Electronic Thesis and Dissertation Repository

Thesis Format

Integrated Article

Degree

Master of Science

Program

Biostatistics

Supervisor

Sarma, Sisira

Affiliation

ICES

2nd Supervisor

Zou, Guangyong

Affiliation

Robarts Research Institute

Co-Supervisor

Abstract

The government of Ontario initiated primary care reform in the early 2000s, leading to a shift away from the traditional fee-for-service (FFS) physician remuneration to incentive-based blended remuneration models. Research on the association between change in physician remuneration and patients' health status is unknown. The objectives of this thesis are to (i) construct a statistical model to predict the Health Utility Index 3 (HUI3) values for all non-institutionalized Ontario residents, and (ii) study the association between the change in physician remuneration models and patients' health status measured by HUI3. The data came from the Canadian Community Health Survey (CCHS) 2000-2001 and 2009-2010 linked with Ontario health administrative data in the corresponding fiscal years from ICES. To study objective (i), four types of statistical models were compared, and the two-part beta mixture model was found to perform the best. Given that only a few datasets contain preference-based measures to construct HRQOL, the model-based prediction for the HUI3 is an important step towards predicting HUI3 values in population-based health administrative data. For objective (ii), the associations between predicted HUI3 values and change in physician remuneration were analyzed using the first-difference estimator with clustered patient data within physicians. After adjusting for all potential confounders, change in physician remuneration from the traditional FFS to blended remuneration is associated with higher HUI3 values and gain in quality-adjusted life years (QALYs). The main policy implication is that the introduction of primary care reform is associated with improved health status of patients.

Summary for Lay Audience

The government of Ontario initiated primary care reform in the early 2000s, with one of the key policy initiatives being the introduction of new primary care physician payment models. Although previous research has studied how physicians respond to this policy change, there has been no study on the impact on patients’ health status. In this thesis, the impact was quantified by studying the relationship between change in physician payment models and patients’ health status. Since only a few datasets contain health utility data, I first constructed and validated statistical models to predict health status for everyone in Ontario. Second, I studied the association between change in physician payment models and the predicted health status controlling for all potential confounders. I found that, with reasonable prediction accuracy, patients’ predicted health status increased as their physicians change from the traditional fee-for-service payment model to new models. The findings of this thesis will inform policy makers in Ontario and across Canada that the introduction of primary care reform is associated with improved patients’ health status.

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