Grant: Team Grant: Chronic Disease Risk and Intervention Strategies

Cardiovascular risk factors (smoking, high blood pressure, high cholesterol, diabetes, etc.) and chronic conditions (angina, heart failure, stroke) are an increasing burden to many Canadians and the health care system. Despite advances in prevention and treatment, a wide gap exists between the care people with these risk factors and/or chronic diseases receive and what optimally should be provided. Many care gaps exist including smokers not receiving cessation counselling, people with blood pressure levels and/or cholesterol levels that are too high, resulting in many preventable heart attacks, cases of heart failure and strokes. A major contributor to these care gaps is the fragmented nature of the health care system. Family doctors (providing most of the preventive and chronic care) and specialist physicians, e.g., cardiologists/neurologists (providing most of the acute hospital care) often operate in separate silos with limited care coordination or information sharing. A new system of chronic disease care is needed where family doctors and specialists work more closely together with patients to provide optimal care. Our team of 22 leading researchers will conduct 3 studies to improve the outpatient care provided to patients with cardiovascular risk factors and/or chronic conditions. We will develop indicators of high-quality outpatient care measurable using 20 large, population-based databases in Ontario. We will study how differences in how care is provided influence differences in the rates of new cardiovascular events in 73 newly identified multispecialty Ontario physician networks (made up of family doctors and specialists). Results will be released in novel public report cards and academic papers, describing how outpatient cardiac and stroke care is delivered across different regions and physician networks in Ontario. This initiative will stimulate health system changes and quality improvement activities resulting in better patient outcomes.