General practitioner services under Medicare

Abstract: This paper examines how general practitioner numbers, bulk-billing rates and sociodemographic variables determined usage of general practitioners and services delivered over the period from 1984 to 1990. A 10 per cent sample of patient services, maintained by the Commonwealth Department of Health, Housing and Community Services, provided the data. Data were aggregated into 148 electorates. Separate regression analyses examined the determinants of the proportion of the population attending a general practitioner and of the number of general practitioner services delivered per patient. Determinants of the growth of these levels over the seven-year period were also examined. Region (metropolitan versus rural), age structure and general practitioner supply were significant factors in these analyses. Bulk-billing rates explained nine per cent of variance in patient numbers and 22 per cent of variance in service numbers after sociodemographic variables and general practitioner supply had been taken into account. The analyses suggest that bulk-billing and general practitioner supply influence the behaviour of patients and doctors and that the effect of bulk-billing is independent of indices of medical need. This implies that bulk-billing may increase service rates and this increase is not clearly directed to improving access to medically necessary services. Because no measures of treatment outcome are available, it is not possible to decide whether the effects observed represent an improvement in health care or are better seen as overuse by patients and demand inducement by practitioners.     

Family planning in ramsgate: a community study of unmet need

Summary A postal survey of 1051 women, aged 16–50, was undertaken to determine the differences between users and non-users of family planning services. We received 787 replies. Of those who replied 201 (26 per cent) were infertile and 330 (42 per cent) used the facilities. A non-user tended to depend on less reliable methods and to be poorly informed of the availability of services. The general practitioner was the consistently favoured adviser by women of all social classes. Continuation of education after leaving school was more closely associated with take-up of advice than social class. Of the parous respondents, 169 (55 per cent) claimed to have received no contraceptive advice during their most recent pregnancy. Younger couples showed an increased interest in sterilization as a method of birth control. The respondents asked for more information on contraceptive methods and more publicity about the facilities. We recommend the extension of general practitioner contraceptive services, education of both hospital staff and health visitors on the importance of giving family planning advice and improved publicity about local facilities.     

The use of primary, secondary, community and social care by families who frequently consult their general practitioner

There have been very few studies that have examined either the use of other health and social services by patients who frequently consult their general practitioner, or the patterns of service use of frequently attending families. This study has three aims: to quantify the number of contacts to primary, secondary, community and social services of families who frequently attend their general practitioner; to examine the temporal patterns of these contacts and the patterns of use within families; and to determine the nature of these contacts and how they were valued by patients and health professionals. Thirty-five individuals in seven families completed diaries of health service use for 8 weeks; records from primary and community care records were analysed; health professionals and patients provided satisfaction scores for their contacts. The data were compared to standard datasets. The subjects made far more consultations with all health services than predicted, and less than half of these were with the general practitioner. Thirty-two per cent of the contacts with staff based within the health centre were not reported on the diary sheets. Temporal patterns of consulting were apparent within the families. The "index frequent attenders" within each family had most contacts. The differences between professional groups for the nature of the contact were marked, with over two-thirds of general practitioner contacts being for "specific symptoms or problems", and over two-thirds of health visitor contacts being for "weight problems". These findings show that patients who make high use of general practitioners' services also have a large number of contacts for health reasons with a range of other health and social services. These need to be considered as an outcome measure for trials of intervention for frequent attendance. More work is needed to explore why some individuals and their families make high use of health services.     

Responses to non-emergency questions in rural medicine: their usefulness to practice decisions

This study reports the nature of non-emergency, day-to-day practice-related questions which arose in rural practice and were phoned in to a medical information system (MIS). The usefulness of these questions, and their responses, to clinical decision-making is outlined. Sixty-seven practitioners from 10 rural communities enrolled in the project. In response to each inquiry two or three articles were sent to the practitioner and to a consultant for validation. At the conclusion of the study the questions posed, and their responses, were examined. Forty-six per cent of the questions received were categorized as diagnostic; 30% as management; and 24% as therapeutic. Questions were classified using the ICD.9.CM. Those most frequently posed were in the nervous system/sense organs (13%), injury/poisoning (9%), and genito-urinary (9%) categories. Interviews with doctors and consultants were conducted to assess the usefulness of the service. Study findings suggest that an MIS can provide helpful information for improving daily aspects of clinical care, doctor-patient communication, administrative decision-making, and physician education. Practitioners, consultants, and medical librarians reported benefits from this service.     

