Economic efficiency of gate-keeping compared with fee for service plans: a Swiss example

STUDY OBJECTIVE: The impact of isolated gate-keeping on health care costs remains unclear. The aim of this study was to assess to what extent lower costs in a gate-keeping plan compared with a fee for service plan were attributable to more efficient resource management, or explained by risk selection. DESIGN: Year 2000 costs to the Swiss statutory sick funds and potentially relevant covariates were assessed retrospectively from beneficiaries participating in an observational study, their primary care physicians, and insurance companies. To adjust for case mix, two-part regression models of health care costs were fitted, consisting of logistic models of any costs occurring, and of generalised linear models of the amount of costs in persons with non-zero costs. Complementary data sources were used to identify selection effects. SETTING: A gate-keeping plan introduced in 1997 and a fee for service plan, in Aarau, Switzerland. PARTICIPANTS: Of each plan, 905 randomly selected adult beneficiaries were invited. The overall participation rate was 39%, but was unevenly distributed between plans. MAIN RESULTS: The characteristics of gate-keeping and fee for service beneficiaries were largely similar. Unadjusted total costs per person were Sw fr 231 (8%) lower in the gate-keeping group. After multivariate adjustment, the estimated cost savings achieved by replacing fee for service based health insurance with gate-keeping in the source population amounted to Sw fr 403-517 (15%-19%) per person. Some selection effects were detected but did not substantially influence this result. An impact of non-detected selection effects cannot be ruled out. CONCLUSIONS: This study hints at substantial cost savings through gate-keeping that are not attributable to mere risk selection.     

Service Utilization and Health-Care Costs in the Advanced Elderly

Objectives:  Despite their increasing importance, the advanced elderly are often neglected in service utilization and costing studies. The purpose of this study was to analyze from societal perspective service utilization and direct health-care costs and its predictors in the advanced elderly population.
Methods:  A bottom-up costing study was conducted using a cross-sectional primary care sample aged 75+ (n = 452) in Germany. The main instruments were a questionnaire of service utilization and costs administered by an interviewer and the chronic disease score (CDS). Predictors were derived by means of multivariate regression models.
Results:  Respondents caused mean direct costs of €3730 (95% CI 3203–4257) in prices of 2004/2005. This included inpatient care 34%, pharmaceuticals 29%, outpatient physician services 15%, nursing care 10%, medical supply and dentures 6%, outpatient nonphysician providers 5%, assisted living 1%, and transportation 2%. A shift from lower to middle education and a one-point increase in CDS were associated with an increase of €1678 (95% CI 250–3369) and €482 (95% CI 316–654), respectively. Total mean direct costs did not differ significantly between sexes. Ischemic heart disease and diabetes mellitus were associated with excess costs of €711 and €290, both being not significant. Altogether 55% of the respondents accounted for 90% of total direct costs.
Conclusions:  Advanced elderly used a wide range of health services. Our study still underestimates the true costs to society. Further research should focus on economic evaluation of new health-care programs for this increasingly important age group.     

The role of psychological well-being in retaining rural general practitioners

OBJECTIVE: Retention of rural GPs is an increasing area of concern and is receiving considerable attention from the government, medical authorities and the media. This study aimed to examine the potential for psychological interventions to assist in the retention of rural GPs through targeting their psychological well-being. DESIGN: GPs completed a questionnaire, including questions about their level of support in rural practice, psychological health (work-related morale and distress, distress related specifically to working in rural general practice, quality of work life) and intentions to leave rural practice. SETTING: Rural general practices in South Australia. PARTICIPANTS: One hundred and eighty-seven rural GPs. RESULTS: Results indicated that rural GPs who were seriously considering leaving rural practice had higher work-related distress, higher distress related specifically to working in a rural general practice and lower quality of work life. GPs who considered leaving rural practice also reported having fewer colleagues with whom to discuss professional issues. CONCLUSION: Results indicated that psychological interventions (such as cognitive behavioural training), assistance with stress reduction and coping mechanisms (such as more interaction with colleagues) may be of benefit to GPs who are considering leaving rural practice. Such training may increase the number of GPs who ultimately stay in rural practice.     

