Identification, summary and comparison of tools used to measure organizational attributes associated with chronic disease management within primary care settings.

RATIONALE, AIMS AND
OBJECTIVES: Given the increasing emphasis being placed on managing patients with chronic diseases within primary care, there is a need to better understand which primary care organizational attributes affect the quality of care that patients with chronic diseases receive. This study aimed to identify, summarize and compare data collection tools that describe and measure organizational attributes used within the primary care setting worldwide.
METHODS: Systematic search and review methodology consisting of a comprehensive and exhaustive search that is based on a broad question to identify the best available evidence was employed.
RESULTS: A total of 30 organizational attribute data collection tools that have been used within the primary care setting were identified. The tools varied with respect to overall focus and level of organizational detail captured, theoretical foundations, administration and completion methods, types of questions asked, and the extent to which psychometric property testing had been performed. The tools utilized within the Quality and Costs of Primary Care in Europe study and the Canadian Primary Health Care Practice-Based Surveys were the most recently developed tools. Furthermore, of the 30 tools reviewed, the Canadian Primary Health Care Practice-Based Surveys collected the most information on organizational attributes.
CONCLUSIONS: There is a need to collect primary care organizational attribute information at a national level to better understand factors affecting the quality of chronic disease prevention and management across a given country. The data collection tools identified in this review can be used to establish data collection strategies to collect this important information.

Introduction

Chronic diseases are currently the highest cause of preventable death worldwide, accounting for approximately 36 million deaths annually [1]. Within Canada, 3 out of 5 individuals currently have a chronic disease and the management of chronic diseases accounts for approximately 40–70% of total health care costs [2,3]. As the population ages and the rates of obesity continue to rise, the prevalence and costs associated with chronic diseases will continue to increase. The appropriate management of patients with chronic diseases within the primary care setting can reduce the utilization of health care resources and improve patient outcomes [4]. The delivery of high-quality care to patients with chronic diseases is therefore pivotal to the health and well-being of this patient population, and is an integral component of health care systems worldwide. Given that patients with chronic diseases are primarily managed within the primary care setting 5–8, there is a need to better understand which primary care organizational attributes affect the quality of care that patients with chronic diseases receive.

In general, organizational attributes can be defined as characteristics and structures that are intrinsic to the organization and delivery of care at a practice level. A wide range of innovative organizational attributes, including the addition of allied health care professionals to form multidisciplinary primary care teams, the utilization of electronic medical records (EMRs), changes in physician payment models and extended opening hours, have been implemented within primary care to address the increasing burden that patients with chronic diseases place on the health care system [3,9]. Many of these organizational strategies have purportedly increased access to health care services, enhanced the efficiency of resource utilization and improved chronic disease management 3,9–15. In Canada and many other countries, the implementation of these organizational strategies has occurred at a jurisdictional level, resulting in substantial variability in the chronic disease management delivery models and strategies used in primary care practices across different jurisdictions. Importantly, this variability provides an opportunity to determine which primary care organizational attributes support high-quality care for patients with chronic diseases.

There is currently limited information regarding the distribution and nature of primary care organizational attributes, which has made it difficult to study their effects on chronic disease management. This gap in knowledge may be the result of the variability in tools used to assess a wide range of organizational attributes, the collection of data at jurisdictional levels rather than national levels, and inconsistent and incomplete descriptions of organizational attributes within primary care. The present study aimed to identify, summarize and compare organizational attribute tools associated with chronic disease management that have been used within the primary care setting worldwide.

Methods

Literature search strategy

This study used systematic search and review methodology, as described by Grant and Booth [16]. Systematic search and review methodology consists of a comprehensive and exhaustive search that is based on a broad question to identify the best available evidence. Unlike systematic reviews, the topic area in a systematic search and review is not sharply focused, and considers a wide range of study designs for inclusion, and does not require included articles to undergo critical appraisal [16]. This type of review was necessary to ensure that all existing primary care organizational attribute data collection tools were captured, regardless of their quality or the quality of the study in which they were used within. In addition, prior to study commencement, the Cochrane Database of Systematic Reviews [17] and the Joanna Briggs Institute Library of Systematic Reviews [18] were searched and no previous systematic reviews on this topic were identified.

