Anxiety management in Australian general practice: an analysis of encounters from 2006 - 2016

BACKGROUND

Anxiety disorders are highly prevalent mental health conditions managed predominantly by general practitioners (GPs). This study aimed to examine the management of anxiety by Australian GPs since the introduction of the Better Access to Psychiatrists, Psychologists and General Practitioners initiative in 2006.

METHODS

We conducted secondary analysis of Bettering the Evaluation and Care of Health data on GP encounters for anxiety from 2006 to 2016 (N = 28,784). We calculated point estimates and used multivariate logistic regression to explore the effect of GP and patient characteristics on rates and types of management.

RESULTS

The management rate of anxiety increased from 2.3% of GP encounters in 2006 to 3.2% in 2016. Over the 10-year period, increases were seen in referrals to psychologists (AOR = 1.09, 95%CI = 1.07-1.11, p < .0001) and selective serotonin / serotonin-noradrenalin reuptake inhibitors (AOR = 1.05, 95%CI = 1.03-1.06, p < .0001), and benzodiazepines decreased (AOR = 0.94, 95%CI = 0.92-0.95, p < .0001). Systematic differences in management were found for patient and GP characteristics, including high rates of benzodiazepines in certain groups.

CONCLUSIONS

Anxiety is accounting for more of the GP workload, year on year. GP management of anxiety has become more closely aligned with practice guidelines since 2006. However, high rates of benzodiazepine prescribing in certain groups remains a concern. Further research is needed into GP treatment decision making for anxiety.

Factors associated with Australian female doctors' long term, as opposed to short term, rural Family Medicine work

OBJECTIVE

In light of current debate around securing and distributing the General Practitioner (GP) workforce in Australia, we analysed rural health workforce data to identify characteristics associated with long-term tenure for rural female GPs, an importantly lacking part of the rural workforce in Australia.

METHODS

In this cohort study, 555 currently practicing rural female GPs with long, versus short, rural work histories were surveyed annually. Their data were compared.

RESULTS

In logistic regression, as expected the factors associated with 7+ years (long-term) versus <7 years (short-term) rural work were: being older (odds ratio [OR] 6.18, 95% confidence interval [CI] 1.16, 13.0, P < 0.001); being an Australian resident (OR 4.64, 95% CI 2.17, 9.91, P < 0.001); having a practice teaching commitment (OR 3.55, 95% CI 1.67, 7.55, P = 0.001); having multiple children (OR 2.19, 95% CI 1.23, 3.88, P = 0.008); rural health club experience as a medical student (OR 5.23, 95% CI 1.11, 23.86, P = 0.033); and, marginally, being rurally experienced as an undergraduate through the Rural Clinical School programme (OR 8.89, 95% CI 0.921, 85.75, P = 0.059) and having a rural background spouse (OR 1.20, 95% CI 0.94, 4.21, P = 0.070).

CONCLUSION

The factors involved in long-term rural work for female GPs include a longitudinal set from medical school into postgraduate practice life, some based on Australian government policy initiatives and others on lifestyle choices. These factors should be considered in providing a clinically mature female GP workforce to rural populations.

General practitioner gender and use of diagnostic procedures: a French cross-sectional study in training practices

OBJECTIVES

The acceleration in the number of female doctors has led to questions about differences in how men and women practice medicine. The aim of this study was to assess the influence of general practitioner (GP) gender on the use of the three main categories of diagnostic procedures-clinical examinations, laboratory tests and imaging investigations.

DESIGN

Cross-sectional nationwide multicentre study.

SETTING

French training general practices.

PARTICIPANTS

The patient sample included all the voluntary patients over a cumulative period of 5 days per office between November 2011 and April 2012. The GP sample included 85 males and 43 females.

METHODS

54 interns in general practice, observing their GP supervisors, collected data about the characteristics of GPs and consultations, as well as the health problems managed during the visit and the processes of care associated with them. Using hierarchical multilevel mixed-effect logistic regression models, we performed multivariable analyses to assess differences in each of the three main categories of diagnostic procedures, and two specific multivariable analyses for each category, distinguishing screening from diagnostic or follow-up procedures. We searched for interactions between GP gender and patient gender or type of health problem managed.