A national survey of turnover intention among general practitioners in China

Studies on turnover intention among Chinese general practitioners (GPs) at the national level are limited. This study aimed to assess intention to leave and its associated factors among a nationally representative sample of GPs. The participants were selected using a multistage stratified random sampling method. A self-administered structured questionnaire was used to collect data from 3236 GPs in China between October 2017 and February 2018. A multiple linear stepwise regression analysis was used to identify factors associated with turnover intention. Over 70.0% GPs had a moderate or high turnover intention. GPs who were male, were younger, had a higher education level, had a lower professional title, had a lower income level, and had a temporal work contract had higher turnover intention. In addition, GPs who worked night shifts, had low job satisfaction, and had few opportunities for professional development reported higher turnover intention. Substantial gender and regional differences in predictors of turnover intention among GPs were observed. The study showed that turnover intention in Chinese GPs is high, and the factors influencing turnover intention were low professional title and income level, high education level, having a temporary work contract, working night shifts, and limited opportunities for professional development.     

Experience with and attitudes towards HIV patients among Italian general practitioners

Italian general practitioners (GPs) were surveyed to assesstheir experience in treating HIV patients: asymptomatic HIVpatients (P-HIV) and patients with AIDS (P-AIDS). The GPs' attitudestowards treating P-HIV/P-AIDS, their feelings of competenceand their interest in improving their competence were also assessed.The survey was based on structured interviews conducted In November1992 on a stratified random sample of 900 GPs. Half the sampleanswered questions about P-AIDS, while the other half answeredquestions about P-HIV. The percentage of GPs who have treatedpatients was 10% for P-AIDS and 34% for P-HIV. They generallyjudged this experience negatively due to its dramatic nature,as well as their sense of therapeutic helplessness and the difficultiesthey have when communicating with the patients and, to somedegree, even with the hospital centres. The majority of subjectswere willing to treat patients (56% P-AIDS and 65% P-HIV). Thiswillingness leaned more towards psychological or educationalassistance than medical therapy. Discriminant analysis demonstratesthat the willing GPs were younger and felt more committed totheir profession. Once again, the majority of the intervieweesalso stated they do not feel competent enough to treat patients(78% P-AIDS and 70% P-HIV) and that they were personally interestedin improving their own skills in this area. This paper stressesthe importance of careful evaluation of the opportunity of gettingGPs more involved in dealing with P-HIV/P-AIDS.     

Evaluation of an independent, radiographer-led community diagnostic ultrasound service provided to general practitioners

BACKGROUND: Health care services traditionally offered in a secondary setting are increasingly being offered in a primary setting. There has been little assessment of quality and efficiency of diagnostic services such as ultrasound delivered in primary settings and no studies have looked at independently provided services. AIMS: To assess the benefits and disadvantages of a radiographer delivered, primary care-based mobile diagnostic ultrasound service by comparing it to an NHS Trust diagnostic ultrasound service. DESIGN: A retrospective, comparative study. SETTING: A primary care area in the West Midlands. METHOD: Random samples of 200 and 193 adult patients who underwent diagnostic ultrasound in 2001/2002 with the community and NHS Trust services respectively, and all GP principals in the area were identified. Patient access (including wait for appointments), patient and GP satisfaction, clinical quality of services, and cost-effectiveness were assessed by postal questionnaires, interviews, review of stored ultrasound images, patient record review and collection of data on unit costs. RESULTS: Mean wait for an appointment was 17.44 (15.85-19.02) and 44.53 days (38.83-50.23) for the community and NHS Trust services respectively. Response rates from the community and hospital patient groups were 52.9 percent and 44.6 percent, respectively. Demographic characteristics of the two groups of respondents did not differ significantly, therefore justifying comparison between the two groups of respondents. High proportions of patients from both services reported time and location of appointment as convenient. Access to secondary care following an abnormal ultrasound was not systematically different for the services. Patients were highly satisfied with both services. GPs were markedly less satisfied with the NHS Trust service compared to the community service. Quality of stored ultrasound images and reports were comparable for the services. Cost per abnormality detected was higher for the community service (107.69 pound sterling compared to 77.35 pound sterling for the NHS Trust service, not statistically significant). CONCLUSION: The community diagnostic ultrasound service offers reduced waiting times compared to the NHS Trust service, and is of comparable quality. This benefit, together with high patient and GP satisfaction levels, may justify the possible reduced cost-effectiveness of the service compared to the NHS Trust service.     