The search strategy aimed to find both published and unpublished studies. An initial search of MEDLINE, Embase and CINAHL was undertaken to identify optimal search terms by examining words contained in the title and abstract, and indexing words of relevant articles. Initial search terms were ‘data collection’, ‘chronic disease’, ‘disease management’, ‘delivery of health care’, ‘chronic disease management’ and ‘organizational attribute’. A second extensive search was conducted applying all of the identified search terms and syntax as required by each database. A complete outline of the search terms and syntax used within each database can be found in Supporting Information Table S1. The databases searched included MEDLINE, CINAHL, Embase, HealthStar, Global Health, PsycINFO, Health and Psychosocial Instruments, and Google Scholar. In addition, reference lists of all relevant articles were searched, and full texts of studies deemed relevant were retrieved to determine eligibility to be included in the review. Key author and journal searches were also conducted, and relevant articles were retrieved and assessed for inclusion. Subsequently, grey literature databases, including Grey Matters, Mednar and ProQuest, and health care-related web sites on the worldwide web, including the Association of Ontario Health Centers, Ontario Ministry of Health and Long-Term Care, Canadian Foundation for Healthcare Improvement, Canadian Institute for Health Information, Canadian Nurses Association, the Commonwealth Fund, the Netherlands Institute for Health Services Research and the World Health Organization (WHO), were searched for relevant articles, documents or reports. Additional database searches were conducted once an exhaustive list of organizational attribute data collection tools was developed to ensure that all published articles that used the identified organizational attribute tools were captured. The search terms included in this phase of the study included a combination of the name of the tool, abbreviations used for the tool and alternate names that have been given to the tool (e.g. modified versions). Many organizational attribute tools were not readily available in the published studies and, as a result, the corresponding authors were contacted to request a copy of the tool. This also provided an opportunity to verify with the authors that all relevant articles that used the tool were captured in our search, and in some instances, the corresponding authors provided citations to additional articles that used the tool that had not been previously identified.

Study inclusion criteria

Articles were considered for inclusion if they were specific to the primary care setting and if they identified the name of an organizational attribute tool, even if it was not discussed in detail, if they discussed any aspect of the development of an organizational attribute tool or if they discussed any psychometric properties associated with an organizational attribute tool. Only tools that were intended to be completed by clinic administrative personnel or health care providers were included.

This systematic search and review considered studies that identified tools that collected information on organizational attributes, including those identified within the chronic care model (CCM) [7] and the conceptual framework for primary care organizations [19]. Within the CCM, certain primary care practice organizational attributes are required to ensure appropriate prevention and management of chronic diseases within the primary care setting. These key primary care organizational attributes include self-management support, delivery system design, decision support and clinical information systems [7]. With respect to the conceptual framework for primary care organizations, only studies that identified tools that specifically focused on the ‘organization of the practice’ components from the structural domain were included as they are intrinsic to the primary care practice setting and are important in the delivery of high-quality care for patients with chronic diseases [19].

The primary outcome was to identify and provide an overall description and comparison of primary care organizational attribute tools. Therefore, this systematic search and review considered studies that included any of the following information related to organizational attribute tools: author(s) and/or developer(s), including contact information for corresponding author to acquire a copy of the tool; location of publication; name of the instrument; country of origin; theoretical foundation; setting in which the tool was used; length (e.g. number of items, time it takes to complete the tool); language translations; administration and completion methods; scoring instructions; psychometric properties; clinical applicability (e.g. ease of completion, feasibility of administration, ability to be replicated); description of specific organizational attributes the tool captured; and identification of multidisciplinary elements within the tool.

In accordance with systematic search and review methodology [16], this review considered a range of quantitative study designs including quasi-experimental designs, cohort studies, case control studies, cross-sectional studies, case series, case reports, expert opinions and reports. Qualitative studies were excluded. Only articles written in the English language were included due to lack of resources available to translate information; however, articles were not limited by location of publication. Only articles published prior to April 2013 were included. Unpublished articles were considered for inclusion if a copy of the manuscript was accessible from the authors.

Titles and abstracts were reviewed for relevancy by two independent reviewers, and articles that were deemed relevant were retrieved and assessed for inclusion using pre-established selection criteria. Disagreements that arose between the reviewers were resolved through discussion. The methodological quality of each study was not a focus for the inclusion of the article [16], as the overall aim of this study was to identify and provide an overall description and comparison of primary care organizational attribute tools.

Data extraction and synthesis

Data extracted included specific details about the organizational attribute tools. Given the heterogeneity of the studies included with regard to the use of different methodologies, study populations, interventions and outcomes, findings are reported as a narrative summary and include tables and figures to aid in data presentation where appropriate [16].