Psychiatric diagnoses of medical service users: evidence from the Epidemiologic Catchment Area Program.

Based on data from the five sites of the National Institute of Mental Health-sponsored Epidemiologic Catchment Area (ECA) Program, this paper examines the prevalence of psychiatric disorder among recent medical service users versus nonusers, with a particular focus on affective disorders, substance abuse/dependence, and phobias. The rate of current Diagnostic Interview Schedule (DIS) disorders among medical users in all five ECA sites is 21.7 per cent (slightly higher than general population rates) versus 16.7 per cent among nonusers; there is generally no difference between users and nonusers with past DIS diagnoses. Affective disorders were among the most common mental disorders of medical service users, especially among females, with little variation between sites: females: users: 6.9 per cent to 9.3 per cent, nonusers: 3.4 per cent to 6.4 per cent, and males: users: 3.3 per cent to 6.5 per cent, nonusers: 1.2 per cent to 4.1 per cent. Rates of phobias among persons using medical services are also higher than among nonusers. Substance abuse disorders are at least as common among persons who use medical services (8 per cent to 14 per cent of male users) as among those who do not (9 per cent to 11 per cent of male nonusers). The high rates of affective disorders among women and of substance abuse among male medical service users underscore the need to increase the ability of general medical practitioners to recognize and manage or refer these conditions.     

Patterns and costs of post-acute care: a longitudinal study of people aged 60 and over in Dubbo

Abstract: Declining length of stay of older people in hospital has caused concern about shifting of costs from acute to community care services. Because the two types of care are funded through different programs and from different jurisdictions, the coordination of acute and post-acute care has become the major issue. There is, however, little information available on patterns of use and costs of post-acute care either in Australia or elsewhere. In an existing longitudinal community study of older people in Dubbo, New South Wales, data on use of services by people aged 60 years and over for 12 months of hospitalisations was collected by linkage to the records of Home and Community Care providers. Only a quarter of older people received any type of Home and Community Care service in the 12 weeks after discharge and two-thirds of these received only one type of service. While less than 5 per cent received a service from an occupational therapist, physiotherapist or speech therapist, 78 per cent visited a general practitioner after discharge. The average cost of all Home and Community Care services received after hospital discharge was around $12.50 per week per person discharged. The predictors of higher costs of service use were: living alone, and the interactions of high levels of disability with owning a house. Results on service coordination, the identification of post-acute services, cost consequences of program funding, assessment and discharge planning are related to debates emerging from the Commonwealth Heads of Government.     

Organisation of ambulatory care by consumers

Abstract This paper deals with how consumers arrange their ambulatory care in a system such as the United States which offers many possible choices. Patters of the different affiliations (sources) that people maintain throughout the year for ambulatory care are formed. The data were obtained in interviews in a sample survey of Rhode Island households conducted in 1974. Although most people in the sample (89.5 per cent) cluster with one to three sources of care, there were over 80 people with four or more affiliations. For those persons with a large number of affiliations, the provider sets become quite varied. Two conceptual typologies are formed, one focusing on type (private physicians versus places) and the other focusing on both the speciality of the physicians involved and the number of different affiliations involved. The United States, at least in theory, maintains a‘free market’health care system. Are there limitations of choice imposed by differential distributions of knowledge, income or age? A wide array of social, demographic, and illness variables were examined to determine their relationship to the patterns. Income has little relationship with the provider set patterns, but persons with a higher education are more likely to report a provider set that includes a primary care specialist (internist or paediatrician), rather than a general practitioner or osteopath. Blacks have different patterns of providers, as do those on Medicaid funding. Thus there is evidence of the continuation of a dual market for health care. The research describes the diversity and complexity of current health care patterns under a loosely structured system of health care such as that found in the United States. While the British health system has traditionally represented a tightly structured system with one path of entry (the general practitioner) into more complex health care services, this may be changing somewhat if current trends in the growth of the private insurance sector in Great Britain continue. Thus the experience of the United States may be of greater policy interest in Britain in the future. There has been a great deal of research in medical sociology and health services research dealing with health behaviour, especially as it relates to ambulatory medical care services. This paper examines how people structure their own health care with the presumably‘free market’system of choice such as operates in the United States. It provides an introductory picture of how people organise services and the variety of sources to which they go to fulfil their medical needs. Berkanovic and Reeder have pointed out that one can study use of medical services through examining the sources from which care Is received or the volume.¹ Much past research has focused on volume of care, emphasising amount of utilisation and number of physicians visits or outpatients visits.^2,3,4,5 The aim of this paper is to analyse sources of care and patterns of ambulatory medical care, not utilisation statistics. An important question is whether there are limitations of choice imposed by differential distribution of social characteristics such as knowledge, income or age. This paper first describes patterns of care-seeking and then relates them to social, demographic and illness variables.     