RESULTS

This analysis of 45 582 health problems managed in 20 613 consultations showed that female GPs performed more clinical examinations than male GPs, both for screening (OR 1.75; 95% CI 1.19 to 2.58) and for diagnostic or follow-up purposes (OR 1.41; 95% CI 1.08 to 1.84). Female GPs also ordered laboratory tests for diagnostic or follow-up purposes more frequently (OR 1.21; 95% CI 1.03 to 1.43). Female GPs performed even more clinical examinations than male GPs to diagnose or follow-up injuries (OR 1.69; 95% CI 1.19 to 2.40).

CONCLUSION

Further research on the appropriateness of diagnostic procedures is required to determine to what extent these differences are related to underuse or overuse.

Prevalence and management of people with eating disorders presenting to primary care: A national study

OBJECTIVE

Primary care practitioners are well placed to support diagnosis and appropriate treatment of eating disorders as they are often the first point of contact with the health care system. However, little is known about management of eating disorders in primary care. We aimed to estimate the prevalence of management of eating disorders in primary care and identify how these disorders are managed.

METHODS

This study used data from the Bettering the Evaluation of Care of Health programme, which annually surveys 1000 randomly sampled general practitioners in Australia who each record details of 100 successive patient encounters. In total, data were utilised from 1,568,100 primary care encounters between 2000/2001 and 2015/2016.

RESULTS

Eating disorders were managed in less than 1% of primary care encounters between 2000/2001 and 2015/2016. When extrapolated to the Australian population, up to 0.32% of the population were managed in primary care for a primary or probable eating disorder. In the majority of encounters where an eating disorder was managed (58.5%), the encounter was initiated for reasons other than the eating disorder itself. Of a group of patients identified with a clinically significant low body mass index (N = 5917), a small number (n = 118) had either no other diagnosis or a related condition that may be indicative of an eating disorder. In encounters where an eating disorder was managed, referrals to a mental health specialist/service, medical specialist and nutritionist/dietician were provided in 20%, 8% and 6% of encounters, respectively. Mental health treatment plans, which provide subsidised access to mental health services, were ascribed in approximately 7.7% of encounters where an eating disorder was managed.

CONCLUSION

Primary care provides an opportunity to improve detection and management of eating disorders, particularly when patients present for 'other' issues or with unexplained low body mass index and one or more symptoms related to an eating disorder.

Management of plantar heel pain in general practice in Australia

BACKGROUND

Studies have described general practitioner (GP) management of plantar heel pain from some countries; however, there is limited information from Australian general practice.

OBJECTIVES

To describe patient and GP characteristics, and management actions for plantar heel pain in Australian general practice.

DESIGN

Secondary analysis of data from the Bettering the Evaluation and Care of Health (BEACH) dataset.

METHODS

Data were summarised using descriptive analysis and robust 95% confidence intervals (CIs) were calculated around point estimates. Multivariate logistic regression identified predictors of plantar heel pain management.

RESULTS

From 1,568,100 encounters between April 2000 and March 2016, plantar heel pain was managed at 3007 encounters. GPs manage plantar heel pain approximately once every 500 encounters, which extrapolates to 271,100 encounters in 2015-2016. Patient factors independently associated with plantar heel pain encounters included female sex (OR 1.27, 95% CI 1.17-1.34 cf. males), being aged 45-64 (OR 3.44, 95% CI 2.94-4.01 cf. aged 75+) and patients from a non-English speaking background (OR 1.22, 95% CI 1.07-1.39). Plantar heel pain was frequently managed using medication (45.1 per 100), with non-steroidal anti-inflammatory drugs the most common (22.8 per 100). GPs also commonly provided counselling/advice/education (32.4 per 100), and referrals for diagnostic imaging (19.1 per 100) and to podiatrists (12.0 per 100).

CONCLUSIONS

Plantar heel pain is a frequently managed foot condition in Australian general practice. GPs use medication, counselling and education, diagnostic imaging and referral to podiatrists for management. Further research is required to understand the drivers of these management actions and whether they are effective.

