jean karl soler mipc. inter-doctor and inter-practice variation maltese context what do we know? ...

Jean Karl SolerMIPC

Inter-doctor and inter-practice variation

Maltese contextWhat do we know?Transition project dataSummaryReflection

Continuing doctor-patient relationship is a core value for primary care

Long term doctor-patient relationship Longitudinal care and consultation

experiences Knowledge, trust, loyalty, regard

Benefits of concentrating care in one team less than concentrating care in one provider

Haggerty J. The future for personal doctoring. BJGP 2009; 59(561): 236-7

Move from single-handed practice to multi-disciplinary practice has an impact

Trade-off between being seen promptly by a doctor and longitudinal continuity Accessibility... ...as against longitudinal continuity

Co-ordinated care as against longitudinal continuity

Patients value the personal care given by one doctor, but also accessibility

Haggerty J. The future for personal doctoring. BJGP 2009; 59(561): 236-7

Differences between family doctors Different doctor interests (disease, prevention) Different ways doctor conceptualises diagnoses

and manages health problems (e.g. symptom diagnoses)

Differences between practices All above, but doctors also influence each other Common work practices and/or protocols Different prevalence of disease Different practice populations (age, sex, culture)

Patients choose their doctor, influenced by above

Primary care reform Government

Registration (Weak) commitment to reform primary care

Family doctors Specialists, but not treated as such in

practice Apprehension of working in group practices Out of hours Reform, without support and resources?

154 responses out of 324 FM specialists(effective response rate of 47.7%)

More than 50% agreed strongly with increasing access to investigations facilitating chronic disease care improving continuity of care, investing in PHC, and having a

public campaign for PHC More than 50% agreement on

patient registration, harmonising private and public care, career progression in public FM, instituting specialist FM clinics (ranked jointly at 6)

increasing access to private insurances was ranked lowest as a priority by respondents, with a median rank of 7

In almost all questions, the percentage of respondents who agreed or agreed strongly with these initiatives was 90% or more, with few exceptions (patient registration with 69.7%, and specialist FM clinics with 81.6% agreeing)

Soler JK, Stabile I, Borg R. MCFD Questionnaire 2007. Malta, MCFD.

Informal discussions between colleagues Family doctors are ready to accept change

Unity instead of fragmentation Improvements in quality of service provision Improvements in quality of life for doctors Access to investigations and special interventions

Family doctors have issues with change Registration brings responsibilities Out of hours care is an issue Resources to support change

▪ Capitation fee▪ Item of service payments▪ Support for staff, premises, IT

Change to group and/or out of hours system Move from solo practice to collaboration Patients will be exposed to different styles of

doctoring Patients may gain accessibility at the cost of less

continuity of care / doctor-patient relationship Family doctor becomes manager and team leader New responsibilities New challenges How to start?

We can learn from our colleagues

Attitudes and behaviour more similar for GP pairs/groups as against solo GPs

Shared circumstances is most important influence

Adaptation plays a role Selection is least important

tested by age and gender of GPs Actual pairs are more similar than random pairs

for consultation time More similarities between respiratory diagnoses

than other systemsDe Jong J, Groenewegen PP, Westert GP. Mutual influences of general practitioners in partnerships. Social Science and Medicine 2003; 57:1515-1524

Patterns in inter-doctor variation Patient utilisation varies between practices

312 to 404 per 1000 do not consult in one year 132 to 246 per 1000 have more than 5 encounters 18 to 54 per 1000 have more than 10 encounters

Variation in numbers of encounters between practices in a period are less than variation within practice between periods of time

Less variation in referral (8%); number of physical examinations and prescriptions (15%); average variation in blood investigations (28%); higher variation in giving advice (36%) and counselling (62%)

Marinus AMF. Inter-doktervariatie in de huisartspraktijk . Amsterdam, the Netherlands 1993.

GP “styles” GPs with many encounters and episodes per

year carry out more physical examinations, blood tests, radiology, advice, prescriptions and referrals than expected

GPs with more symptom diagnoses (e.g. cough, abdominal pain as against bronchitis, gastroenteritis) associated with fewer blood tests and little diagnostic radiology, more advice and therapeutic counselling

Marinus AMF. Inter-doktervariatie in de huisartspraktijk . Amsterdam, the Netherlands 1993.