INEQUALITIES IN PRIMARY MEDICAL CARE AMONG WORKING MALES, 15–64, IN NEW ZEALAND

The welfare state has come under increasing scrutiny, especially in relation to the efficiency and fairness with which it delivers key human services such as health care. The paper mounts a preliminary investigation of such issues in the context of the delivery of primary medical care in New Zealand. The study is based on a 1 per cent sample of all general practice visits in the Hamilton Health District over a period of a year. The data are presented only for employed males in the 15–64 age group. Manual workers and the Maori visit the general practitioner more frequently for all illness conditions, for certain predicted groups of illnesses, and for more severe health problems. There is also evidence of a social class/ethnic group interaction effect. However, the extent of these disparities in utilisation are less marked than those indicated by epidemiological measures of need based on mortality data.     

FROM MEDIBANK TO MEDICARE: TRENDS IN AUSTRALIAN MEDICAL CARE COSTS AND USE FROM 1976 TO 1986

Private medical care costs and service use in Australia from 1976 to 1986 are compared. In each of these years Australia had a compulsory, universal, fee-for-service, national health insurance scheme - Medibank in 1976 and Medicare in 1986. Over the period of 1976 to 1986, the number of private medical services per capita, in the 6 month period 1 April to 30 September, increased from 2.79 to 3.95, an increase of 3.54 per cent per year. The cost of services per capita, adjusted for increases in schedule fees for each item-group of services (the ‘fee-adjusted cost’), grew at a rate of 3.91 per cent per year. The results are reported by subsets of age, sex and item-group of service. It is found that very little of the large increases in use and cost of services can be attributed to demographic changes or population growth. Rather, they represent rapid increases in age and sex-specific rates of use, primarily among the very young, the very old and, for some types of service, women of child-bearing age. The most dramatic increases in service use are found in pathology, radiotherapy and miscellaneous procedures.     

What problems do patients present with outside normal general practice surgery hours? A prospective study of the use of general practice and accident and emergency services.

BACKGROUND: This study was designed to address some current issues concerning the use of general practice and accident and emergency (A & E) services outside normal surgery hours. METHOD: Six general practices in Nottingham (with a combined population of 46,698 patients) were recruited to take part in the study. Over a six month period, data were collected on patient contacts with general practice services and the local A & E department outside normal surgery hours. RESULTS: General practice services dealt with 63 per cent of first contacts over the course of the study. There were 3181 (136 per 1000 patients per year) contacts with general practitioners and deputizing service doctors (of which 1009 (31.7 per cent) were dealt with by telephone alone) and 1876 (80 per 1000 patients per year) attendances at the A & E department. There were marked differences in the distribution of problems that patients presented to the two types of service. The proportion of presentations dealt with by telephone alone by general practice services varied with the type of presentation. However, the use of the telephone was not particularly high, even for problems such as a sore throat. CONCLUSIONS: Given the differences in presentations to both general practice and A & E services there may be limited scope for altering patients' consulting patterns without making significant changes to service provision. However, there may be scope for increasing the proportion of general practice contacts dealt with by telephone alone.     

Item of Service Remuneration in General Practice in the UK: What Can We Learn From Dentists?

Birch S. Item of service remuneration in general practice inthe UK: what can we learn from dentists? Family Practice 1988;5: 265–270. In response to the UK Government's proposal to increase theproportion of general practitioner income accruing from capitationpayments the General Medical Services Committee of the BritishMedical Association has called for an extension of fee for itemof service provision in general practice. In this paper theallocation of resources in primary care dentistry, where feefor service provision is currently used, is analysed in orderto shed light on the debate. Since dentists' fees are set inaccordance with average dentist time inputs, differences incost per treatment course reflect differences in course content.Multiple regression techniques are used to estimate a cost pertreatment course function. Using cross-sectional data for familypractitioner committees in England and Wales for 1982 a significantnegative correlation is found between cost per course and populationper dentist after allowing for patient demand and need characteristics.A 10% decrease in population per dentist is associated witha 2.5% increase in cost per course. The observation cannot beexplained by dentists rationing treatment in the presence ofexcess demand owing to the nature of the dentist contract. These results imply that in areas of greater supplies of dentistsadditional course content is being induced by dentists in orderto maintain workloads. Hence although fee for service provisionoffers a financial incentive to increase service provision itoffers no incentive to allocate services efficiently, that isin accordance with greatest need. The extension of fee for serviceprovision in general medical practice would appear to be inconsistentwith an objective of allocating scarce primary care resourcesin accordance with patient need.     