Gender differences in physician decisions to adopt new prescription drugs

Physician adoption of new technologies is a key issue for population health and the sustainability of the healthcare system. This paper explores gender differences in general practitioners' (GPs) adoption of new oral anticoagulants. We combine detailed individual data on physician and practice style characteristics from the Medicine in Australia: Balancing Employment and Life (MABEL) panel survey of Australian physicians with administrative prescribing data from the Australian Pharmaceutical Benefits Scheme (PBS) and the Medicare Benefits Schedule (MBS) for the period January 1, 2012 and December 31, 2015. After adjusting for various factors proposed in the literature as drivers of this gender gap, in addition to risk preferences and personality traits, we find a large statistical gender difference in the speed of adoption with men being faster than women in uptake. However, conditional on having prescribed for the first time, female and male GPs differ only slightly in the intensity of use of these new drugs. We show that the gender gap depends on the measure of uptake and discuss possible channels that could be driving the relatively large gender difference that remains in the speed of adoption.

Characteristics of general practitioner referrals to podiatrists in Australia, 2000-2016

OBJECTIVE

The aim of the study was to describe patterns of referral to podiatrists by general practitioners (GPs) in Australia.

STUDY DESIGN

This is a continuous cross-sectional study of Australian general practice activity.

METHODS

We analysed data from the Bettering the Evaluation and Care of Health program, collected from April 2000 to March 2016 inclusive. Data were summarised using descriptive statistics with 95% confidence intervals around point estimates. Multivariate logistic regression was used to identify GP and patient characteristics independently associated with referral.

RESULTS

The data set included 1,568,100 encounters, including 5,912 podiatry referrals. Referrals increased from 7.0 to 39.5 per 1000 population over the evaluation period. In multivariate analyses, female GPs were more likely than male GPs to refer, and GPs aged ≥55 years were less likely to refer. Patients referred to podiatrists were more likely to be aged ≥85 years, be Indigenous, be from an English-speaking background and have previously been seen at the practice. The problem generating the highest number of referrals was diabetes. After the introduction of Medicare funding, referred patients were more likely to be women, be aged >45 years, have a healthcare card, be socio-economically disadvantaged and have previously been seen at the practice.

CONCLUSIONS

GP referral to podiatrists in Australia increased markedly after the introduction of Medicare funding and appears to be targeted to those with the greatest need. Further research is required to determine whether this policy has improved outcomes and is cost-effective.

Gender equity at last: a national study of medical students considering a career in rural medicine

BACKGROUND

The rural medical workforce internationally suffers from a significant imbalance between male- and female- identifying practitioners. Not only do male doctors outnumber female doctors, but additionally female doctors work fewer hours than their male counterparts. This has health implications for rural communities. In response, In Australia, Rural Clinical Schools (RCSs) are a national training strategy to increase the number of graduates entering the rural medical workforce. It has been observed that RCSs attract a greater number of female students than male students. However, the future work intentions of male versus female RCS students is not known. This paper therefore asked whether male and female RCS students have equivalent intent for future rural practice.

METHODS

Participants were all students who attended RCSs from 2015 to 2017, who completed an exit survey that gathered data on demographic, experiential and intentional variables. Univariate analyses examined differences between the sexes. A multivariate model was constructed to determine the independent predictors for rural intention.

RESULTS

There were 2017 respondents across the 3 years, of whom 937 identified as male, and 1138 identified as female. In univariate analysis, female-identifying students had significantly higher rural intention than male-identifying students. There were no other sex-based differences in age, rural background, overall perception of support, and overall excellence of clinical education whilst in RCS. However, in multivariate analysis, sex was not a significant predictor for rural work intention, whereas older age, rural background, and first preference for RCS were all predictive of increased rural intent, as expected from the literature. There were no differences between male and female students in their perceptions of the overall support and the clinical education provided by RCS.

CONCLUSION

We conclude from this national study that sex is not an independent predictor for future rural work intention among RCS students. Considering the disproportionate number of female students entering RCS, this is reassuring for ultimately achieving rural workforce gender equity.

Influence of Physician Sex and Gender on Prescribing Practices Among Older Adults

Although prescribing is the most common intervention provided by physicians, limited research has examined the role of physician sex and gender on prescribing practices. In this article, we briefly summarize research relating to differences in prescribing behaviors based on physician sex and gender. To identify articles, PubMed was searched for studies from the last 20 years reporting on prescribing differences by physician sex or gender for the general population and specifically for older adults. We describe major themes emerging from the studies, illustrate findings from key studies, and note the major gaps in the literature, notably the lack of evidence on prescribing for older adults. Given the paucity of research in this area, we also explore evidence on the impact of physician sex and gender on other aspects of healthcare delivery, such as communication within the patient-physician relationship, and consider how these findings may also apply to prescribing behaviors. In general, we note that female physicians have been observed to engage in more careful and conservative healthcare provision including prescribing. A careful and conservative approach to prescribing may reduce the incidence of adverse drug events in older adults and be linked to a more patient-centered approach to care. To what extent these differences in prescribing are important for patient health outcomes is unknown, and further research is required to identify optimal prescribing practices that minimize harms.

