The first general practitioner hospital in The Netherlands: towards a new form of integrated care?

OBJECTIVE: To describe the types of patients admitted to the first Dutch general practitioner (GP) hospital, their health-related quality of life and its substitute function. DESIGN: A prospective observational study. SETTING: The remaining 20-bed ward of a former district general hospital west of Amsterdam; a region with 62000 inhabitants and 26 GPs. SUBJECTS: All patients admitted during the 12 months between 1 June 1999 and 1 June 2000. MAIN OUTCOME MEASURES: Patients' health-related quality of life (Medical Outcome Study 36-item Short Form Health Survey, Groningen Activities Restriction Scale), GPs assessments of severity of illness (DUSOI/WONCA Severity of Illness Checklist) and alternative modes of care. RESULTS: In total, 218 admissions were recorded divided into 3 bed categories: GP beds (n = 131), rehabilitation beds (n = 62) and nursing home beds (n = 25). The mean age of all patients was 76 years. Main reasons for admission were immobilization due to trauma at home (GP beds), rehabilitation from surgery (rehabilitation beds) and stroke (nursing home beds). Overall, patients showed a poor health-related quality of life on admission. If the GP beds had not been available, the GPs estimated that the admissions would have been almost equally divided among home care, nursing home and hospital care. The severity of the diagnosis on admission of the 'hospital-care group' appeared to be significantly higher than the other care groups. CONCLUSION: The GP hospital appears to provide a valuable alternative to home care, nursing home care and hospital care, especially for elderly patients with a poor health-related quality of life who are in need of short medical and nursing care.     

Factors influencing emergency hospital admissions from nursing and residential homes: positive results from a practice‐based audit

Background and aims Emergency admissions of frail older people in care homes, many of whom have dementia, are critical events which should be avoided if possible. To identify and influence factors related to emergency admissions and place of death. Method Design of study: Completed audit cycle. Setting: Jenner Health Centre patients in six local care homes. Data collection over 12 months in 05/6, repeated in 08/9. Emergency admissions, admitting health professional, assessment prior to admission, length of hospital stay, annual visit workload and place of death. Results Admission numbers fell from 91 (194 patients) in 05/6 to 52 (183 patients) in 08/9, related to a fall in admissions by general practitioners (GPs) and out of hours (OOH). The proportion of admissions by care home staff doubled. There was a highly significant difference (P < 0.001), between GPs and OOH in patients visited prior to admission in 05/6 which persisted in 08/9 (P < 0.01). A hospital stay >72 hours was significantly more likely if patients were visited prior to admission. In 05/6, 55% of deaths occurred in the care home rising to 75.5% in 08/9 (total numbers deaths unchanged). There was a highly significant difference (P < 0.001 05/6 and 08/9), between deaths in nursing compared with residential homes. GP visits to nursing home patients rose by 10.3% but visits to residential home patients fell by 5.4%. Conclusions The aims of the audit were achieved with a 43% reduction in emergency admissions and a 45% reduction in deaths in hospital but at the expense of a 12% increase in visits. Improved anticipatory planning and increased medical and nursing support for patients and staff in residential homes may help to further reduce emergency admissions and deaths in hospital in future.     

Contact with primary health care physicians before an acute hospitalisation

Abstract

Objectives: To assess contacts with general practitioners (GPs), both regular GPs and out-of-hours GP services (OOH) during the year before an emergency hospital admission.

Design: Longitudinal design with register-based information on somatic health care contacts and use of municipality health care services.

Setting: Four municipalities in central Norway, 2012–2013.

Subjects: Inhabitants aged 50 and older admitted to hospital for acute myocardial infarction, hip fracture, stroke, heart failure, or pneumonia.

Main outcome measures: GP contact during the year and month before an emergency hospital admission.

Results: Among 66,952 identified participants, 720 were admitted to hospital for acute myocardial infarction, 645 for hip fracture, 740 for stroke, 399 for heart failure, and 853 for pneumonia in the two-year study period. The majority of these acutely admitted patients had contact with general practitioners each month before the emergency hospital admission, especially contacts with a regular GP. A general increase in GP contact was observed towards the time of hospital admission, but development differed between the patient groups. Patients admitted with heart failure had the steepest increase of monthly GP contact. A sizable percentage did not contact the regular GP or OOH services the last month before admission, in particular men aged 50–64 admitted with myocardial infarction or stroke.

