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Patient and physician-level factors associated with adherence to C-CHANGE recommendations in primary care settings in Ontario


Background — We previously found large variation amongst family physicians in adherence to the Canadian Cardiovascular Harmonization of National Guidelines Endeavour (C-CHANGE). We assessed the role of patient- and physician-level factors in the variation of adherence to recommendations for managing cardiovascular disease risk factors.

Methods — We conducted a retrospective study using multilevel logistic regression analyses with the Electronic Medical Record Administrative data Linked Database (EMRALD®) housed at ICES in Ontario. Five quality indicators (QIs) based on C-CHANGE guidelines were modelled. Effects of clustering and between-group variation, patient-level (sociodemographics, comorbidities) and physician-level characteristics (demographic and practice information) were assessed to determine odds ratios of receiving C-CHANGE recommended care.

Results — 324 Ontario physicians practicing in 41 clinics who provided care to 227,999 adult patients were studied. We found significant variation in QIs, with 15% to 39% of the total variation attributable to non-patient factors. The largest variation was in performing 2-hour plasma glucose testing in prediabetic patients. Patient-level factors most frequently associated with recommendation adherence included sex, age, and multi-comorbidities. Women were more likely than men to have their BMI measured, and their blood pressure controlled, but less likely to receive antiplatelets and liver enzyme testing if overweight or obese.

Conclusions — The majority of variation in adherence were attributable to patient attributes, but a substantial proportion of unexplained variation remained due to differences between physicians and clinics. This may signal suboptimal processes or structures and warrant further investigation to improve the quality of primary care management of cardiovascular disease in Ontario.



Lee TM, Tobe SW, Butt DA, Ivers NM, Gershon AS, Barnsley J, Liu P, Jaakkimainen L, Walker K, Tu K. CJC Open. 2020; 2(6):563-76. Epub 2020 Jul 16.

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