Management of people with venous leg ulcers by Australian general practitioners: An analysis of the national patient-encounter data

Venous Leg Ulcers cost Australia's healthcare system millions yearly, as they are underdiagnosed, and possibly undertreated. Most Venous Leg Ulcers are seen in general practice. However, it is currently unknown as to what treatment actions are most common in these contexts. Understanding how they are managed in these settings can improve healthcare delivery and patient outcomes. Using cross-sectional general practitioner patient encounter data collected April 2006 to March 2016 from the Bettering the Evaluation and Care of Health program, a continuous national study of general practice clinical activity in Australia, we aimed to describe the characteristics of venous leg ulcer management by general practitioners in Australia. Among the 972 100 general practitioner-patient encounters recorded, 3604 (0.34%) involved management of VLU. Male general practitioners managed Venous Leg Ulcers significantly more often than female general practitioners. Most Venous Leg Ulcers were treated via dressings (76%) and/or pharmacological treatments (25.7%), with few patients receiving the best practice treatment of medical compression (2.1%) or referral (4.9%). Patients with new (first visit) Venous Leg Ulcers were more likely to receive pharmacological treatments and to be referred elsewhere, and less likely to receive dressings than patients receiving follow-up care. There appears to be a large gap between best practice guidelines and actual Venous Leg Ulcers treatments, as referrals and appropriate treatment was low. Further longitudinal studies are needed to determine the effectiveness of care for people with Venous Leg Ulcers who are managed by general practitioners.

Influence of patient multimorbidity on GP burnout: a survey and register-based study in Danish general practice

BACKGROUND

Patient multimorbidity and GP burnout are increasing problems in primary care and are potentially related.

AIM

To examine whether patient multimorbidity was associated with GP burnout in a Danish primary care setting.

DESIGN AND SETTING

Questionnaire data from 1676 Danish GPs and register data on their patients.

METHOD

GPs completed the Maslach Burnout Inventory. Patients listed in a national registry with ≥2 chronic physical diseases from a list of 10 were classified with multimorbidity. For each practice, crude and sex- and age-standardised rates of multimorbidity were calculated, the latter computed as a weighted average with the weights taken from a reference population (5 646 976 Danish citizens). Data were analysed with logistic regression and adjusted analyses included GPs' age and sex, number of GPs in practice, and socioeconomic deprivation among patients as covariates.

RESULTS

A high crude rate of patient multimorbidity increased GPs' likelihood of burnout (odds ratio [OR] 1.79, 95% confidence interval [CI] = 1.13 to 2.82), and when adjusting for covariates the association remained significant when comparing GPs in the third highest quartile of the multimorbidity rate against GPs in the lowest quartile (OR 1.64, 95% CI = 1.02 to 2.64). The sex- and age-standardised patient multimorbidity rate was not associated with GPs' likelihood of burnout.

CONCLUSION

A high crude rate of patient physical multimorbidity increased the likelihood of burnout among GPs. The sex- and age-standardised rate of multimorbidity was not related to GPs' likelihood of burnout. Thus, the absolute amount of multimorbidity, and not the relative, affects the GP's burnout risk. GPs with high numbers of patients with complex needs should be supported to prevent suboptimal care and GP burnout.

General practice management of rotator cuff related shoulder pain: A reliance on ultrasound and injection guided care

OBJECTIVE

To describe general practitioner's (GP's) current management of rotator cuff related shoulder pain (RCRP) in Australia and identify if this is consistent with recommended care and best available evidence. The secondary aim was to determine if GP management of RCRP changed over time.

METHODS

Data about management of RCRP by Australian GPs was extracted from the Bettering the Evaluation of Care of Health program database over its final five years (April 2011-March 2016). Patient and GP characteristics and encounter management data were extracted. Results are reported using descriptive statistics with point estimates and 95% confidence intervals. A secondary analysis over a 16 year period (2000-2016) examined management data for RCRP in four year periods.