Percentage variationCode Label G F P H W

1 A98 Prevention -5.6% 19.3% 7.9% -10.7% -21.7%2 R74 URI (head cold) 51.4% -2.5% -5.7% -4.1% -36.4%3 R05 Cough -49.0% -18.8% 30.0% 40.5% 49.2%4 R78 Acute bronchitis/bronchiolitis -32.8% 37.8% -68.8% 41.9% -27.6%5 U71 Cystitis/other urin infect NOS -12.1% -4.5% -28.7% 60.7% -14.6%6 L03 Low back complt excl radiation 8.9% -3.7% -32.2% -1.1% 19.9%7 S88 Contact dermatitis/other eczema -19.6% 11.6% -21.0% -1.4% 17.1%8 A97 No disease -12.7% -14.1% 35.3% 70.2% -35.6%9 S74 Dermatophytosis 12.6% -23.5% -4.9% 50.6% -11.4%

10 H81 Excessive ear wax -0.3% 13.0% -34.0% 0.5% -8.8%11 R75 Sinusitis acute/chron -28.3% 11.4% -57.9% 65.4% -6.1%12 W11 Family plan/oral contraceptive -1.1% -7.6% -18.9% 24.8% 9.3%13 L81 Other injury -13.2% 21.5% -0.6% -14.9% -22.3%14 A04 General weakness/tiredness -13.8% 8.2% -8.8% 22.0% -18.2%15 L01 Neck sympt/complt excl headache 37.7% -33.4% -9.1% 10.3% 21.3%16 P06 Disturbances of sleep/insomnia -8.8% -9.1% -14.4% 28.8% 20.0%17 S03 Warts -14.8% 1.9% -24.6% 15.2% 22.3%18 A85 Adv effect med agent proper dose 1.5% 18.1% -63.3% -0.8% 3.9%19 F70 Infectious conjunctivitis -0.9% 4.1% -34.4% 17.2% 12.7%20 D12 Constipation -1.8% -21.5% -28.3% 77.2% 10.0%

1 A98 Prevention -5.6% 19.3% 7.9% -10.7% -21.7%2 R74 URI (head cold) 51.4% -2.5% -5.7% -4.1% -36.4%3 R05 Cough -49.0% -18.8% 30.0% 40.5% 49.2%4 R78 Acute bronchitis/bronchiolitis -32.8% 37.8% -68.8% 41.9% -27.6%5 U71 Cystitis/other urin infect NOS -12.1% -4.5% -28.7% 60.7% -14.6%6 L03 Low back complt excl radiation 8.9% -3.7% -32.2% -1.1% 19.9%7 S88 Contact dermatitis/other eczema -19.6% 11.6% -21.0% -1.4% 17.1%8 A97 No disease -12.7% -14.1% 35.3% 70.2% -35.6%9 S74 Dermatophytosis 12.6% -23.5% -4.9% 50.6% -11.4%

10 H81 Excessive ear wax -0.3% 13.0% -34.0% 0.5% -8.8%11 R75 Sinusitis acute/chron -28.3% 11.4% -57.9% 65.4% -6.1%12 W11 Family plan/oral contraceptive -1.1% -7.6% -18.9% 24.8% 9.3%13 L81 Other injury -13.2% 21.5% -0.6% -14.9% -22.3%14 A04 General weakness/tiredness -13.8% 8.2% -8.8% 22.0% -18.2%15 L01 Neck sympt/complt excl headache 37.7% -33.4% -9.1% 10.3% 21.3%16 P06 Disturbances of sleep/insomnia -8.8% -9.1% -14.4% 28.8% 20.0%17 S03 Warts -14.8% 1.9% -24.6% 15.2% 22.3%18 A85 Adv effect med agent proper dose 1.5% 18.1% -63.3% -0.8% 3.9%19 F70 Infectious conjunctivitis -0.9% 4.1% -34.4% 17.2% 12.7%20 D12 Constipation -1.8% -21.5% -28.3% 77.2% 10.0%

Percentage variationCode Label F J M R

1 R74 Upper respiratory infection acute 49.1% -9.3% 2.8% -7.9%2 A98 Health maint/preventive medicine 25.1% 27.4% 19.2% -25.7%3 D73 Gastroenteritis presumed infection -29.6% -11.0% -2.9% 6.7%4 L18 Muscle pain -70.6% -6.6% 11.7% 12.6%5 A97 No disease -34.1% 18.8% -52.1% 17.7%6 R78 Acute bronchitis/bronchiolitis 161.2% -73.3% -84.6% 8.9%7 K86 Hypertension uncomplicated -48.1% -46.8% -22.9% 33.2%8 R76 Tonsillitis acute -49.1% -48.7% 16.6% 8.3%9 R96 Asthma -61.4% 1.9% -54.5% 28.0%