Medication compliance problems in general practice: detection and intervention by pharmacists and doctors

ABSTRACT: Medication compliance; the role of a portable Medical Summary Card as a compliance aid; and the role of a medical practice-based clinical pharmacist in identifying medication-related problems in a rural general practice setting is evaluated. A clinical pharmacist checked the medications of 50 predominantly aged patients against their medical summary and noted inconsistencies and potential medication problems. From this information the general practitioner (GP) assessed patient compliance with prescribed medications and transcribed the correct medication regimen and medical problems onto a Medical Summary Card for the patient to carry. Forty per cent of the patients were non-compliant. A Medical Summary Card alone was unable to improve compliance. Issues noted by the clinical pharmacist warranted a change in therapy for 8% of patients. Eighteen per cent of patients provided medical information to the clinical pharmacist of which the GP was unaware. Non-compliance with prescribed medications is common. A portable Medical Summary Card may not rectify this problem. Patients' withholding medical information from their medical practitioner is of particular concern.     

Patients' needs after radiotherapy, the role of the general practitioner

This study assessed the physical and psychosocial sequelae of radical radiotherapy among patients with bladder or prostate cancer and investigated the support received from community health services. When interviewed two months after treatment, over half reported that they had experienced several physical side-effects as well as curtailment of social and everyday activities. Such side-effects were still being experienced by up to half the patients at the time of interview. Seventy-one per cent were unprepared for the duration and type of such effects. Most had seen their general practitioner in connection with their side-effects and 76% felt that this contact had been helpful. Patients appreciated the willingness to spend time listening to their concerns and explaining side-effects, as well as accessibility and flexibility which made it easy to obtain advice and support. Patients who expressed dissatisfaction with their general practitioner all felt that they should have been visited at home. The study suggests that general practitioners can play a valuable role in meeting patients' needs after radiotherapy.     

Who enrolls in a general practitioner model? The behavioral model of health services use and general practitioner-centered care in Germany

Since July 2009, statutory health insurance companies in Germany are obliged to offer a so-called general practitioner model. By strengthening the general practitioner??s position, these models should optimize healthcare especially for people with higher demands for health services. So far, little is known about which patients participate in the model. Our study??s aim was to describe correlates of enrollment based on the behavioral model of health services use. The data were obtained from the Robert Koch Institute??s 2006 telephone health survey. Variables influencing enrollment in the general practitioner models were determined through logistic regression models. Main indicators for enrollment were age above 60 years, lower social status, lower income status, and living in less populated areas. Insured persons with a higher demand for medical services were more often enrolled in general practitioner models. Most of them had consulted their general practitioner very frequently even before the general practitioner model was introduced.     

Do community based self-reading sphygmomanometers improve detection of hypertension? A feasibility study

BACKGROUND: Hypertension is a major risk factor for stroke and ischaemic heart disease. Most hypertension is detected opportunistically by general practitioners. Those who rarely use medical services are less likely to have their blood pressure (BP) measured. We hypothesized that open access self-reading BP measurement would detect previously unrecognized hypertension. METHODS: Self-reading sphygmomanometers were placed at 13 public sites in Exeter, Devon, United Kingdom. Machine use was determined by users completing a proforma and by direct observation of sites. Users whose BP reading was above an action level of 135/85 mmHg were asked to attend their general practice. General practitioner records were reviewed 6 months after machine use to identify diagnoses of hypertension. A random sample of users was interviewed, and local general practices were asked about effects on their workload. RESULTS: A total of 758 first time users completed a proforma fully, although direct observations suggested total use was much higher. Of the total, 221 (29.2 per cent) readings were above the action level. Eleven new hypertensives were found, 1.4 per cent (95 per cent confidence interval (CI 0.7-2.5) of the total users. User acceptability was high. All general practice replies were supportive. CONCLUSION: Open access sphygmomanometry for detection of hypertension is feasible. This scheme led to the diagnosis of hypertension in 1.4 per cent of users, and allowed many people to measure their BP in a way convenient to them. Before recommending wider implementation we suggest a study examining if our results are transferable to other settings, and if this approach reduces inequalities and is cost-effective.     