RESULTS

RCRP was the most common shoulder condition managed by GPs at 5.12 per 1,000 encounters; and at an estimated 732,000 times nationally in 2015-2016. Management rate was higher among male patients (5.5 per 1000 encounters c.f. 4.8 for female patients) and was highest in the 45-64 year old age group (8.6 per 1000). RCRP was most frequently managed with medications (54.7%), steroid injection (19.5%) followed by non-steroidal anti-inflammatory drugs (NSAIDs) (19.1%). Imaging was ordered for 43.4% (ultrasound 41.2% and x-ray 11.6%) of all RCRP presentations (new and returning). Over half (53.0%) of new RCRP presentations were referred for ultrasound imaging. In the 16 year period 2000-16 ultrasound imaging more than doubled from 19.1% to 41.9% of management occasions. In parallel, prescribed steroid injection increased from 9.8% to 19.7%.

CONCLUSION

The usual care provided by GPs for RCRP relies on the use of ultrasound and steroid injection. This is not consistent with recommended care and clinical guidelines that recommend these are delayed until after 6-12 weeks of NSAID medication, exercise and activity modification. There has been a significant increase in the rate of steroid injection and ultrasound imaging, which may be due in part to policy change.

Discussing lifestyle behaviors: perspectives and experiences of general practitioners

Background: Initiatives aimed at increasing participation in preventive health behaviors has been identified as a priority for addressing the increasing incidence of non-communicable chronic disease. General practice is an existing network that can be leveraged to intervene and promote messages for health behavior change. We aimed to explore the extent to which ‘lifestyle’ behaviors are discussed by general practitioners (GPs) with their patients in their practices, and the context and content of these discussions.

Methods: GPs (N = 26) practising in Australian clinics participated in semi-structured interviews. Data were analyzed using an inductive thematic analysis.

Results: Results showed discussions of lifestyle behaviors were brief, but relatively frequent and often initiated by the GP. GPs generally provided basic advice and education that was often ad-hoc and in reaction to prompts from the patient. GPs recognized the importance of addressing lifestyle behaviors in practice, but also highlighted substantive barriers that limit the initiation of these discussions. These included patient readiness for change, patient acceptance and openness, patient accountability and responsibility, patient background factors, GPs’ role and knowledge, GP financial implications, GP-patient relationship, and lack of time.

Conclusions: Current findings provide important preliminary knowledge on the extent to which Australian GPs discuss lifestyle behavior change with patients during routine consultations, the context and content of these discussions, and barriers to initiating these discussions. Further research should seek to gain a better understanding of barriers and identify strategies to mitigate their impact. This might maximize the potential for GPs to promote adaptive lifestyle behavior change for improving patient health.

General practitioner referrals to exercise physiologists during routine practice: A prospective study

OBJECTIVES

Physical activity is essential in the primary and secondary prevention of several chronic diseases and should be a standard component of clinical care. The aims of this study were to examine the trends and characteristics of referrals to exercise physiologists in routine care in a nationally representative sample of general practitioners (GPs) in Australia.

DESIGN

This prospective study was an analysis of Bettering the Evaluation and Care of Health (BEACH) GP data from April 2009 to March 2016.

METHODS

In total, each of 6827 randomly sampled GPs recorded details of 100 consecutive encounters (N=682,700). The rate of exercise physiologist referrals was calculated by patient and GP characteristics.

RESULTS

Over the study period, the rate at which GPs referred their patients significantly increased from 0.38 to 1.44 per 1000 encounters. Patients aged 45-64 years were most likely to be referred (1.32 per 1000 encounters). Patients from non-English-speaking backgrounds were referred at less than half the rate (0.41 per 1000) of those from English speaking backgrounds (0.96). Female GPs referred patients (1.27 per 1000 encounters) twice as often as male GPs (0.64). One-third (35.3%) of GP referrals were made for problems relating to the endocrine, nutritional and metabolic systems (e.g., obesity, diabetes mellitus); only 1.6% of referrals were made for mental health conditions.

CONCLUSIONS

Although increasing, the rate of GP referral to exercise physiologists was low and associated with patient and GP characteristics. Education of GPs about the role of exercise physiologists in the prevention and management of chronic disease is needed.

No abatement of steroid injections for tennis elbow in Australian General Practice: A 15-year observational study with random general practitioner sampling

Objective

Evaluate general practitioner (GP) management of tennis elbow (TE) in Australia.