10 R80 Influenza -98.7% -82.0% -96.6% 57.5%11 R05 Cough -41.7% -73.1% 185.7% -32.3%12 A85 Adverse effect medical agent -94.6% 60.5% -70.0% 37.2%13 R29 Respiratory symptom/complaint other -99.1% -94.5% 460.5% -98.2%14 T93 Lipid disorder -28.1% -5.5% -36.7% 18.1%15 R97 Allergic rhinitis -55.6% 83.7% -70.4% 18.9%16 R75 Sinusitis acute/chronic -34.3% -38.1% -13.8% 14.9%17 P17 Tobacco abuse -97.2% -30.5% -91.0% 52.5%18 P76 Depressive disorder -65.3% -54.7% -68.2% 52.4%19 H82 Vertiginous syndrome -24.3% -75.7% -21.9% 28.4%20 T90 Diabetes non-insulin dependent -50.0% -63.3% -31.3% 41.0%

The NetherlandsPercentage variation

Code Label G F P H W1 R05 Cough 6.4% -1.2% -30.6% 29.8% -1.0%2 A03 Fever 18.7% -15.5% -42.7% 29.2% 37.0%3 A04 General weakness/tiredness -6.0% 3.2% -15.7% 17.4% -13.0%4 S06 Local redness/erythema/rash 21.3% 5.6% -58.2% -46.0% 48.9%5 L03 Low back complt excl radiation 10.9% 8.3% -37.1% 0.5% -6.9%6 R02 Shortness of breath dyspnea -8.3% 23.0% -41.0% -13.3% 6.6%7 R21 Sympt/complt throat -4.1% -10.3% -8.0% 27.6% 15.0%8 D06 Other localized abdominal pain 6.1% -3.2% -6.5% -12.1% 12.6%9 S04 Local swelling/papul/lump/mass 20.6% -3.8% 20.4% -40.7% 7.4%

10 N01 Headache (excl N02 N89 R09) -10.3% 7.8% -29.0% 9.6% 8.4%11 S03 Warts -50.2% 27.2% -7.4% -2.4% 5.9%12 L08 Shoulder symptoms/complaints -14.6% 6.0% -37.3% 34.0% -1.4%13 L01 Neck sympt/complt excl headache 17.5% -14.1% -24.6% 13.1% 13.3%14 L15 Knee symptoms/complaints -9.4% 15.0% -32.6% 6.8% -10.0%15 H01 Ear pain/earache -5.9% -2.6% -35.8% 19.7% 26.2%16 L14 Leg/thigh symptoms/complaints -18.4% 40.0% -40.2% -14.0% -12.7%17 S02 Pruritis (excl D05 X16) 15.3% 25.5% -50.7% -17.8% -13.4%18 R74 URI (head cold) -50.6% 18.0% -11.1% 40.4% 0.5%19 L17 Foot & toe symptoms/complaints -9.1% 5.4% -28.2% 12.3% 5.1%20 H02 Hearing complaints (excl H84) -36.1% 54.2% -6.5% -67.0% 3.9%

The NetherlandsPercentage variation

Code Label G F P H W1 R05 Cough 6.4% -1.2% -30.6% 29.8% -1.0%2 A03 Fever 18.7% -15.5% -42.7% 29.2% 37.0%3 A04 General weakness/tiredness -6.0% 3.2% -15.7% 17.4% -13.0%4 S06 Local redness/erythema/rash 21.3% 5.6% -58.2% -46.0% 48.9%5 L03 Low back complt excl radiation 10.9% 8.3% -37.1% 0.5% -6.9%6 R02 Shortness of breath dyspnea -8.3% 23.0% -41.0% -13.3% 6.6%7 R21 Sympt/complt throat -4.1% -10.3% -8.0% 27.6% 15.0%8 D06 Other localized abdominal pain 6.1% -3.2% -6.5% -12.1% 12.6%9 S04 Local swelling/papul/lump/mass 20.6% -3.8% 20.4% -40.7% 7.4%