The organizational attributes measured within each tool were categorized based on a classification system established in a recent scoping review that was conducted on a similar topic [20]. Levesque et al. [20] used a comprehensive process to establish and define organizational concepts used to classify specific attributes captured within tools measuring the attributes and performance of primary health care systems. Specifically, Levesque et al. [20] identified seven organizational concepts including identification of the organization, practice context, organizational vision, organizational resources, organizational structures, service provision and clinical practice, and outputs and outcomes. Within each of these concepts, specific organizational attributes have been defined [20].

Results

Overview

Overall, 152 articles and reports, including three review articles 20–22, met the inclusion criteria for this systematic search and review. Thirty-four articles that were deemed relevant to be included in this systematic search and review had to be excluded because a copy of the organizational attribute data collection tool could not be located in the peer-reviewed literature, and attempts to contact the corresponding author(s) were unsuccessful. A flow diagram providing a detailed breakdown of the search results is located in Fig. 1.

Figure 1

Flow chart of search results.

A total of 30 organizational attribute data collection tools that have been used within the primary care setting worldwide were identified (Table 1). A breakdown of the specific organizational attributes captured within each data collection tool is presented in Table 2. Overall, the most common attributes captured by the data collection tools were technical organizational resources (93%), clinical processes (90%) and quality improvement and patient safety mechanisms (90%) (Table 2). The percentage of attributes captured by each data collection tool is displayed in Fig. 2. The remainder of the results section will serve to emphasize details of the most relevant data collection tools identified from each region. The reader is encouraged to look through Supporting Information Table S2 for a detailed description of each of the tools.

Table 1

List of organizational attribute data collection tools

Region	Study or data collection tool	Developer and/or organizational affiliation/sponsor	References
International	Quality and Costs of Primary Care in Europe	Coordinated by the Netherlands Institute for Health Services Research (NIVEL)	[30,31]
	International Survey of Primary Care Doctors	The Commonwealth Fund, Harris Interactive	[23–29]
	World Health Organization (WHO) Primary Care Evaluation Tool	Regional Office for Europe of the World Health Organization; the NIVEL	[32–41]
Canada	Primary Health Care Practice-Based Surveys	Canadian Institutes of Health Information	[20,56,57]
	Primary Care Network Survey	University of Calgary, Alberta	[42]
	Organizational Questionnaire	Institut national de santé publique du Québec	[48–53]
	Primary Care Organization Surveys	Nova Scotia Department of Health	[55]
	Comparison of Models of Primary Health Care in Ontario	University of Ottawa; Elisabeth Bruyère Research Institute	[11–13,44–46]
	The Management of Patients with Chronic Illness	University of Alberta	[43]
	Accessibility and Continuity of Primary Care in Québec	Principal investigator: Jeannie Haggerty, Centre de recherche du Centre hospitalier de l'université de Montreal	[54]
	Survey of Primary Care Practices in Ontario	Collaborative project of the University of Toronto, University of Western Ontario, and McMaster University	[47]
United States of America	Translating Research into Action for Diabetes	Study Coordinating Center: University of Medicine and Dentistry of New Jersey	[82–86]
	Primary Care Depression Management Organizational Survey	Corresponding author: Dr. Edward P. Post, University of Michigan and Ann Arbor Veterans Affairs Medical Centre	[99]
	Prescription for Health Independent Evaluation	Robert Wood Johnson Medical School, University of Medicine and Dentistry of New Jersey	[96,97]
	Physician Practice and Quality of Care Survey	Corresponding author: Dr. Mark Friedberg, RAND Corporation	[120]
	Chronic Disease Prevention and Control Healthcare Practice Surveys	Washington State Department of Health	[98]
	National Survey of Physician Organizations and the Management of Chronic Illness	University of California, Berkeley, support of the Robert Wood Johnson Foundation	[87–95]
	Assessment of Chronic Illness Care	McColl Institute for Healthcare Innovation, Group Health Cooperative	[58–73,79,121–132]
	Improving Chronic Illness Care Evaluation Survey	Robert Wood Johnson Foundation; University of California, Berkeley	[66]
	1999 Veterans Health Affairs Survey of Primary Care Practices	Veterans Affairs Health Services Research and Development Center of Excellence for the Study of Healthcare Provider Behaviour	[133–135]
	Medical Group Practice Organization Survey	Corresponding author: Dr. Kralewski, Division of Health Services Research and Policy, University of Minnesota	[100,136–138]
	Minnesota Health Care Survey for Physicians	Corresponding author: Dr. Nancy Keating, Harvard Medical School	[139]
	Primary Care Access Study	Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, School of Medicine	[101]
	Primary Care Assessment Tool	Developed by Dr. Barbara Starfield	[102–107]
Europe	Improving Quality of Care in Diabetes	Institute of Health and Society, Newcastle University; Newcastle Primary Care Trust	[108,140,141]
	National Survey of the Provision of Diabetes Services	Nuffield Institute for Health, University of Leeds, Leeds, West Yorkshire, England	[109,110]
	WHO Primary Care Quality Management Tool	Regional Office for Europe of the World Health Organization; the NIVEL	[74,111]
	Survey of the Provision of Diabetes Services in Galway City and County	Corresponding author: Dr. Evans, Department of Public Health, Merlin Park Hospital, Galway, Republic of Ireland	[75,76]
	National Survey of Chronic Disease Management in General Practice	Department of Public Health and Primary Care, Trinity College Dublin	[77,78]
Australia	General Practice Chronic Care Team Profile	Centre of Primary Health Care and Equity, University of New South Wales	[80,81,112,113]

