The impact of primary healthcare reform on equity of utilization of services in the province of Quebec: a 2003–2010 follow-up

Introduction In 2003, the Quebec government made important changes in its primary healthcare (PHC) system. This reform included the creation of new models of PHC, Family Medicine Groups (e.g. multidisciplinary health teams with extended opening hours and enrolment of patients) and Network Clinics (clinics providing access to investigation and specialist services). Considering that equity is one of the guiding principles of the Quebec health system, our objectives are to assess the impact of the PHC reform on equity by examining the association between socio-economic status (SES) and utilization of healthcare services between 2003 and 2010; and to determine how the organizational model of PHC facilities impacts utilization of services according to SES. Methods We held population surveys in 2005 (n = 9206) and 2010 (n = 9180) in the two most populated regions of Quebec province, relating to utilization and experience of care during the preceding two years, as well as organizational surveys of all PHC facilities. We performed multiple logistical regression analyses comparing levels of SES for different utilization variables, controlling for morbidity and perceived health; we repeated the analyses, this time including type of PHC facility (older vs newer models). Results Compared with the lowest SES, highest SES is associated with less emergency room visits (OR 0.80) and higher likelihood of at least one visit to a PHC facility (OR 2.17), but lower likelihood of frequent visits to PHC (OR 0.69), and higher affiliation to a family doctor (OR 2.04). Differences remained stable between the 2005 and 2010 samples except for likelihood of visit to PHC source which deteriorated for the lowest SES. Greater improvement in affiliation to family doctor was seen for the lowest SES in older models of PHC organizations, but a deterioration was seen for that same group in newer models. Conclusions Differences favoring the rich in affiliation to family doctor and likelihood of visit to PHC facility likely represent inequities in access to PHC which remained stable or deteriorated after the reform. New models of PHC organizations do not appear to have improved equity. We believe that an equity-focused approach is needed in order to address persisting inequities. Electronic supplementary material The online version of this article (doi:10.1186/s12939-015-0243-2) contains supplementary material, which is available to authorized users.


COLLABORATION
Team of researchers and partners associated with this research project.

FUNDING ORGANIZATIONS AND PARTNERS
This study was funded by Canadian Institutes of Health Research (CIHR) and Fonds de la recherche en santé du Québec -Santé (FRSQ) along with ministère de la Santé et des Services sociaux du Québec. It also receives financial support from the Agences de la santé et des services sociaux (ASSS) de Montréal and Montérégie, and from the Institut national de santé publique du Québec (INSPQ). The Fédération des médecins omnipraticiens du Québec and the Collège des médecins du Québec have given their support to the project.
The project has received ethical approval from the research ethics committee of the Agence de la santé et des services sociaux de Montréal, the main committee. The multicentre nature of the research project requires ethical approval from research ethics committees in each health and social services centre in the territories under study.
1 Section A -Health services utilization Utilization profile over the last two years A1 In the last two years, since 2008, how many times were you hospitalised (you spent at least one night in the hospital)? 0 never 1 once 2 twice 3 3 times or more 8 doesn't know /doesn't remember A2 In the last two years, how many times did you go to a hospital emergency room to get medical care? 0 never 1 once 2 twice 3 3 times 4 4 times 5 5 times or more 8 doesn't know /doesn't remember A3 In the last two years, did you go to a CLSC to see a doctor? 1 yes 2 no 8 doesn't know /doesn't remember

A4
In the last two years, did you go to a doctor's office or medical clinic to see a general practitioner or a family physician (other than the CLSC)? (including regular check-ups and follow-ups or for a form to be filled) (Note : including UMF (Family Medicine Unit)) 1 yes 2 no 8 doesn't know /doesn't remember If the respondent did not use medical services in a CLSC or a medical clinic (A3 = 2 or 8 and A4 = 2 or 8), ask A4B then go to A11

A4B
Are you followed by a medical specialist? 1 yes 2 no 8 doesn't know /doesn't remember 2

Identification of usual source of care
The next questions refer to the place you usually go to or the doctor you usually see when you need general medical care. All information is anonymous and confidential, and no personal information will be given to a clinic or doctor. We are now going to talk only about the "Name of the source of care" to get a better idea of the services available.

A6
How long have you been going to this place? 1 less than 2 years 2 2 to 5 years 3 6 to 9 years 4 10 years or more 8 doesn't know /doesn't remember

A7
In the last two years, how many times did you go to this place to seek care for yourself? (Approximately, about) 1 once 2 2 to 5 times 3 6 to 9 times 4 10 times or more 8 doesn where you go, you can't have a regular physician 6 you're being followed by one or several specialists 97 others, Specify __________________________________________ 98 doesn't know /doesn't remember If the respondent is a non user of services (A3 = 2 or 9 and A4 = 2 or 9) or doesn't have a regular source of care in a medical clinic (A5 ≥ 4 and A5B ≥ 4), go to C1 If not, go to B1 For people who did not use services in the past two years and for respondents who don't have a regular source of care:

A11
Do When you go to the («Name of the source of care»), tell me if the following statements apply always, often, sometimes or never.