10 N01 Headache (excl N02 N89 R09) -10.3% 7.8% -29.0% 9.6% 8.4%11 S03 Warts -50.2% 27.2% -7.4% -2.4% 5.9%12 L08 Shoulder symptoms/complaints -14.6% 6.0% -37.3% 34.0% -1.4%13 L01 Neck sympt/complt excl headache 17.5% -14.1% -24.6% 13.1% 13.3%14 L15 Knee symptoms/complaints -9.4% 15.0% -32.6% 6.8% -10.0%15 H01 Ear pain/earache -5.9% -2.6% -35.8% 19.7% 26.2%16 L14 Leg/thigh symptoms/complaints -18.4% 40.0% -40.2% -14.0% -12.7%17 S02 Pruritis (excl D05 X16) 15.3% 25.5% -50.7% -17.8% -13.4%18 R74 URI (head cold) -50.6% 18.0% -11.1% 40.4% 0.5%19 L17 Foot & toe symptoms/complaints -9.1% 5.4% -28.2% 12.3% 5.1%20 H02 Hearing complaints (excl H84) -36.1% 54.2% -6.5% -67.0% 3.9%

MaltaPercentage variation

Code Label F J M R1 R05 Cough -13.0% -12.2% 29.4% -2.4%2 R21 Throat symptom/complaint 76.9% -28.6% 40.5% -21.3%3 R07 Sneezing/nasal congestion 22.4% -38.0% -2.2% 1.5%4 A03 Fever -7.0% -13.6% 38.9% -5.0%5 D06 Abdominal pain localized other -45.1% -65.4% 17.4% 13.1%6 D11 Diarrhoea -40.6% 6.3% -4.0% 8.3%7 N01 Headache -27.9% 11.2% 22.7% -3.6%8 D10 Vomiting -38.8% -11.8% 11.6% 8.7%9 L02 Back symptom/complaint -46.7% -26.9% 2.2% 12.8%

10 A04 Weakness/tiredness general -10.8% 26.8% 3.4% 0.3%11 N17 Vertigo/dizziness -73.6% 9.9% 45.0% 4.5%12 H01 Ear pain/earache -41.2% 25.9% 1.6% 0.8%13 S06 Rash localized -59.4% -1.3% 8.6% 7.8%14 D01 Abdominal pain/cramps general -49.1% -3.5% -22.0% 14.2%15 D09 Nausea 40.1% -21.7% 38.5% -13.4%16 L04 Chest symptom/complaint -55.1% -30.8% -4.4% 20.6%17 P01 Feeling anxious/nervous/tense -21.1% 67.1% -55.7% 14.9%18 R02 Shortness of breath/dyspnoea -66.8% -5.9% -11.5% 24.5%19 L14 Leg/thigh symptom/complaint -24.8% 19.9% 18.3% -2.0%20 L01 Neck symptom/complaint -1.3% -1.8% 4.9% -5.4%

MaltaPercentage variation

Code Label F J M R1 R05 Cough -13.0% -12.2% 29.4% -2.4%2 R21 Throat symptom/complaint 76.9% -28.6% 40.5% -21.3%3 R07 Sneezing/nasal congestion 22.4% -38.0% -2.2% 1.5%4 A03 Fever -7.0% -13.6% 38.9% -5.0%5 D06 Abdominal pain localized other -45.1% -65.4% 17.4% 13.1%6 D11 Diarrhoea -40.6% 6.3% -4.0% 8.3%7 N01 Headache -27.9% 11.2% 22.7% -3.6%8 D10 Vomiting -38.8% -11.8% 11.6% 8.7%9 L02 Back symptom/complaint -46.7% -26.9% 2.2% 12.8%

10 A04 Weakness/tiredness general -10.8% 26.8% 3.4% 0.3%11 N17 Vertigo/dizziness -73.6% 9.9% 45.0% 4.5%12 H01 Ear pain/earache -41.2% 25.9% 1.6% 0.8%13 S06 Rash localized -59.4% -1.3% 8.6% 7.8%14 D01 Abdominal pain/cramps general -49.1% -3.5% -22.0% 14.2%15 D09 Nausea 40.1% -21.7% 38.5% -13.4%16 L04 Chest symptom/complaint -55.1% -30.8% -4.4% 20.6%17 P01 Feeling anxious/nervous/tense -21.1% 67.1% -55.7% 14.9%18 R02 Shortness of breath/dyspnoea -66.8% -5.9% -11.5% 24.5%19 L14 Leg/thigh symptom/complaint -24.8% 19.9% 18.3% -2.0%20 L01 Neck symptom/complaint -1.3% -1.8% 4.9% -5.4%