Methods

Data about the management of TE by GPs from 2000 to 2015 were extracted from the Bettering the Evaluation of Care of Health program database. Patient and GP characteristics and encounter management data were classified by the International Classification of Primary Care, version 2, and reported using descriptive statistics with point estimates and 95% confidence intervals.

Results

TE was managed by GPs 242,000 times per year on average. Patients were mainly female (52.3%), aged between 35 and 64 years (mean: 49.3 yrs), had higher relative risks of concomitant disorders (e.g. carpal tunnel syndrome and other tendonitis) and their TE was 10 times more likely to be work related than problems managed for patients who did not have TE. Use of diagnostic tests was low, implying a clinical examination based diagnosis of TE. Management was by procedural treatments (36 per 100 TE problems), advice, education or counselling (25 per 100), and referral to other health care providers (14 per 100, mainly to physiotherapy). The rate of local injection did not change over the 15 years and was performed at similar rates as physiotherapy referral.

Conclusion

The high risk of comorbidities and work relatedness and no abatement in the reasonably high rate of local injections (which is contrary to the evidence from clinical trials) provides support for the development and dissemination of TE clinical guidelines for GPs.

A valuable approach to the use of electronic medical data in primary care research: Panning for gold

Background:

Electronic medical data (EMD) from electronic health records of general practice computer systems have enormous research potential, yet many variables are unreliable.

Objective:

The aim of this study was to compare selected data variables from general practice EMD with a reliable, representative national dataset (Bettering the Evaluation and Care of Health (BEACH)) in order to validate their use for primary care research.

Method:

EMD variables were compared with encounter data from the nationally representative BEACH program using χ2 tests and robust 95% confidence intervals to test their validity (measure what they reportedly measure). The variables focused on for this study were patient age, sex, smoking status and medications prescribed at the visit.

Results:

The EMD sample from six general practices in the Illawarra region of New South Wales, Australia, yielded data on 196,515 patient encounters. Details of 90,553 encounters were recorded in the 2013 BEACH dataset from 924 general practitioners. No significant differences in patient age ( p = 0.36) or sex ( p = 0.39) were found. EMD had a lower rate of current smokers and higher average scripts per visit, but similar prescribing distribution patterns.

Conclusion:

Validating EMD variables offers avenues for improving primary care delivery and measuring outcomes of care to inform clinical practice and health policy.

Resource allocation and the burden of co-morbidities among patients diagnosed with chronic obstructive pulmonary disease: an observational cohort study from Danish general practice

Background

Chronic obstructive pulmonary disease is a leading cause of mortality, and associated with increased healthcare utilization and healthcare expenditure. In several countries, morbidity-based systems have changed the way resources are allocated in general practice. In primary care, fee-for-services tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated expenditures for patients with chronic obstructive pulmonary disease has not previously been examined. The aim of this study is to analyze fee-for-service expenditure of patients diagnosed with chronic obstructive pulmonary disease visiting Danish general practice clinics and further to assess what proportion of fee-for-service expenditure variation was explained by patient morbidity and general practice clinic characteristics, respectively.

Methods

We used patient morbidity characteristics such as diagnostic markers and multi-morbidity adjustment based on adjusted clinical groups (ACGs) and fee-for-service expenditure for a sample of primary care patients for the year 2010. Our sample included 3,973 patients in 59 general practices. We used a multi-level approach.

Results

The average annual fee-for-service expenditure of caring for patients diagnosed with chronic obstructive pulmonary disease in general practice was about EUR 400 per patient. Variation in the expenditures was driven by multimorbidity characteristics up to 28 % where as characteristics such as age and gender only explained 5 %. Expenditures increased progressively with the degree of multimorbidity. In addition, expenditures were higher for patients who had diagnostic markers based on ICPC-2 (body systems and/or components such as infections and symptoms). Nevertheless, 9.8–15.4 % of the variation in expenditure was related to the clinic in which the patient was cared for.

Conclusion

Patient morbidity and general practice clinic characteristics are significant patient-related fee-for-service expenditure drivers in chronic obstructive pulmonary disease care.

Reasons for elderly patients GP visits: results of a cross-sectional study

OBJECTIVE

The aim of this study is to describe the frequency of reasons for elderly patients visits to a general practice (GP) setting.