Table 2

Organizational attributes covered in data collection tools

	Identification of the organization			Practice context			Organizational resources					Organizational structures				Service provision and clinical practice				Outputs
							Human
	Survey respondent	Location	History and evolution of the clinic	Demographic characteristics	Environment and practice integration	Organizational vision	GPs	Nurses	Other	Economic	Technical	Governance and administration	Funding mechanisms	Clinical processes	QI and patient safety mechanisms	Scheduling and opening hours	Type and range of services	Specific disease management	Degree of integration	Accessibility	Functioning and climate
Percentage of tools measuring attribute (%)	77	53	37	33	63	27	77	77	70	20	93	77	53	90	90	43	53	70	67	60	20
QUALICOPC	+				+		+	+	+		+		+	+	+	+	+	+	+	+
International Survey of Primary Care Doctors	+				+		+	+	+		+	+	+	+	+	+			+	+	+
WHO Primary Care Evaluation Tool	+			+	+		+	+	+		+	+		+	+	+	+	+	+	+
Primary Health Care Practice-Based Surveys	+	+	+		+	+	+	+	+	+	+	+	+	+	+	+	+	+	+	+	+
Primary Care Network Survey	+	+					+	+	+		+			+	+			+
Organizational Questionnaire		+	+		+	+	+	+			+	+	+	+	+	+	+	+	+	+
Primary Care Organization Surveys	+			+	+	+					+	+		+	+	+	+	+	+	+	+
COMP-PC	+		+		+		+	+	+	+	+	+	+		+	+	+			+
The Management of Patients with Chronic Illness	+					+	+	+	+		+		+	+	+				+
Accessibility and Continuity of Primary Care in Quebec		+			+	+	+	+	+		+	+		+		+	+			+
Survey of Primary Care Practices in Ontario	+	+	+	+			+	+	+	+	+	+	+	+	+	+	+	+		+
Translating Research into Action for Diabetes	+		+	+			+	+	+	+	+	+	+	+	+		+	+	+
Primary Care Depression Management Organizational Survey	+	+			+		+	+	+		+			+	+			+	+
Prescription for Health Independent Evaluation	+	+	+	+	+	+	+	+	+		+	+		+	+			+	+		+
Physician Practice and Quality of Care Survey					+		+	+	+		+		+	+	+	+		+	+	+
Chronic Disease Prevention and Control Healthcare Practice Surveys	+	+	+	+							+	+		+	+		+	+	+
NSPO and the Management of Chronic Illness	+	+	+	+	+		+	+		+	+	+	+	+	+			+			+
Assessing Chronic Illness Care	+	+				+					+	+		+	+			+	+
ICICE Survey	+				+					+	+	+	+		+				+
1999 VHA Survey of Primary Care Practices	+	+	+		+		+	+	+		+	+	+	+	+		+	+	+	+
Medical Group Practice Organization Survey							+	+	+		+	+	+	+	+			+		+
Minnesota Health Care Survey for Physicians	+	+					+	+	+		+	+	+	+	+			+	+
Primary Care Access Study	+	+	+		+		+	+	+		+			+		+	+			+
Primary Care Assessment Tool	+	+			+								+	+	+	+	+		+	+
Improving Quality of Care in Diabetes	+		+	+	+	+	+	+	+		+	+		+	+		+	+			+
National Survey of the Provision of Diabetes Services		+		+	+		+	+	+		+	+		+	+	+	+	+	+	+
WHO Primary Care Quality Management Tool	+						+	+	+			+	+	+	+
Survey of the Provision of Diabetes Services in Galway City and County				+							+	+					+	+	+	+
National Survey of Chronic Disease Management in General Practice	+	+			+						+	+		+	+			+	+	+
General Practice Chronic Care Team Profile							+	+	+		+	+		+	+					+

