چکیده (انگلیسی):

Background:Several new primary care models have been implemented in Ontario, Canada over the past two
decades. These practice models differ in team structure, physician remuneration, and group size. Few studies have
examined the impact of these models on specialist referrals. We compared specialist referral rates amongst three
primary care models: 1) Enhanced Fee-for-service, 2) Capitation- Non-Interdisciplinary (CAP-NI), 3) Capitation–
Interdisciplinary (CAP-I).
Methods:We conducted a cross-sectional study using health administrative data from primary care practices in
Ontario from April 1st, 2008 to March 31st, 2010. The analysis included all family physicians providing comprehensive
care in one of the three models, had at least 100 patients, and did not have a prolonged absence (eight consecutive
weeks). The primary outcome was referral rate (# of referrals to all medical specialties/1000 patients/year). A
multivariable clustered Poisson regression analysiswas used to compare referral rates between models while
adjusting for provider (sex, years since graduation, foreign trained, time in current model) and patient (age, sex,
income, rurality, health status) characteristics.
Results:Fee-for-service had a significantly lower adjusted referral rate (676, 95% CI: 666-687) than the CAP-NI
(719, 95% confidence interval (CI): 705-734) and CAP-I (694, 95% CI: 681-707) models and the interdisciplinary
CAP-I group had a 3.5% lower referral rate than the CAP-NI group (RR = 0.965, 95% CI: 0.943-0.987, p = 0.002).
Female and Canadian-trained physicians referred more often, while female, older, sicker and urban patients were
more likely to be referred.
Conclusions:Primary care model is significantly associated withreferral rate. On a study population level, these
differences equate to 111,059 and 37,391 fewer referrals by fee-for-service versus CAP-NI and CAP-I, respectively–a
difference of $22.3 million in initial referral appointment costs. Whether a lower rate of referral is more appropriate or
not is not known and requires further investigation. Physician remuneration and team structure likely account for the
differences; however, further investigation is also required to better understand whether other organizational factors
associated with primary care model also impact referral.