Conclusion: The majority of patients acutely admitted to hospital for different common severe emergency diagnoses have been in contact with GPs during the month and year before the admission. This points towards general practitioners having an important role in these patients’ health care.

• KEY MESSAGES

• There is scarce knowledge about primary health care contact before an emergency hospital admission.

• The percentage of patients with contacts differed between patient groups, and increased towards hospital admission for most diagnoses, particularly heart failure.

• More than 50% having monthly general practitioner contact before admission underscores the general practitioners’ role in these patients’ health care.

• Our results underscore the need to consider medical diagnosis when talking about the role of general practitioners in preventing emergency hospital admissions.

     

Providing palliative care for cancer patients: the views and exposure of community general practitioners and district nurses in Japan

ContextThe role of general practitioners (GPs) and district nurses (DNs) is increasingly important to achieve dying at home.ObjectivesThe primary aim of this region-based representative study was to clarify 1) clinical exposure of GPs and DNs to cancer patients dying at home, 2) availability of symptom control procedures, 3) willingness to participate in out-of-hours cooperation and palliative care consultation services, and 4) reasons for hospital admission of terminally ill cancer patients.MethodsQuestionnaires were sent to 1106 GP clinics and 70 district nursing services in four areas across Japan.ResultsTwo hundred thirty-five GPs and 56 district nursing services responded. In total, 53% of GPs reported that they saw no cancer patients dying at home per year, and 40% had one to 10 such patients. In contrast, 31% of district nursing services cared for more than 10 cancer patients dying at home per year, and 59% had one to 10 such patients. Oral opioids, subcutaneous opioids, and subcutaneous haloperidol were available in more than 90% of district nursing services, whereas 35% of GPs reported that oral opioids were unavailable and 50% reported that subcutaneous opioids or haloperidol were unavailable. Sixty-seven percent of GPs and 93% of district nursing services were willing to use palliative care consultation services. Frequent reasons for admission were family burden of caregiving, unexpected change in physical condition, uncontrolled physical symptoms, and delirium.ConclusionJapanese GPs have little experience in caring for cancer patients dying at home, whereas DNs have more experience. To achieve quality palliative care programs for cancer patients at the regional level, educating GPs about opioids and psychiatric medications, easily available palliative care consultation services, systems to support home care technology, and coordinated systems to alleviate family burden is of importance.     

Subjective Dysfunction after Stroke. A study with Sickness Impact Profile

In 1986, the functional capacity of 124 patients with an acute stroke was assessed one week after admission to Södertelje hospital, Sweden. In order to analyse health-related quality of life, interviews were undertaken to determine sickness impact 6–9 months after stroke. 57 of the 91 surviving patients could participate. 53 persons were living in their own homes. 70% had a clinically significant subjective dysfunction, which correlated both to the objective functional capacity and to age.

Sickness Impact Profile was a useful measure, yielding information of value for planning of long-term rehabilitation and home care.     

First four years of operation of a municipal acute bed unit in rural Norway

Abstract

Objective: To evaluate the use of a small municipality acute bed unit (MAU) in rural Norway resulting from the Coordination reform regarding occupancy-rate, patient characteristics and healthcare provided during the first four years of operation. Further, to investigate whether implementation of the new municipal service avoided acute hospital admissions.

Design: Observational study.

Setting: A two-bed municipal acute bed unit.

Subjects: All patients admitted to the unit between 2013 and 2016.

Main outcome measures: Demographics, comorbidity, main diagnoses and level of municipal care on admission and discharge, diagnostic and therapeutic initiatives, MAU occupancy rate, and acute hospital admission rate.

Results: Altogether, 389 admissions occurred, 215 first-time admissions and 174 readmissions. The mean MAU bed occupancy rate doubled from of 0.26 in 2013 to 0.50 in 2016, while acute hospital admission rates declined. The patients (median age 84.0 years, 48.9% women at first time admission) were most commonly admitted for infections (28.0%), observation (22.1%) or musculoskeletal symptoms (16.2%). Some 52.7% of the patients admitted from home were discharged to a higher care level; musculoskeletal problems as admission diagnosis predicted this (RR =1.43, 95% CI 1.20–1.71, adjusted for age and sex).

Conclusion: Admission rates to MAU increased during the first years of operation. In the same period, there was a reduction in acute hospital admissions. Patient selection was largely in accordance with national and local criteria, including observational stays. Half the patients admitted from home were discharged to nursing home, suggesting that the unit was used as pathway to a higher municipal care level.

