Abstract
Introduction
Measuring the performance of interprofessional primary care is needed to examine whether this model of care is achieving its desired outcomes on patient care and health system effectiveness as well as to guide quality improvement initiatives. The aim of this scoping review is to map the literature on primary care performance measurement indicators to determine the extent to which current indicators capture or could be adapted to capture processes, outputs and outcomes that reflect interprofessional primary care.
Methods and analysis
The review will be guided by the six-stage framework by Arksey and O’Malley (2005). MEDLINE, Embase, CINAHL, grey literature and the reference list of key studies will be searched to identify any study, published in English or French between 2000 and 2022, related to the concepts of performance indicators, frameworks, interprofessional teams and primary care. Two reviewers will independently screen all abstracts and full-text studies for inclusion. Eligible indicators will be classified according to process, output and outcome domains proposed by two validated frameworks. This study started in November 2022 and is expected to be completed by July 2023.
Ethics and dissemination
This review does not require ethical approval. The results will be disseminated through a peer-reviewed publication, conference presentations and presentations to stakeholders.
Keywords: interprofessional relations, quality in health care, primary care
STRENGTHS AND LIMITATIONS OF THIS STUDY.
To the best of our knowledge, this will be the first scoping review to focus on identifying performance indicators that can measure the contribution of interprofessional primary care providers to processes, outputs and outcomes.
A large cross-disciplinary stakeholder group including clinicians, managers and patient–partners will be consulted throughout the scoping review process.
The study followed established and systematic methods for conducting scoping reviews.
While we sought to use broad search strategy and eligibility criteria to identify relevant studies, exclusion criteria by language, date range and country may limit the assessment of other potentially relevant studies. Furthermore, we limited the results to studies using conceptual frameworks to identify indicators. Complementary studies have been added to the review through backward citation research and consultation with experts in primary care.
There will be no formal assessment of included studies quality or quality of the indicators identified.
Introduction
Primary care constitutes the first point of contact between a patient and the healthcare system to provide services including prevention, diagnosis, treatment, health promotion and counselling.1 2 An interprofessional approach to primary care is considered a key tenet in achieving high-quality primary care by facilitating access to integrated, comprehensive and continuous person-centred care.3–5 As the population ages and the prevalence of chronic disease increases, health systems globally have shifted towards interprofessional primary care (IPC) teams.6–8 These teams bring together interprofessional health providers with complementary expertise, including family physicians, nurse practitioners, nurses, social workers, pharmacists, physiotherapists, psychologists, kinesiologists, occupational therapists, dietitians and others, to ‘enhance the integration of services and emphasise health promotion and chronic disease management’.9
Measuring the performance of IPC teams is needed to examine whether these new models of care are achieving their desired outcomes on patient care and health system effectiveness as well as to guide quality improvement initiatives.10 11 In general, performance measurement aims to improve the quality of decisions made by all actors within the health system.11 Performance measurement of IPC teams has also been cited as a key feature for high-performing IPC teams.12
Several primary care performance measurement frameworks have been proposed, including indicators on care processes such as the types of services provided, outputs related to quality of care such as timely access, continuity of care, comprehensiveness, coordination as well as patient and health system outcomes.13–18 Despite the shift to IPC teams, the measurement of many of the indicators proposed within these frameworks rely on information related to physician encounters, obscuring the involvement and impact of the various members of the interprofessional team. For example, continuity of care is frequently measured through the proportion of visits made to the regular family physician in a given time period.19 Excluding visits to and tasks performed by other interprofessional health providers within the team may distort the extent to which IPC teams are providing accessible and ongoing care to their patients and, more generally, may lead to potentially misleading evidence on performance.9 20 To the best of our knowledge, there is currently no knowledge synthesis on performance indicators that can measure the contribution of IPC providers, across multiple diseases or care settings. However, the need to develop such indicators is growing.9
The aim of this scoping review is thus to map the literature on primary care performance measurement indicators to determine the extent to which current indicators capture or could be adapted to capture processes, outputs and outcomes that reflect IPC. This review constitutes the first step in a larger research project aimed at developing and measuring a core set of stakeholder-informed indicators to guide ongoing performance measurement and quality improvement of IPC teams. Overall, this review will provide new insights on existing indicators relevant to IPC teams and identify gaps for future research. Ultimately, we hope the results of this review will support practice and policymakers in planning the organisation, resources and quality initiative based on indicators that reflect IPC.