The determinants of reproductive health service provision by general practitioners in Pakistan

OBJECTIVE: The aim of this cross-sectional study was to identify the factors that influence the provision of reproductive health services by General Practitioners (GPs) working in the province of Sind, Pakistan. METHODS AND PARTICIPANTS: One hundred and ninety-eight GPs were selected as the study participants by a multistage, randomized stratified, proportionate sampling procedure. Data were collected using a self-completed questionnaire, which was validated for content validity by an expert review panel and for face validity by a pilot test administered to doctors from developing countries. Data collection took place between November 2000 and February 2001. RESULTS: Eighty-six percent of GPs (171/198) responded to the questionnaire. Of those, only 25% reported providing reproductive health services in their clinics. The major determinants of reproductive health service provision were found to be the urban location of the GP clinic, being a female GP, postgraduate training in reproductive health and a good knowledge of reproductive health. CONCLUSIONS: The findings of this study suggest that the provision of reproductive health services in Sind could be improved by increasing the involvement of female GPs. This can be achieved by encouraging more female GPs into the specialty, with the use of incentives if necessary, and providing adequate postgraduate training to improve their reproductive health knowledge and skills. The results of this study have broadened understanding of the factors that influence GPs in their provision of reproductive health services, and will contribute significantly to research on reproductive health in Pakistan.     

Older people with heart failure and general practitioners: temporal reference frameworks and implications for practice

The aim of the study was to identify the time experiences of older patients and general practitioners (GPs). Secondary analysis of qualitative data collected from two longitudinal studies, one in the United Kingdom (UK) and the other in New Zealand (NZ), was carried out. The UK study involved interviews with 44 older people with heart failure and nine focus group discussions with primary health professionals during 2004-2005. The NZ study involved 79 interviews with 25 older people with heart failure and 30 telephone interviews with GPs during 2008-2009. Temporal reference frameworks function as background expectations and influence how patients and GPs experienced time and act as time controls. The key themes identified were: clock time was evident in how it structured the consultations; both patients and GPs valued needing time and for some GPs this involved creating space for emotional time. There were also tensions between needing time and wasting time; being known over time was important to both patients and GPs. For older people with heart failure improving their quality of care is essential and time is integral to this, not only the clock time and length of consultations. Identifying temporal reference frameworks provides an understanding that there are multiple times and exposes the influence of these in the lives of both the older people and GPs.     

Immigrant and native regular general practitioners in Norway. A comparative registry-based observational study

Background: More than 10% of the population and nearly 20% of all general practitioners (GPs) in Norway have an immigrant background. There are reasons to believe that immigrant GPs have different demographic characteristic and serve different populations than native GPs.

Objectives: To describe the characteristics of the lists and population subscribed to immigrant GPs in Norway and compare them with those of Norwegian-born GPs.

Methods: Immigrant GPs were defined as persons born abroad with both parents from abroad. Two national registers were linked with information about all inhabitants and GPs in Norway in 2008: the GPs Database, and the National Population Register. Logistic regression was used to study the influence of the GP's immigrant background on different characteristics.

Results: Compared to native GPs, immigrant GPs are younger, more often women, and more frequently work alone and in rural areas. GPs with immigrant background have a higher proportion of immigrant patients (OR = 3.2; 95% CI: 2.7–3.8), not only from their own culture, but also from other cultures, and this proportion increases over time. Immigrant GPs have more difficulties recruiting patients compared to their native colleagues (OR = 0.3; 95% CI: 0.3–0. 4 for having closed lists), but this difference seems to diminish over time. There are, however, substantial differences between immigrant GPs from different areas of the world.

Conclusion: The characteristics of the populations assigned to GPs with or without immigrant background are different. This should be taken into account when studying differences between immigrant and native GPs.     

