Total number of rostered patients with primary care visit post acute discharge in a given time period. Selected conditions (select HIGS) are: AMI, stroke, COPD, pneumonia, congestive heart failure, diabetes, cardiac conditions and gastrointestinal disorders.

Selected conditions (select HIGS) are: AMI, stroke, COPD, pneumonia, congestive heart failure, diabetes, cardiac conditions and gastrointestinal disorders.

Inclusions:

• A physician visit is counted if there is a service claim billed by any primary care physician in the group that the patient is enrolled within 0 to 7 days of their discharge from hospital.

• Includes patients rostered at the time of discharge to an Ontario physician in a primary care practice model. Follow up is restricted to professional services provided by any general practitioner, family physician, geriatrician or pediatrician in the practice group to which the patient is rostered. Does not include telephone calls to patients, visits to the family physician in ED, or visits to other non-physician providers.

Exclusions:

• Hospital discharge records with missing or invalid discharge date, admission date, health number, age and gender.
• Ontario Health Insurance Plan (OHIP) claims that are negated, duplicates, physician claims from laboratory groups, and claims paid by the Workplace Safety and Insurance Board (WSIB).

Steps:

Identify enrolled patients with primary care visit within 7 days of discharge to any physician in the group they are enrolled with:

1. Link discharge records for enrolled patient (see denominator) to the Claims History Database on health number to find services billed by an Ontario primary care physician where the service date of the claim is within 7 days of the hospital discharge date. Negated claims, duplicate claims and lab claims are excluded.

2. For clients with services, determine if the billing physician is in the group the patient is rostered to:

a. Link the records of OHIP services 7 days after discharge to the Corporate Provider Database (CPDB) on the billing number of the physician who provided the service.

b. Extract the group membership(s) for that physician and verify if it matches the group number on the patient’s enrollment record.

c. Patients have a visit within 7 days if they have at least one service from a physician in the group that they were enrolled with at the time of discharge.

Total number rostered patients discharged from hospital (select HIGs) in a given time period.

Inclusions:

• Acute inpatients in the specified HBAM Inpatient Grouper (HIGs) enrolled with a primary care physician at the time of discharge.
• Cases that are typical, transfer in, short stay, long stay or long stay transfer in per the HIG atypical indicator (i.e. the HIG atypical indicator must be ‘00’, ‘01’, ‘09’, ‘10’, ‘11’); 3. Included ages are cohort specific: a) patients ≥ 45 for acute myocardial infarction (AMI), stroke, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF); b) patients ≥ 40 for cardiac HIGs, c) all ages for pneumonia, diabetes, and gastrointestinal (GI).