to 2016, with a median publication date of 2009. Twenty-two of these studies could be considered to have a quantitative observational design. In terms of the PMH ‘pillar’ identified, 14 of the studies were concerned with access, six with comprehensiveness, five with electronic medical records, and one with continuity.

Table 2 shows the full results of data extraction. Key results are described below, organized by the four pillars of quality PHC (access, comprehensiveness, continuity, EMR use) chosen from the PMH model.