COMP-PC, Comparison of Models of Primary Health Care in Ontario; GP, general practitioner; ICICE, Improving Chronic Illness Care Evaluation; NSPO, National Survey of Physician Organizations and the Management of Chronic Illness; QI, quality improvement; QUALICOPC, Quality and Costs of Primary Care in Europe; VHA, Veterans Health Affairs.

Figure 2

Percentage of organizational attributes captured within each data collection tool. Each percentage was calculated based on the 19 organizational concepts identified in Table 2. The Canadian Primary Health Care Practice-Based Surveys covered the most organizational attributes.

International

Three international primary care organizational attribute tools, including the International Survey of Primary Care Doctors 23–29, the Quality and Costs of Primary Care in Europe (QUALICOPC) study [30,31] and the WHO Primary Care Evaluation Tool (PCET) 32–41 were identified (Table 1).

The International Survey of Primary Care Doctors was developed by the Commonwealth Fund in the United States and was first used in 2006 to describe primary care organizational attributes that affect the practice's capacity to manage patient care and support quality improvement initiatives. It has also been used to address physicians' views and experiences towards patient access, health information technology capacity, communication across health care sites, feedback related to practice performance, their satisfaction practicing medicine and the overall health care system. The International Survey of Primary Care Doctors was updated in 2009 and 2012, and the most recent version of this survey was administered to primary care physicians in Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Switzerland, Sweden, United Kingdom and the United States to collect information on primary care organizational attributes within these countries [25]. The International Survey of Primary Care Doctors provided respondents with several completion options, including mail, online and telephone or in-person interviews with general practitioners (GPs).

The QUALICOPC study was performed by the Netherlands Institute for Health Services Research to describe, compare and analyse how primary health care systems perform in terms of quality, costs and equity across 35 countries, including Australia, Canada, Iceland, Macedonia, New Zealand, Norway, Switzerland, Turkey and 27 countries of the European Union. Four questionnaires were developed as part of the QUALICOPC tool, namely, a practice questionnaire, a GP questionnaire, a patient experiences questionnaire and a patient values questionnaire. The questionnaires were developed through an iterative and comprehensive process involving a literature search, consensus process and pilot survey, and are based on existing validated questionnaires including Starfield's Primary Care Assessment Tool and surveys developed by the Commonwealth Fund. The QUALICOPC questionnaires were paper based and were developed and administered between 2010 and 2013 [30,31]. No studies reporting the findings from these questionnaires were identified in the present systematic search and review.

The development of the WHO PCET was based on the Primary Care Evaluation Framework and a comprehensive literature review. The WHO PCET has been administered in several countries worldwide including Belarus, Kazakhstan, Moldova, Romania, Russia, Serbia, Slovakia, Turkey and Ukraine. It consists of three instruments to evaluate the complexity of the primary care system: a questionnaire to be administered at a national level concerning the situation of primary care policies, a questionnaire for family doctors and a questionnaire for patients. The questionnaire for family doctors is the component of the WHO PCET tool that inquires about organizational attributes that are intrinsic to the practice setting. In 2007 and 2008, the WHO PCET was pilot tested in Turkey and Moscow Oblast. Based on results from the pilot test, modifications to the questionnaire for family doctors were made to make it more factual and clear, its length was reduced by removing questions that were considered to be outside of the scope of family doctors and the terminology utilized throughout the questionnaire was changed to make it more consistent. The content within the questionnaires has been validated by international experts in primary care.

Common gaps in organizational attribute data collected across all three of the international tools related to practice location, history and evolution of the clinic, organizational vision, and economic resources (Table 2).