Variation in how mothers, health visitors and general practitioners use the personal child health record

BACKGROUND: In the UK, a national personal child health record (PCHR) with local adaptations is in widespread use. Previous studies report that parents find the PCHR useful and that health visitors use it more than other health professionals. This study was carried out in Nottingham, where the local PCHR is similar to the national PCHR. OBJECTIVES: To explore variation in use of the PCHR made by mothers with differing social characteristics, to compare heath visitors' and general practitioners' (GPs') use of the PCHR, and to compare health visitors' and GPs' perceptions of the PCHR with those of mothers for whose children they provide care. METHODS: Questionnaires to 534 parents registered with 28 general practices and interviews with a health visitor and GP at each practice. A score per mother for perceived usefulness of the PCHR was developed from the questionnaire, and variation in the score was investigated by linear regression adjusted for clustering. RESULTS: Four hundred and one (75%) questionnaires were returned. Three hundred and twenty-five (82%) mothers thought the PCHR was very good or good. Higher scores for usage of the PCHR were significantly associated with teenage and first-time mothers, but no association was found with mother's social class, education or being a single parent. There was no association between variation in the score and practice, health visitor or GP characteristics. Mothers, health visitors and GPs reported that mothers took the PCHR to baby clinic more frequently than when seeing their GP, and that health visitors wrote in the PCHR more frequently than GPs. Eighteen (67%) health visitors and 20 (71%) GPs said they had difficulty recording information in the PCHR. CONCLUSION: The PCHR is used by most mothers and is important for providing health promotion material to all families with young children. It may be particularly useful for first-time and teenage mothers.     

Hours worked by general practitioners and waiting times for primary care

The decline in the working hours of general practitioners (GPs) is a key factor influencing access to health care in many countries. We investigate the effect of changes in hours worked by GPs on waiting times in primary care using the Medicine in Australia: Balancing Employment and Life longitudinal survey of Australian doctors. We estimate GP fixed effects models for waiting time and use family circumstances to instrument for GP's hours worked. We find that a 10% reduction in hours worked increases average patient waiting time by 12%. Our findings highlight the importance of GPs' labor supply at the intensive margin in determining the length of time patients must wait to see their doctor.     

Narratives and gatekeeping: making sense of triage nurses’ practice

It is well documented that emergency service staff consider some patients to be ‘inappropriate attenders’. A central example is ‘trivia’, denoting patients with medical problems considered too ‘trivial’ to warrant attention. Although research has repeatedly shown that frontline staff violate guidelines in turning away ‘trivial’ patients, existing research has paid insufficient attention to why staff are willing to engage in guideline‐violating gatekeeping, which may put both themselves and ‘trivial’ patients at risk. To address this issue, the present article explores nurses’ narratives about ‘trivial’ patients – referred to in this context as ‘GP patients’ – drawing on fieldwork data from a Norwegian emergency service. The article reconstructs three narrative clusters, showing that nurses’ gatekeeping is motivated by concerns for the patient being turned away, for nurses and more critically ill patients, and for the service they work for. Some of the issues embedded in these narratives have been under‐analysed in previous research – most importantly, the role of identity and emotion in nurses’ gatekeeping, and how patient narratives can function as ‘social prognoses’ in nurses’ assessments. Analysis of these narratives also reveals an antagonistic relationship between nurses and ‘trivial’ patients that contradicts nurses’ ethical guidelines and indicates a need for healthcare reform.     

Primary Care System Factors and Clinical Decision-making in Patients that Could Have Lung Cancer: a Vignette Study in Five Balkan Region Countries

IntroductionLung cancer is the leading cause of cancer death, with wide variations in national survival rates. This study compares primary care system factors and primary care practitioners’ (PCPs’) clinical decision-making for a vignette of a patient that could have lung cancer in five Balkan region countries (Slovenia, Croatia, Bulgaria, Greece, Romania).MethodsPCPs participated in an online questionnaire that asked for demographic data, practice characteristics, and information on health system factors. Participants were also asked to make clinical decisions in a vignette of a patient with possible lung cancer.ResultsThe survey was completed by 475 PCPs. There were significant national differences in PCPs’ direct access to investigations, particularly to advanced imaging. PCPs from Bulgaria, Greece, and Romania were more likely to organise relevant investigations. The highest specialist referral rates were in Bulgaria and Romania. PCPs in Bulgaria were less likely to have access to clinical guidelines, and PCPs from Slovenia and Croatia were more likely to have access to a cancer fast-track specialist appointment system. The PCPs’ country had a significant effect on their likelihood of investigating or referring the patient.ConclusionsThere are large differences between Balkan region countries in PCPs’ levels of direct access to investigations. When faced with a vignette of a patient with the possibility of having lung cancer, their investigation and referral rates vary considerably. To reduce diagnostic delay in lung cancer, direct PCP access to advanced imaging, availability of relevant clinical guidelines, and fast-track referral systems are needed.