• Key Points

• Evaluation of the first four years of operation of a municipality acute bed unit (MAU) in rural Norway revealed:

• ??Admission rates to MAU increased, timely coinciding with decreased acute admission rates to hospital medical wards.

• ??Most patients were old and had complex health problems.

• ??Only half the patients were discharged back home; musculoskeletal symptoms were associated with discharge to a higher care level.

     

The quality of GP consultation in two different salary systems A Finnish experience

Objective – To compare the quality of consultations between two Finnish employment contract systems: the capitation-based contract (CB) and the time-based contract (TB).

Design – Cross-sectional study based on paired questionnaires answered by patients and general practitioners (GPs).

Setting and subjects – 81 GPs with their patients from four health care centres in Finland, 2191 encounters.

Main outcome measures – Both patients’ and GPs’ opinions on the role of personal doctor, medico-professional quality, quality of communication, consultation conditions, economic quality (= number of examinations and treatments), and duration of consultation.

Results – Patients were more satisfied than the doctors with the quality of consultations. We found no differences between the groups in the patients’ opinions on the quality. The GPs in the CB group rated their work quality higher than the GPs in the TB group. The patients’ and the GPs’ understanding of the GP as a personal doctor varied so that the patients considered their GP as their personal doctor more often than the GPs in question.

Conclusions – The GPs with a capitation-based contract evaluated the quality of their work higher than other GPs. Patient satisfaction was not dependent on the GP's contract.     

Health service consumption and parent reported episodes of illness in children 0–3 years

Objective - To describe health service consumption and to find out whether a series of possible explanatory variables can help us to predict the number of contacts among children.

Design - A prospective study following a cohort of children during the first four years of life.

Setting - A municipality in southern Norway.

Participants - 183 children born in the community from October 1979 to and including December 1980.

Main outcome measure - Direct and indirect encounters with general practitioners (GPs) from the bills to the national insurance office, outpatient encounters and hospital admissions from the hospital files, and episodes of illness as reported in postal questionnaires to the parents. Results - Each child had on average 10.6 GP contacts (2.6 per year), and the frequency of contacts decreased as they grew. Telephone contacts were almost as frequent as consultations at the doctor's surgery, and the doctors made more home visits to the youngest children. Of the contacts, 4/5 took place in the day tune, but most of the home visits took place during the evening/night/weekend. Each child had 1.9 hospital contacts in 4 years, i.e. 0.3 admissions and 1.6 outpatient department contacts.

The parents reported an average of 11.5 episodes of illness during the period, more than twice as many in the first year as in the last year. Information about sex, duration of breast feeding, smoking in the family, family history of allergy, parents' education, whether in kindergarten, and presence of psychosocial problems cannot help in predicting health care consumption. Conclusion - The low number of contacts with GPs can partly be explained by the fact that the children also have contact with a well-baby clinic. In our study, a series of possible explanatory factors did not help us to predict the amount of health care consumption during the first four years of life.     

Swing bed program in a small rural hospital: discharge outcome.

Swing beds contribute significantly to inpatient rehabilitation and skilled nursing care of the rural elderly, but little information is available in the general clinical literature regarding the types and outcomes of patients admitted to these programs. All swing bed admissions to a small rural hospital for the 1989 fiscal year were identified and the records were reviewed. The mean age of the patients was 81 years, and the average length of stay was 13 days. Most patients were admitted because of acute problems necessitating short-term rehabilitation or because no bed was available in an appropriate skilled-care nursing home. At discharge, 40% of patients were able to return home. Information regarding the availability and appropriate use of swing beds needs to be disseminated to physicians who care for the elderly. More study is needed to determine optimal use of and requirements for swing beds on a national level.     

“It is not the fading candle that one expects”: general practitioners’ perspectives on life-preserving versus “letting go” decision-making in end-of-life home care

Background Many general practitioners (GPs) are willing to provide end-of-life (EoL) home care for their patients. International research on GPs’ approach to care in patients’ final weeks of life showed a combination of palliative measures with life-preserving actions.

Aim To explore the GP’s perspective on life-preserving versus “letting go” decision-making in EoL home care.

Design Qualitative analysis of semi-structured interviews with 52 Belgian GPs involved in EoL home care.

Results Nearly all GPs adopted a palliative approach and an accepting attitude towards death. The erratic course of terminal illness can challenge this approach. Disruptive medical events threaten the prospect of a peaceful end-phase and death at home and force the GP either to maintain the patient’s (quality of) life for the time being or to recognize the event as a step to life closure and “letting the patient go”. Making the “right” decision was very difficult. Influencing factors included: the nature and time of the crisis, a patient’s clinical condition at the event itself, a GP’s level of determination in deciding and negotiating “letting go” and the patient’s/family’s wishes and preparedness regarding this death. Hospitalization was often a way out.

