Grant: Team Grant: Chronic Disease Risk and Intervention Strategies - LOI

Many Canadians suffer from heart attack, heart failure, stroke and related risk factors (RF) (e.g. high blood pressure, cholesterol, blood sugar; kidney disease; obesity etc.). A growing number have >1 of these RFs and/or lifelong diseases. Family doctors (FP) and others (nurse practitioners [NP], pharmacists, dieticians etc.), provide much of the care for patients with chronic diseases and are challenged to provide longitudinal, coordinated, and patient-centered care within a complex, fragmented health care system. Studies show these patients often receive care that is incomplete/inappropriate/out of date. We will study how to measure and improve chronic disease care in 73 large informal networks of FPs, NPs, specialists and hospitals serving Ontario and its 12 million+ residents. Pilot data show up to 3-fold variation across these networks regarding the number of patients with chronic diseases admitted/readmitted to hospital, and the preventive care and medications they receive, indicating considerable opportunities exist to improve the quality of chronic disease care. Our multidisciplinary team will conduct 3 major projects. I: Develop a performance management system to measure the quality of chronic cardiovascular disease care provided in these 73 physician networks, building on our deep expertise developing quality indicators and report cards for hospital-based care. II: Analyze 20+ comprehensive health care databases available to us at the Institute for Clinical Evaluative Sciences, and conduct surveys, site visits, and case studies to identify the highest/lowest quality physician networks in Ontario. III: Develop, test & evaluate report cards, for these physician networks, on the care provided to patients with multiple chronic diseases. These report cards will be provided to the physician networks, and eventually released publicly, to share best practices and stimulate quality improvement in chronic disease care, coordination, and outcomes.