Canada

Within Canada, eight primary care organizational attribute data collection tools were identified (Table 1). Seven of these tools collected primary care organizational attribute information at a jurisdictional level within the provinces of Alberta [42,43], Ontario 11–13,44–47, Québec 48–54 and Nova Scotia [55].

The Primary Health Care Practice-Based Surveys were the only Canadian tool that was intended to measure primary care characteristics nationally to enable a comprehensive assessment of outcomes, and support the identification of contributing factors. The Primary Health Care Practice-Based Surveys were developed in 2013 based on the framework for primary care organizations, the results-based logic model for primary health care, a scoping review, existing survey tools and feedback from relevant stakeholder groups across Canada [20,56,57]. This tool is available in English and French, and is composed of an organizational-level survey, a provider-level survey and a patient-level survey that can be used separately or together. The organizational-level survey contains questions that provide information on basic practice characteristics, organizational vision, organizational resources, economic resources, technical resources, organizational structures, service provision and clinical practices, and organizational context. It is intended to be completed by an individual who is most familiar with how the primary care practice is organized and operates. The provider-level survey contains questions that provide information on provider demographics, structure and organization of the practice, team functioning, and health care service delivery, and is intended to be completed by all health care providers at the clinic who care for patients. No studies that used the Primary Health Care Practice-Based Surveys were identified in the present systematic search and review, and the psychometric properties of these surveys have yet to be assessed in detail. The Primary Health Care Practice-Based Surveys was the only tool identified in this systematic search and review that collected information on nearly all of the organizational concepts identified in Levesque et al.'s [20] classification system (Fig. 2; Table 2). ‘Demographic characteristics’ of the population or patients served by the practice was the only organizational attribute not captured by this tool (Table 2).

United States

Thirteen primary care organizational attribute data collection tools that originated from the United States were identified (Table 1). The organizational attribute data collection tool that was cited the most in publications (n = 30) of this systematic search and review was the Assessment of Chronic Illness Care (ACIC) survey developed by the MacColl Institute for Healthcare Innovation, Group Health Cooperative 58–73,79,121–132. The ACIC tool was developed in 2000 to help primary care organizations evaluate strengths and weaknesses of their delivery of care for individuals with chronic diseases. The ACIC tool, which is based on the CCM, includes questions that address six elements of the CCM that purportedly relate to the quality of chronic disease prevention and management care, namely, community linkages, self-management support, decision support, delivery system design, clinical information systems and organization of care. The ACIC has very clear completion and scoring instructions and consists of Likert-type scales that range from 0, meaning that the practice has limited support for chronic disease management, to 11, meaning that the practice has fully developed chronic disease management care practices. Previous studies have suggested that the ACIC tool is responsive to changes that result from health care quality improvement efforts and may be a useful tool to guide and monitor quality improvement efforts over time. Specifically, the ACIC tool has been associated with clinical outcomes related to diabetes and cardiovascular care [59,60,62,67,69,70,73,121,122,125,127,132]. For example, patients who attended primary care clinics who had higher ACIC scores had better managed diabetes as indicated by their haemoglobin A1C values than patients who attended primary care clinics with lower ACIC scores [121,122]. However, the ACIC survey only provides a generic assessment of the quality of chronic disease care. The ACIC captured less than 50% of organizational concepts identified by Levesque et al. [20] (Table 2; Fig. 2).

In addition to the ACIC survey, five American organizational attribute data collection tools were also developed based on the CCM, including the surveys used in the Translating Research into Action for Diabetes (TRIAD) study 82–86, the National Survey of Physician Organizations and the Management of Chronic Illness 87–95, the Prescription for Independent Evaluation Surveys [96,97], Chronic Disease Prevention and Control Healthcare Practice Survey [98], and the Improving Chronic Illness Care Evaluation Survey [66]. There were two American data collection tools found that were developed to measure disease-specific primary care organizational attributes, namely, the surveys utilized within the TRIAD study 82–86 and the Primary Care Depression Management Organizational Survey [99].

Europe

Five primary care organizational attribute data collection tools from Europe met the selection criteria for inclusion in this study (Table 1). Three of these tools assessed organizational attributes that specifically related to diabetes care, namely, the questionnaires used within the Improving Quality of Care in Diabetes Study [108,140,141], the National Survey of the Provision of Diabetes Services [109,110] and the Survey of the Provision of Diabetes Services in Galway City and County [75,76]. The most commonly collected organizational attributes within the European tools were related to funding mechanisms, governance and administration, clinical processes, quality improvement, and patient safety mechanisms (Table 2). The WHO Primary Care Quality Management Tool [74,111] and the Survey of the Provision of Diabetes Services in Galway City and County [75,76] captured less than 40% of important organizational concepts [20] (Fig. 2).