Conclusions GPs regard alternation between palliation and life-preservation as part of palliative care. They feel uncertain about their mandate in deciding and negotiating the final step to life closure. A shortage of knowledge of (acute) palliative medicine as one cause of difficulties in letting-go decisions may be underestimated. Sharing all these professional responsibilities with the specialist palliative home care teams would lighten a GP’s burden considerably.

• Key Points

• A late transition from a life-preserving mindset to one of “letting go” has been reported as a reason why physicians resort to life-preserving actions in an end-of-life (EoL) context. We investigated GPs’ perspectives on this matter.

• Not all GPs involved in EoL home care adopt a “letting go” mindset. For those who do, this mindset is challenged by the erratic course of terminal illness.

• GPs prioritize the quality of the remaining life and the serenity of the dying process, which is threatened by disruptive medical events.

• Making the “right” decision is difficult. GPs feel uncertain about their own role and responsibility in deciding and negotiating the final step to life closure.

     

Caring pathways of terminal cancer patients: a retrospective survey

Caring pathways of terminal cancer patients: a retrospective survey. Introduction. The caring patways of terminal cancer patients of the Vallagarina district, dead in 2008, cared at home and/or by district services in the last 90 days of life of cancer patients, were retrospectively described. Aim. To describe the last 90 days of life of all patients dead for cancer. Methods. Data were collected from different sources: hospital discharge forms, local health unit informative systems, data bank of the palliative care service (PC), charts of PC and home care services and through interviews to caregivers, for patients cared by General practitioners (GPs). Results. Four caring pathways were identified: patients mainly cared by GPs, in nursing homes, in long term care or by the PC service. The rate of hospital admissions varies widely: 25% of potential days of care for GPs patients; 1.3% for PCs patients; same for length of hospital stay: mean duration 18.7 days for GPs and 5.6 days for PC patients. Only rarely the GPs activate other forms of care such as care by multidisciplinary teams (10.8% patients) or visits at home by GPs (12.7% patients). Caregivers would like more information on the clinical situation of the patient and on the different caring services, to be involved in the decision making process. Conclusions. Patients cared by GPs and PC Service experience different caring pathways. Lack of information to caregivers may profoundly impact the type of care received.     

The availability of allied health care in nursing homes

Purpose. To determine the availability of allied health care in nursing homes in the Netherlands, and its dependency on characteristics of the nursing home.

Methods. Structured surveys by telephone were carried out in a sample of 100 from a country total of 286 somatic (for somatic patients only) and combined (with units for both somatic and psychogeriatric patients) nursing homes. Multiple linear regression analyses were performed to determine relationships between the availability of care and the type of nursing home, its country location (urban/non-urban) and the presence of specific wards/units within the nursing home.

Results. Physiotherapy and occupational therapy were present in almost all nursing homes (99% and 93% respectively); 92% of the nursing homes offered speech- and language therapy and 88% had dietetics available. Average availability rates were: 2.16 full time equivalents per 100 beds/places for physiotherapy, 0.96 for occupational therapy, 0.38 for speech- and language therapy and 0.18 for dietetics. Somatic nursing homes and nursing homes with stroke-units, day-care, or outpatient care present, had higher availability rates on allied health care.

Conclusions. Allied health care disciplines varied in terms of full-time equivalents per 100 beds/places. Per discipline also a wide variation exists in full-time equivalents per 100 beds/places among all participating nursing homes, regardless of their type. Characteristics of nursing homes had small effects on availability rates. International research is recommended in order to compare data and eventually reach consensus on optimal availability rates of allied health care in nursing homes, tuned to the demand.     

A randomized controlled trial of a hospital at home service for the terminally ill

This study evaluated the impact of a Cambridge hospital at home service (CHAH) on patients' quality of care, likelihood of remaining at home in their final 2 weeks of life and general practitioner (GP) visits. The design was a randomized controlled trial, comparing CHAH with standard care. The patient's district nurse, GP and informal carer were surveyed within 6 weeks of patient's death, and 225 district nurses, 194 GPs and 144 informal carers of 229 patients responded. There was no clear evidence that CHAH increased likelihood of remaining at home during the final 2 weeks of life. However, the service was associated with fewer GP out of hours visits. All respondent groups rated CHAH favourably compared to standard care but emphasized different aspects. District nurses rated CHAH as better than standard care in terms of adequacy of night care and support for the carer, GPs in terms of anxiety and depression, and informal carers in terms of control of pain and nausea. Thus whilst CHAH was not found to increase the likelihood of remaining at home, at appeared to be associated with better quality home care.     

