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UBC Theses and Dissertations

Primary care evaluation : a study of a community clinic Robertson, Ann


This thesis presents a discussion of Primary Care Evaluation using a specific quality of care evaluation as a case study. The nature of Primary Care is discussed and a brief review of quality assessment methodology is presented. The issue of process versus outcome evaluation as it is presented in the literature is discussed. The study itself is a quality of care assessment undertaken in an urban, multi-disciplinary community family practice clinic. Using an indicator condition approach, and explicit process criteria for chart auditing developed for the Burlington Randomized Control Trail (BRCT), we reviewed randomly selected charts demonstrating episodes of care given in seven specific indicator conditions: otitis media; hypertension; urinary tract infection; care of the newborn (up to 12 months of age); prenatal care; depression; and childhood immunization. The study period was specified as July 1, 1981 to June 30, 1982. Of the 583 total charts available for study (i.e. charts "active" during the study period), 103 (17.7%) fit the criteria for the indicator conditions chosen. The final study sample represented 8.6% of the 1200 charts randomly selected from the total of 6,923 charts available in the record-room. The work of all seven (5 doctors and 2 nurses) practitioners active during the study period was surveyed. The 103 charts contained 124 episodes of care in the seven indicator conditions. Interrater reliability was determined and overall agreement between two observers (one physician, one non-physician) was 85%, with agreement beyond chance (KAPPA) of .66. Overall, 83 (66.9%) of the 124 episodes of care studied were rated adequate or superior, and 33.1% rated inadequate, using the criteria as given. Reinterpretation of the prenatal component, to adjust for episodes which had features of superior and inadequate care increased the proportion of episodes judged adequate or superior to 70.2%. Across the seven indicator conditions the proportion of episodes judged adequate or superior ranged from a low of 33.3% for hypertension to 80.9% for care of the newborn. Comparison with the results obtained with these seven indicator conditions (using the same criteria) in the two clinic groups studies in the BRCT revealed that the study clinic had a higher proportion of episodes rated adequate or superior than either BRCT clinic group for otitis media and urinary tract infection; had a proportion of episodes rated adequate or superior, which was intermediate between the two BRCT groups, for hypertension, depression, care of newborn, and immunization; and had fewer episodes rated as adequate or superior than either of the two BRCT clinics for prenatal care. In terms of overall proportions of episodes rated adequate or superior, a test of proportions found that the study clnic was not significantly different from either of the BRCT study groups. The reasons for inadequacy and the implications of these findings for quality assurance activities at the study clinic are discussed. Finally, the general relevance of process evaluations, such as the one applied at the study clinic, as a policy tool is discussed.

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