Australia

Within Australia, the General Practice Chronic Care Team Profile [80,81,112,113] was the only organizational attribute data collection tool that was identified (Table 1). This structured interview schedule is designed to measure multidisciplinary teamwork structures and functions for chronic disease care in general practice, and takes approximately 15 minutes to complete. The tool is intended to be administered to a principal GP within a primary care setting or a practice manager. It is composed of questions that relate to team functions, non-GP clinical functions and staff management, administrative functions, and practice management structures. It reflects 32% of the organizational attributes identified in the classification system developed by Levesque et al. [20] (Fig. 2). The tool was developed by consulting best-practice guidelines for chronic disease care and performance standards for general practice in Australia and internationally, expert consultations to determine which items were relevant and suitable to be included in the interview schedule, and a pilot test within 11 general practices. Psychometric testing of the General Practice Chronic Care Team Profile identified that it has a Cronbach's alpha of 0.85.

Discussion

Patients with chronic diseases are most effectively managed within the primary care setting 5–8. To determine how to optimize the care for patients that have chronic diseases, it is important to investigate the heterogeneity in organizational attributes within primary care and assess the impact of these attributes on health outcomes within this patient population. This study identified a wide range of comprehensive primary care organizational attribute data collection tools that could feasibly be utilized by clinicians or scientists in this type of evaluation and research. Specifically, 30 organizational attribute data collection tools were identified in this systematic search and review. The review found that the tools varied with respect to overall focus and level of organizational details captured, theoretical foundations, administration and completion methods, length and types of questions asked, and the extent to which psychometric property testing has been completed. Each tool that was identified captures important information about primary care organizational attributes that could be used to better understand the delivery of chronic disease prevention and management within the primary care setting. Given the breadth of organizational attributes that were captured in the data collection tools, the variation between tools and the fact that many of the tools were developed for use within a specific jurisdiction, no one tool was found to be superior for all potential research and clinical applications. Many of the organizational attribute data collection tools identified have the potential to be used or adapted for use for different research purposes. The decision on which tool is most suitable will likely depend on the location in which the clinicians or researchers intend to conduct the research and the attributes in which they are interested in investigating.

It is important to note that several weaknesses with the tools were apparent. For example, not all of the data collection tools were based on existing theoretical frameworks, which may limit their applicability to the primary care setting or chronic disease management. Utilizing a framework to guide the development of a tool is important to help identify variables and understand the relationships between these variables [114]. Furthermore, the most common method of completion was the use of a paper-based postal questionnaire that relied on self-report from respondents and is often associated with low response rates [114]. In addition, many of the data collection tools that were identified were developed over a decade ago and may not accurately reflect current practices and organization within the primary care setting. Recently developed tools, such as the tool utilized within the QUALICOPC study that was implemented between 2010 and 2013 [30,31], and the Canadian Primary Healthcare Practice-Based Surveys that were recently developed and made available for use by researchers, clinicians and decision makers in April 2013 [56,57], are preferable for future studies assessing primary care organizational attributes.

Interestingly, most of the data collection tools that were identified were not disease specific. Only four tools were identified that were specifically developed to measure organizational attributes that related to diabetes care 75,76,82–86,108–110,140,141, and one tool was identified that specifically related to the management of patients with depression [99]. Instead, many of the data collection tools were designed to collect organizational attribute information that could be utilized to better understand the management of several chronic diseases and incorporated disease-specific questions, such as questions specifically related to diabetes, hypertension, asthma and/or cardiovascular disease. It is important to collect organizational attribute information that is related to multiple chronic diseases given that patients are often affected by more than one chronic condition [115].

Organizational attribute details captured by each tool varied substantially. The most commonly assessed attributes across all of the data collection tools were organizational environment and practice integration, human and technical resources, governance and administration, clinical processes, quality improvement and patient safety mechanisms, specific disease management practices, and degree of integration. The data collection tool that contained the most comprehensive description of primary care organizational attributes, as identified by the classification system developed by Levesque and colleagues [20], was the Canadian Primary Health Care Practice-Based Surveys [56,57]. This tool does not collect demographic characteristics of the population and patients served by a practice. However, it can be used in combination with its patient-level survey or linked to data from existing data sets that contain patient demographic details. Furthermore, unlike many of the tools that were identified in this study that were intended to measure attributes at a jurisdictional level, the Canadian Primary Health Care Practice-Based Surveys provide an opportunity to identify organizational attributes at a national level, and to make comparisons across different jurisdictions in Canada [56,57].