Preventing avoidable hospital admission of older people

The National Service Framework for Older People (Department of Health, 2001) stresses the importance of preventing unnecessary hospital admissions for older people. Such admissions arise when there is inadequate health and social support available in the community to meet the needs of this age group. This article reports on a study designed to evaluate the effectiveness of a programme of enhanced primary care support intended to reduce the risk of hospital admission for people aged 75 years and above. Nineteen patients out of a possible 322 in one GP practice were judged by GPs and district nurses to be "at risk" of avoidable hospital admission. All at-risk patients were visited by a GP or district nurse to review their needs for enhanced support, six patients subsequently accepting a referral for additional support. No statistically significant difference in the number of hospital admissions in the intervention group was observed compared with a group of patients with similar demographic characteristics but deemed not to be at such high risk, suggesting that the intervention might have been effective in reducing the number of avoidable hospital admissions.     

Predicting whether the ICU can help older patients: score needed

Because the need for intensive care exceeds its availability in several countries, intensivists must admit those patients most likely to benefit. Intensive care unit admissions of elderly patients will increase substantially in the near future. Decreased self sufficiency and quality of life are common after hospitalization in older patients and they may require discharge to a nursing home, although some patients feel that life in a nursing home would be worse than dying. We have much to learn about matching the use of life-supporting treatments to the health-related values of older patients. A specific outcome-prediction score for older patients would help improve quality of care.     

Admission avoidance and early discharge of acute hospital admissions: an accident and emergency based scheme

Objectives—To validate an accident and emergency (A&E) based approach to assisting early discharge or avoiding admission to acute hospital beds by means of two separate teams, one in hospital and the other in the community, working closely together at the interface between primary and secondary health care.

Design—A purpose designed admission avoidance (AA) team was established in the A&E department, and a target group of patients identified whose admissions might be avoided or curtailed. A rapid response community team (RRCT) based in Cambridge was also established to provide basic health care to patients in their homes after discharge from hospital. The key elements of the project were rapid assessment, careful selection of patients, early decision making at senior level, and close liaison with the community team.

Results—During the first year (1999) of the project the AA team assessed 785 patients and 257 patients were eventually discharged home to the care of the RRCT. Of these, 149 patients (58%) were comparable to a historical control group (from 1997/98), with regard to their demographic and clinical characteristics and care needs, and had an average length of hospital stay of 1.7 days compared with 6.3 days for the control group. The remaining 108 patients were not directly comparable but were supported by the teams because the benefits were clear and exclusion would have been unethical. These patients had an average length of stay of seven days. The readmission rate was 3 of 257(1.2%) for the intervention group and 8 of 531(1.5%) for the control group. A limited patient satisfaction survey among patients cared for at home revealed that 97% of patients were "satisfied to very satisfied" with the care provided. The RRCT had also looked after an additional 194 patients from other sources (total = 451), including postoperative orthopaedic early discharges from an adjacent hospital. The average length of care at home by the RRCT for all 451 patients was 6.6 days. The annual cost of the two teams was £113 900.

Conclusions—These results indicate that an A&E based approach to the identification of patients suitable for short-term domiciliary support that aims rapidly to restore previous levels of independence, can reduce the burden of acute admissions to hospital without reducing quality of care or patient satisfaction. The scheme has now been established on a permanent basis and extension of this strategy to other patient groups is under evaluation.

     

Interdisciplinary cooperation of GPs in palliative care at home: A nationwide survey in the Netherlands

