Toward international primary care reform

We want to thank Dr. Barbara Starfield for her insightful Commentary1 about our paper2 in CMAJ May 26. While we agree with the issues she raised, her article contains a misleading statement that the higher rate of visits to emergency departments in capitation was observed only in rural areas. This appears to be the case in Table 4 of the print version, which presents emergency department visits overall and stratified by rurality. Those analyses, however, were not adjusted for provider or patient characteristics. As case mix is an important confounder (capitation patients were healthier than those in enhanced fee-for- service), overall conclusions should be based on the adjusted analysis. In the online version of the results3, we state that "after adjustment for physician and patient characteristics, we found that patients in capitation practices continued to have higher rates of use of emergency department services than patients in enhanced fee-for-service practices. This finding was consistent and significant across all 3 geographic locations." Not presented in the paper, the values adjusted for physician and patient characteristics were: major urban (odds ratio (OR) 0.83, 95% CI 0.79-0.88), non-major urban (OR 0.87, 95% CI 0.86-0.87) and rural areas (OR 0.87, 95% CI 0.81-0.93). All p-values were < 0.001.

1. Starfield B. Toward international primary care reform. CMAJ 2009;181:1091-1092. 2. Glazier RH, Klein-Geltink J, Kopp A, Sibley LM. Capitation and enhanced fee-for-service models for primary care reform: a population-based evaluation. CMAJ 2009;181:1113-1119 3. E72-E81

Richard H. Glazier, MD Senior Scientist, Institute for Clinical Evaluative Sciences, Toronto, Ont. Julie Klein-Geltink MHSc Alexander Kopp, BA Lyn M. Sibley, PhD

Conflict of Interest:

None declared