Methods and analysis
The protocol for this scoping review was based on the Arksey and O’Malley’s (2005) framework for scoping reviews,21 the Levac et al methodological enhancement,22 as well as the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) extension for Scoping Reviews (PRISMA-ScR).23 Accordingly, six stages will be undertaken: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies; (4) charting the data; (5) collating, summarising and reporting the results and (6) consulting with relevant stakeholders. The protocol is not registered with PROSPERO, as it currently does not accept scoping reviews. The review started in November 2022 and is expected to take approximatively 8 months to be completed. As of March 2023, two electronic databases (MEDLINE and EMBASE) have been searched.
Stage 1: identifying the research question
The main research question for this scoping review was codesigned with our research team consisting of approximately 20 clinicians, researchers, methodologists, managers and a patient–partner. The members of the team have expertise in primary care performance evaluation, IPC teams and primary care policy. Accordingly, the scoping review is centred on the following main question:
Which existing primary care performance measurement indicators measure or could be adapted to measure the involvement and impact of interprofessional health providers on performance?
Based on this initial question, the following secondary questions will be examined:
How are indicators classified according to different domains of performance (processes, outputs, and outcomes)?
What data sources may be utilised to measure these indicators?
Stage 2: identifying relevant studies
Published literature will be searched using the following electronic databases: MEDLINE (PubMed), EMBASE and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Grey literature will also be consulted using Cochrane, Google Scholar, Google, Grey Literature Report and OpenGrey to identify reports relevant to this review. Authors of the identified articles and reports will be contacted if needed for further or missing information. We will also consult local, regional and national organisations’ online sites, published materials and experts from our research teams for relevant studies. Additionally, the reference list of included studies will be hand-searched to identify more relevant literature.
Studies published in English or French will be included. Given that reforms proposing the creation of IPC teams have occurred mainly in the last two decades, only studies published from 2000 to 2022 will be considered.
An initial exploratory search was conducted using MEDLINE to identify search terms contained in relevant articles in order to develop a full search strategy. The search terms and strategy were validated through input from the research team and an experienced research librarian. Additional search terms and keywords were taken from known studies that report indicators to measure interprofessional or overall primary care performance. The search strategy was pilot tested and refined to compile a list of keywords from titles, abstracts, keyword heading, keyword heading word and MeSH terms used in publications most relevant to the review. It combines terms from four concepts: performance indicator, framework, interprofessional team and primary care. The draft search strategy is shown in online supplemental appendix A. It will be further adapted for each database and information source.
bmjopen-2023-072186supp001.pdf (43.3KB, pdf)
Stage 3: study selection
Following the search, the results will be recorded into Endnote, a bibliographic reference management software to remove duplicates and facilitate referencing. The results will then be exported to Covidence for screening and data collection.24 The screening and selection of eligible studies will involve a first screening of title and abstract followed by a full-text review of those studies selected at the first screening stage. Studies meeting the following inclusion and exclusion criteria, as described in table 1, will be considered.
Table 1.
Inclusion and exclusion criteria
| Inclusion criteria | Exclusion criteria | |
| Focus | Indicators measuring the contribution of interprofessional primary care teams on performance including processes, outputs (quality of care) and outcomes | Frameworks outside primary care Theoretical frameworks without operational indicators Indicators specific to a disease (cancer, pain-management…) or subpopulation (veterans, diabetic, palliative…) |
| Type of studies | Reviews, framework development studies, commentaries, qualitative studies, observational studies, cross-sectional studies | Experimental or quasi-experimental studies (focus on evaluation of an intervention or programme) Study protocols, conference proceedings, editorials |
| Context | The 11 high-income countries of the Commonwealth Fund: Australia, Canada, England, France, Germany, Netherlands, New Zealand, Norway, Sweden, Switzerland and USA | Other countries |
| Setting | Primary care clinic in the community | Palliative and end-of-life care Paediatric care Long-term care homes |
Country selection was informed by the Commonwealth Fund’s international health policy surveys.25 We considered these countries in order to select studies covering healthcare systems comparable to the Canadian system.26 We limited the setting to primary care delivered in the community for the general adult population and therefore excluded studies related to paediatric, palliative and end-of-life care.
Two members of our team will review all studies against the inclusion/exclusion criteria. Studies will be sorted as included, excluded or uncertain. Any discrepancies in their independent assessment will be resolved through discussion, consensus and consultation with the lead member of the research team.27 The scoping review will report the reasons for excluding studies at full-text review. Inter-rater reliability will be assessed on a sample of studies at both screening stages to calibrate and refine the process. Suppose agreement between the reviewers is inferior to 75% at any of these stages. In that case, reasons for disagreement will be explored, eligibility criteria will be clarified and testing will be repeated until the inter-rater reliability is adequate.27 Before beginning the abstract review, the inclusion and exclusion criteria will also be tested on a sample of study abstracts produced by the keyword database searches. This will verify that our selection criteria are robust and specific enough to capture relevant studies.