SUBJECTS AND METHODS

Cross-sectional data from 8,877 randomly selected patients were assessed during a 1-year period by 209 GPs in the German federal state of Saxony. The reasons for visits, performed procedures, and results of visits were documented. In this study, the data of patients aged 65 years and older are analyzed and the procedural and nonprocedural reasons for visits are described.

RESULTS

In all, 2,866 patients aged 65 years and older were included. The majority of patients (1,807) were female. A total of 4,426 reasons for visits were found, distributed on 363 International Classification of Primary Care-2 codes. In the mean, there were 1.5 reasons for a GP visit from each patient. The top five nonprocedural reasons for visiting the GP were: cough (1.8%), back complaints (1.6%), shoulder complaints (1.3%), knee complaints (1.1%), and dyspnea (1.0% of all reasons for visit). The top five procedural reasons for visiting the GP included follow-up investigations of cardiovascular or endocrine disorders and immunizations. The top 30 nonprocedural reasons for visits covered 21.9% of all reasons for visiting. The top 30 procedural reasons covered 54.3% of all reasons for visits.

CONCLUSION

The current work indicates that people aged 65 years and older consult the GP more frequently for procedural than for nonprocedural reasons. The top 30 procedural and nonprocedural reasons for visits cover ~75% of all reasons for visits in these patients.

Association between fee-for-service expenditures and morbidity burden in primary care

BACKGROUND

In primary care, fee-for-services (FFS) tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated FFS expenditures has not previously been examined.

OBJECTIVES

To examine the relative explanatory power of morbidity measures and related general practice (GP) clinic characteristics in explaining variation in politically negotiated FFS expenditures.

METHODS

We applied a multilevel approach to consider factors that explain FFS expenditures among patients and GP clinics. We used patient morbidity characteristics such as diagnostic markers, multimorbidity casemix adjustment based on resource utilisation bands (RUB) and related GP clinic characteristics for the year 2010. Our sample included 139,527 patients visiting GP clinics.

RESULTS

Out of the individual expenditures, 31.6% were explained by age, gender and RUB, and around 18% were explained by RUB. Expenditures increased progressively with the degree of resource use (RUB0-RUB5). Adding more patient-specific morbidity measures increased the explanatory power to 44%; 3.8-9.4% of the variation in expenditures was related to the GP clinic in which the patient was treated.

CONCLUSIONS

Morbidity measures were significant patient-related FFS expenditure drivers. The association between FFS expenditure and morbidity burden appears to be at the same level as similar studies in the hospital sector, where fees are based on average costing. However, our results indicate that there may be room for improvement of the association between politically negotiated FFS expenditures and morbidity in primary care.

The implications of the feminization of the primary care physician workforce on service supply: a systematic review

There is a widespread perception that the increasing proportion of female physicians in most developed countries is contributing to a primary care service shortage because females work less and provide less patient care compared with their male counterparts. There has, however, been no comprehensive investigation of the effects of primary care physician (PCP) workforce feminization on service supply. We undertook a systematic review to examine the current evidence that quantifies the effect of feminization on time spent working, intensity and scope of work, and practice characteristics. We searched Medline, Embase, and Web of Science from 1991 to 2013 using variations of the terms 'primary care', 'women', 'manpower', and 'supply and distribution'; screened the abstracts of all articles; and entered those meeting our inclusion criteria into a data abstraction tool. Original research comparing male to female PCPs on measures of years of practice, time spent working, intensity of work, scope of work, or practice characteristics was included. We screened 1,271 unique abstracts and selected 74 studies for full-text review. Of these, 34 met the inclusion criteria. Years of practice, hours of work, intensity of work, scope of work, and practice characteristics featured in 12%, 53%, 42%, 50%, and 21% of studies respectively. Female PCPs self-report fewer hours of work than male PCPs, have fewer patient encounters, and deliver fewer services, but spend longer with their patients during a contact and deal with more separate presenting problems in one visit. They write fewer prescriptions but refer to diagnostic services and specialist physicians more often. The studies included in this review suggest that the feminization of the workforce is likely to have a small negative impact on the availability of primary health care services, and that the drivers of observed differences between male and female PCPs are complex and nuanced. The true scale of the impact of these findings on future effective physician supply is difficult to determine with currently available evidence, given that few studies looked at trends over time, and results from those that did are inconsistent. Additional research examining gender differences in practice patterns and scope of work is warranted.