Informational continuity
The following questions are about other services you might have received.

B46
During the past two years, did you go for any lab tests or radiological examinations prescribed by a doctor at («Name of the source of care»)? (Labs tests : blood or urine tests ; Radiological examinations : X-ray or ultrasound. Radiological exams also include: scanner, magnetic resonance, Doppler, scintigraphy, colonoscopy, mammography, etc.) 1 yes 2 no Go to B50 8 doesn't know /doesn't remember Go to B50 Regarding these tests or exams, tell me if the following statements apply always, often, sometimes or never.

Always Often Sometimes Never
Doesn't know /Doesn't remember B47 Someone at («Name of the source of care») called you or met with you to give you the results of these tests or exams We would like to know the reasons why you didn't see a doctor. I will read you a list of reasons. Tell me if they apply to your situation.

Yes No
Doesn't know /Doesn't remember C8 You have an appointment but have not seen the doctor yet

Section D -Health status
We still have a few questions about your health status and prevention.

D1
In general, would you say your health is... 1 excellent 2 very good 3 good 4 average 5 poor 8 doesn't know /doesn't remember

D2
Can I please confirm that you are a… 1 male 2 female (Note : this question is asked at the beginning of the interview)

D3
How old are you?
The following questions are about current restrictions in your daily activities caused by a health problem or condition that has lasted or will last 6 months or more.
Are you limited in your daily activities due to… The next questions are about various health problems. We would like to remind you that this information is going to be treated anonymously.

D6
Has a doctor ever told you that you have high blood pressure or hypertension?

Note : This section concerns only users of health services who have an eligible usual source of care (A5 or A5b = 1 or 2 or 3) located in Montréal or Montérégie.
The following section looks at preventive health services you obtained at the («Name of the source of care»), either from a doctor or from a nurse.

E1
When was the last time someone talked with you about your diet and eating habits? When did you quit smoking? 1 less than 1 year ago 2 between 1 and 2 years ago 3 more than 2 years ago 8 doesn't know /doesn't remember

E8
At the («Name of the source of care»), when was the last time you were asked whether you smoked? 1 less than 1 year ago 2 between 1 and 2 years ago 3 more than 2 years ago 4 it never happened 8 doesn't know /doesn't remember Note: The following questions are for smokers or ex-smokers who quit less than 2 years ago (E5 = 1 or E7 = 1 or 2). For other respondents, go to E10

E9
When was the last time you were recommended to quit smoking? 1 less than 1 year ago 2 between 1 and 2 years ago 3 more than 2 years ago 4 it never happened 8 doesn't know /doesn't remember

HBP screening
The next questions are about screening for some health problems.

E10
At the («Name of the source of care»), when was the last time someone measured your blood pressure? 1 less than 1 year ago 2 between 1 and 2 years ago 3 more than 2 years ago 4 never 8 doesn't know /doesn't remember

E13
At («Name of the source of care»), when was the last time you were advised to pass a mammography? (that is, an x-ray to detect breast cancer) 1 in the last 2 years 2 more than 2 years ago 3 never 8 doesn't know /doesn't remember Colorectal cancer screening (for people aged 50 and over only) The next questions are about colon and rectal cancer.

E14
When was the last time you were prescribed a test to detect blood in your stools? 1 in the last 2 years 2 more than 2 years ago 3 never 8 doesn't know /doesn't remember

E15
When was the last time you were advised to pass a colonoscopy? (that is, an exam where a long tube is introduced into the rectum in order to see the interior of the intestine) (If the respondent says he (she) has passed a sigmoidoscopy, consider it as a colonoscopy) 1 in the last 5 years 2 between 6 and 10 years ago 3 more than 10 years ago 4 never 8 doesn't know /doesn't remember Dyslipidemia screening (for women aged 50 to 70 or men aged 40 to 70 only)

E16
When was the last time you were prescribed a blood test to measure your cholesterol level? (Only if necessary : lipids or fat in the blood) 1 in the last 3 years 2 more than 3 years ago 3 never 8 doesn't know /doesn't remember Diabetes screening (for people aged 40 and over only)

E17
When was the last time you were prescribed a test to measure your blood sugar level (glycaemia)? 1 in the last 3 years 2 more than 3 years ago 3 never 8 doesn't know /doesn't remember

E18
Over the past year, were you vaccinated against influenza A H1N1 (pandemic)? (At the clinic or elsewhere) 1 yes 2 no 8 doesn't know /doesn't remember

E19
At the («Name of the source of care») when was the last time you were vaccinated against seasonal flu (this vaccine is usually given in the fall) or the last time you were advised to get this vaccine? 1 less than 1 year ago 2 between 1 to 2 years ago 3 more than 2 years ago 4 never 8 doesn't know /doesn't remember