Stage 4: data collection
Study characteristics to be extracted include but are not limited to source details, healthcare context and results extracted. A full list of characteristics is provided in table 2. Data collection will be conducted by two reviewers independently extracting data from all included studies, and disagreement will be discussed among the research team. To ensure the accuracy of the process, the form will be tested on a sample of studies and revised if needed. The scoping review manuscript will acknowledge any modifications to the following form.
Table 2.
Data collection form
| Characteristics | Details |
| Source details | Authors |
| Year | |
| Document type (published or grey literature) | |
| Country | |
| Purpose | |
| Methods | |
| Healthcare context | Model of care (including funding, governance and team composition), if applicable |
| Geographical region, if applicable | |
| Results extracted | Framework, if applicable |
| Domains of performance, if applicable | |
| Indicators | |
| Description of indicators | |
| Data source | |
| Total number of indicators extracted |
Stage 5: data summary and synthesis of results
A table synthesising the indicators identified in the review will be classified based on relevant domains from two frameworks: the primary care measurement framework proposed by the WHO and the Quintuple Aim framework proposed by the Institute for Health Improvement. The WHO framework classifies indicators according to service delivery processes (eg, selection and planning of services, community linkages) and outputs (eg, access, comprehensiveness, continuity, coordination, efficiency and equity) as well as health system outcomes to monitor primary healthcare performance.17 Outcomes will be further classified according to the Quintuple Aim five key outcomes (population health, patient experience, cost reduction, care team well-being and health equity) of a high performing health system.18 If indicators are not explicitly classified into related domains of performance in the studies, they will be deductively categorised into domains from those frameworks with input from the research team. The data source (eg, administrative data, electronic medical records and survey) proposed for each indicator will also be extracted. The final format of the table will depend on the gathered data.
The meaning and implication of the findings captured in this scoping review will be reported considering the stated objectives in consultation with the research team. The PRISMA-ScR instrument for reporting scoping review results will be used to guide the publication of results.23
Stage 6: stakeholder consultation
During the development of the scoping review, there will be regular consultations with the research team. The consultations will be held mainly through videoconference. The purpose of the first consultation will be to collect feedback on the scoping review protocol regarding the search strategy and to refine our research question. It will also be an occasion to gather additional sources of information about potential studies to include in the review. The next consultation will allow us to inform and validate preliminary findings from stage five of the scoping review and discuss the dissemination strategy. A final consultation will take place to inform the synthesis of the results and their implications.
Patient and public involvement
A patient–partner is included in our team and participated in commenting the protocol. She will participate in team meetings and consulted at various stages of the review to inform the interpretation of results and knowledge dissemination strategy.
Dissemination and ethics
This review does not require ethics approval, since it involves reviewing and collecting data from published and/or publicly available articles. This study is expected to be completed by July 2023. The dissemination strategy includes a peer-review publication of the scoping review results, as well as presentations at primary care conferences and to key stakeholders.
The results of the review will inform the development and measurement of a core set of stakeholder-informed indicators to guide ongoing performance measurement and quality improvement of IPC teams. It will also help stimulate a discussion around which actions of the interdisciplinary team could positively and negatively impact the results of these indicators.
Supplementary Material
Footnotes
Twitter: @bretonmylaine
Contributors: NS conceived of the idea, developed the research question and study methods, and contributed meaningfully to the drafting and editing; SMY aided significantly in developing the study methods and contributed meaningfully to the drafting, editing and formatting of the manuscript; M-EP contributed to conceiving the idea and aided in developing the research question and study methods, and contributed meaningfully to the editing of the manuscript. CD, RA, MG, YC, JNN, MB, GL, HB, M-TL, MA, KM, KS, DM and JK aided in developing the research question and study methods, contributed meaningfully to the editing of the manuscript. PF and MM contributed to developing the methods. All authors approved the final manuscript.
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests: None declared.
Patient and public involvement: Patients and/or the public were involved in the design, or conduct, or reporting or dissemination plans of this research. Refer to the Methods section for further details.
Provenance and peer review: Not commissioned; externally peer reviewed.
Supplemental material: This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
Ethics statements
Patient consent for publication
Not required.
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Associated Data
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Supplementary Materials
bmjopen-2023-072186supp001.pdf (43.3KB, pdf)