This review found only one organizational attribute data collection tool developed within Australia [80,81,112,113]. It is possible that fewer organizational attribute data collection tools have been developed in certain countries over the past decade because there are well-established data collection programmes already in place. For example, the Bettering the Evaluation and Care of Health (BEACH) programme has been used in Australia since 1998 to measure primary care organizational attributes, among other variables [116]. Researchers worldwide have been working towards establishing nationwide databases to monitor and evaluate the management of patients within a given population. Establishing a method to obtain national-level data within the primary care setting has become increasingly of interest to health care providers and researchers seeking to improve the quality of care delivered. There are several research networks that have been successful at conducting health surveillance research projects, such as the Clinical Practice Research Datalink in the United Kingdom [117], the European Practice Assessment [118], the Netherlands Information Network of General Practice [119] and the BEACH project in Australia [116].

The Canadian Primary Care Sentinel Surveillance Network (CPCSSN) is Canada's first and only chronic disease EMR surveillance system. It is an initiative established in 2008 that is funded by the Public Health Agency of Canada through a contribution agreement with the College of Family Physicians of Canada. One of the main purposes of CPCSSN is to enhance the effectiveness and efficiency of primary health care delivery, and to improve patient and system outcomes across the country by creating a platform for research, surveillance and education. It is currently composed of 10 practice-based research networks across eight provinces in Canada. CPCSSN collects information on all clinical encounters for all patients visiting practices of sentinel physicians but is specifically focused on the following eight chronic conditions: chronic obstructive pulmonary disease, depression, epilepsy, parkinsonism, dementia, osteoarthritis, hypertension and diabetes [142,143]. The CPCSSN currently has a short questionnaire that is administered to primary care practices affiliated with their network to acquire general demographic information. To best inform quality improvement strategies, a more comprehensive organizational attribute data collection tool would allow us to determine the distribution and nature of primary care organizational attributes across Canada and those organizational attributes associated with optimal health outcomes of patients with chronic diseases.

Strengths and limitations

Despite utilizing a comprehensive search strategy [16], it is possible that there are primary care organizational attribute data collection tools that were not captured in this systematic search and review. Furthermore, reporting on the various elements of each tool was restricted to the extent to which information was available within the articles. Lack of data pertaining to the psychometric properties of the tools limited our ability to assess the quality of many of the organizational attribute data collection tools identified. In addition, two concepts from the classification system established by Levesque et al. [20] were excluded in this study as none or few studies included questions pertaining to them (i.e. sustainability and efficacy, readiness to change and capacity for adaptation) [20].

Despite the limitations associated with this study, the findings provide a thorough description of organizational attribute data collection tools that have been developed and/or used within the primary care setting worldwide. Systematic search and review methodology [16] was utilized to ensure that a complete list of organizational attribute data collection tools was found, and many of the tools that were identified were recent and widely used within the primary care setting. Furthermore, this study categorized the concept of ‘organizational human resources’ to identify the extent in which the tools captured information related to GPs, nurses and other health care or administrative staff within the practice. This review also highlights that there are different approaches to measuring organizational attributes within primary care. Researchers, primary care health care providers and stakeholder groups can use the findings from this study to obtain important information about primary care organizational structures and characteristics with the aim of improving the overall delivery of health care services for patients who have chronic diseases.

Conclusion

Thirty primary care organizational attribute data collections tools were identified in this systematic search and review that have been used in several countries worldwide. No single tool is recommended for use by clinicians or scientists as the decision on which tool to use or adapt will depend on the country of origin and the organizational attributes that are of most interest to capture in each study. The tool that was most recently developed and that captured the most organizational attributes was the Canadian Primary Health Care Practice-Based Surveys. Many of the tools that were identified have been used at a jurisdictional level. There is a need to collect organizational attribute information at a national level to better understand the management of chronic diseases across countries. Although there are existing databases in certain countries that collect information related to primary care organizational attributes, there is no existing platform in Canada. The data collection tools identified in this review can be used to assist countries in establishing a national-level data collection strategy to collect this important information that can be used to better understand the quality of chronic disease prevention and management.