Objective. To investigate the occurrence and predictors of interdisciplinary cooperation of GPs with other caregivers in palliative care at home. Design. In a prospective study among 96 general practices, the GPs involved identified all dying patients during the study period of 12 months. The GPs received an additional post-mortem questionnaire for each patient who died during the study period, and registered the healthcare providers with whom they cooperated. Multivariable logistic regression analysis was used to identify the predictors of GP cooperation with other caregivers. Setting. Second Dutch National Survey in General Practice. Subjects. A total of 743 patients who received palliative care according to their GP. Main outcome measures. Interdisciplinary cooperation between GP and other healthcare providers. Results. During the study period, 2194 patients died. GPs returned 1771 (73%) of the questionnaires. According to the GPs, 743 (46%) of their patients received palliative care. In 98% of these palliative care patients, the GP cooperated with at least one other caregiver, with a mean number of four. Cooperation with informal caregivers (83%) was most prevalent, followed by cooperation with other GPs (71%) and district nurses (63%). The best predictors of cooperation between GPs and other caregivers were the patient's age, the underlying disease, and the importance of psychosocial care. Conclusion. In palliative care patients, GP interdisciplinary cooperation with other caregivers is highly prevalent, especially with informal caregivers and other primary care collaborators. Cooperation is most prevalent in younger patients, patients with cancer as underlying disease, and if psychosocial care is important.     

Structured community-based inpatient rehabilitation of older patients is better than standard primary health care rehabilitation – an open comparative study

Purpose: To compare the outcome of multi-disciplinary, structured rehabilitation of older patients in a district inpatient rehabilitation centre (Model 1) versus standard primary health care rehabilitation (Model 2). Method: Open, prospective, comparative observational study. Totally 302 patients, 202 in Model 1 and 100 in Model 2, aged ≥65 years, with stroke, osteoarthritis, hip fracture or other chronic diseases, considered to have a rehabilitation potential. Referred from district hospital, nursing- or own homes. Outcomes: Primary: Sunnaas ADL Index (SI). Secondary: Umeaa Life Satisfaction Checklist (LSC). Cognitive (MMSE), emotional (SCL-10) and marital status, residence, length of rehabilitation and hours/week care services. Follow-up 3 months after end of rehabilitation. Results: Patients in Model 1 improved and persisted 1.9 points higher in SI (CI (1.0, 2.8), p < 0.001) compared to Model 2, with 2.4 weeks shorter rehabilitation (CI (1.6, 3.1), p < 0.001). LSC indicated similar satisfaction within both models. Fewer Model 1 patients received home care services >3?h/week (OR?=?0.6 CI (0.4, 0.8), p?=?0.002). Cognitive status predicted the SI gain positively, and level of care services negatively, in both models. Conclusions: Disabled older patients increase their independency significantly more within shorter time upon structured, multi-disciplinary rehabilitation in a district inpatient centre compared to standard primary health care rehabilitation.

Implications for Rehabilitation

• Multi-disciplinary, structured primary health care-based inpatient rehabilitation of older people in a dedicated district rehabilitation centre can give improved and sustained independency and should be preferred to standard primary health care rehabilitation in short-term beds in nursing homes.

• The district centre rehabilitation concept may be an interesting model in societies challenged by increasing needs of rehabilitation in an ageing population.

     

Are general practitioners characteristics associated with the quality of type 2 diabetes care in general practice? Results from the Norwegian ROSA4 study from 2014

Objective: To explore the associations between general practitioners (GPs) characteristics such as gender, specialist status, country of birth and country of graduation and the quality of care for patients with type 2 diabetes (T2DM).

Design: Cross-sectional survey.

Setting and subjects: The 277 GPs provided care for 10082 patients with T2DM in Norway in 2014. The GPs characteristics were self-reported: 55% were male, 68% were specialists in General Practice, 82% born in Norway and 87% had graduated in Western Europe. Of patients, 81% were born in Norway and 8% in South Asia. Data regarding diabetes care were obtained from electronic medical records and manually verified.

Main outcome measures: Performance of recommended screening procedures, prescribed medication and level of HbA1c, blood pressure and LDL-cholesterol stratified according to GPs characteristics, adjusted for patient and GP characteristics.

Result: Female GPs, specialists, GPs born in Norway and GPs who graduated in Western Europe performed recommended procedures more frequently than their counterparts. Specialists achieved lower mean HbA1c (7.14% vs. 7.25%, p?p?=?0.018) and lower mean systolic blood pressure (133.0?mmHg vs. 134.7?mmHg, p?p?Conclusion: Several quality indicators for type 2 diabetes care were better if the GPs were specialists in General Practice.

• Key Points

• Research on associations between General Practitioners (GPs) characteristics and quality of care for patients with type 2 diabetes is limited.

• Specialists in General Practice performed recommended procedures more frequently, achieved better HbA1c and blood pressure levels than non-specialists.

• GPs who graduated in Western Europe performed screening procedures more frequently and achieved lower diastolic blood pressure compared with their counterparts.

• There were few significant differences in the quality of care between GP groups according to their gender and country of birth.