Prevalence and frequency of health service use: associations with occupational prestige and educational attainment

Abstract: The accessibility of health care services has been suggested to be one factor with the potential to ameliorate the health effects of socioeconomic disadvantage. From a randomly selected sample of households in the Lower Hunter Valley region, 2623 adults were surveyed in 1987–88 to identify their reported use of medical, allied and alternative health services during the previous four weeks. There was a higher prevalence of use of the ‘usual’ general practitioner and medical services among educationally disadvantaged respondents only. No significant differences were evident between educational or between occupational groups in the prevalence of use of either alternative services or health services generally. Fewer occupationally disadvantaged respondents reported using allied health services. There was no difference in the number of health services used. Disadvantaged respondents were more likely to use medical services exclusively. Only educationally disadvantaged service users reported using any health, medical or general practitioner services more frequently than expected. In contrast, only occupationally disadvantaged service users reported using allied health services (and allied health services other than dentists) more frequently. The lack of consistent differentials in use across health services in favour of disadvantaged respondents suggests that a number of health care services may not be responding to the greater need for health care among disadvantaged members of the community.     

Pap smears in general practice: a secondary analysis of the Australian Morbidity and Treatment Survey 1990 to 1991

Abstract: We investigated the characteristics of Australian general practice that predict performance of Pap smears by secondary analysis of the Australian Morbidity and Treatment Survey 1990 to 1991. Chi–squared analysis identified potential associations between Pap smear rate and patient, doctor and practice variables. Significant associations were examined using logistic regression and generalised estimating equations. Participants were 495 general practitioners who collected information on 113 468 doctor–patient encounters, of which 43 211 encounters involved females aged 18 to 70 years. Pap smear encounters (2449) were identified and classified as patient–requested (62 per cent), diagnostic (5 per cent) or opportunistic (33 per cent). The large difference in the unadjusted Pap smear rates per 100 female encounters for female general practitioners (11.7) and male general practitioners (4.2) required separate analysis by sex of the general practitioner. For male general practitioners, a Pap smear was less likely: as patient age increased; for new patients; for general practitioners with less general practice experience; for general practitioners with no postgraduate qualifications; with metropolitan practice location; and if the practice had more than 25 per cent of patients with English as a second language. For female general practitioners, a Pap smear was less likely: for older known patients; as the age of the general practitioners increased; and for management of fewer problems per 100 encounters. A Pap smear was less likely to be opportunistic: as patient age increased; for general practitioners who were Australian graduates; and for general practitioners with no postgraduate qualifications. Consideration of patient, doctor, and general practice characteristics may facilitate the design of interventions to improve cervical cancer screening.     

Physician workload in primary care: what is the optimal size of practices? A cross-sectional study

OBJECTIVE: To determine the impact of practice size and scope of services on average physician workload in primary care practices in The Netherlands, and to examine the associations between average physician workload, average assistant volume and organisational practice characteristics. METHODS: This was a cross-sectional study in 1188 general practices in The Netherlands. Measures included physician workload per week per 1000 patients, assistant volume per 1000 patients, practice size defined by number of registered patients (10 classes), scope of disease management services (seven classes), and nine organisational characteristics of the practice. RESULTS: Physician workload per 1000 patients differed across levels of practice size, but was not related with the range of disease management services provided. In the smallest practices physicians worked on average 26.2h per 1000 patients and in the largest practices 18.1h. A higher average assistant volume was overall not associated with a lower average physician workload. Large practices had lower assistant volume per 1000 patients, but provided a wider range of disease management services compared to small practices. Delegation of medical tasks was associated with reduced physician workload per 1000 patients, mainly in smaller practices, and with higher assistant volume per 1000 patients, particularly in larger practices. CONCLUSIONS: In The Netherlands the optimum regarding average physician workload was found in the largest practices, while no obvious association with scope of disease management services appeared. It may be that in large practices medical tasks were delegated to practice assistants to provide a wider scope of disease management services and in small practice to reduce average physician workload.