The Netherlands

1 *50 Medication/prescript/injection -18.1% 25.7% -32.6% 2.6% 1.2%2 *31 Med exam/health evalua/partial 1.2% 41.5% -31.8% -27.5% -39.4%3 *45 Advice/health education 1.3% 54.9% -57.2% -39.6% -35.0%4 *34 Other blood test 8.7% 21.1% -51.1% 1.3% -23.7%5 *67 Referral to m.d. -8.3% 0.3% -4.1% 32.0% -18.4%6 *66 Referral pc-provider (excl *67) 1.1% -24.9% 6.0% 49.0% -5.1%7 *41 Diagnostic radiology/imaging 7.1% 2.9% -48.5% 36.7% -23.8%8 *35 Other urine test 3.8% 2.2% -50.6% 47.5% -19.5%9 *52 Excision/biopsy/removal/cautery -11.8% 15.0% -43.1% -4.4% 23.0%

10 *44 Immunization/prevent medication -97.5% 144.9% 48.7% -83.2% -82.2%

The Netherlands

1 *50 Medication/prescript/injection -18.1% 25.7% -32.6% 2.6% 1.2%2 *31 Med exam/health evalua/partial 1.2% 41.5% -31.8% -27.5% -39.4%3 *45 Advice/health education 1.3% 54.9% -57.2% -39.6% -35.0%4 *34 Other blood test 8.7% 21.1% -51.1% 1.3% -23.7%5 *67 Referral to m.d. -8.3% 0.3% -4.1% 32.0% -18.4%6 *66 Referral pc-provider (excl *67) 1.1% -24.9% 6.0% 49.0% -5.1%7 *41 Diagnostic radiology/imaging 7.1% 2.9% -48.5% 36.7% -23.8%8 *35 Other urine test 3.8% 2.2% -50.6% 47.5% -19.5%9 *52 Excision/biopsy/removal/cautery -11.8% 15.0% -43.1% -4.4% 23.0%

10 *44 Immunization/prevent medication -97.5% 144.9% 48.7% -83.2% -82.2%

1 *31 Medical examin/health eval partial -19.1% -10.1% 21.8% -0.7%2 *50 Medication/prescr/renewal/inject -4.6% 12.4% 5.2% -3.5%3 *45 Observ/health educat/advice/diet 27.7% 104.0% -86.0% -1.0%4 *62 Administrative procedure -4.1% 26.3% 68.8% -24.2%5 *34 Blood test -22.1% -0.5% 54.3% -10.9%6 *67 Referral to md/specialist/clin/hosp -45.8% 26.3% 31.9% -3.1%7 *35 Urine test -56.2% -69.2% 146.7% -15.6%8 *58 Therapeutic counselling/listening -46.2% 98.0% -100.0% 26.2%9 *41 Diagnostic radiology/imaging -82.5% -37.8% -35.3% 37.1%

10 *44 Preventive immunization/medication 0.0% 36.8% 93.9% -38.2%

1 *31 Medical examin/health eval partial -19.1% -10.1% 21.8% -0.7%2 *50 Medication/prescr/renewal/inject -4.6% 12.4% 5.2% -3.5%3 *45 Observ/health educat/advice/diet 27.7% 104.0% -86.0% -1.0%4 *62 Administrative procedure -4.1% 26.3% 68.8% -24.2%5 *34 Blood test -22.1% -0.5% 54.3% -10.9%6 *67 Referral to md/specialist/clin/hosp -45.8% 26.3% 31.9% -3.1%7 *35 Urine test -56.2% -69.2% 146.7% -15.6%8 *58 Therapeutic counselling/listening -46.2% 98.0% -100.0% 26.2%9 *41 Diagnostic radiology/imaging -82.5% -37.8% -35.3% 37.1%

10 *44 Preventive immunization/medication 0.0% 36.8% 93.9% -38.2%

-150.0%

-100.0%

-50.0%

100.0%

150.0%

200.0%

F J M R

*31 Medical examin/health eval partial

*50 Medication/prescr/renewal/inject

*45 Observ/health educat/advice/diet

*62 Administrative procedure

*34 Blood test

*67 Referral to md/specialist/clin/hosp

*35 Urine test

*58 Therapeutic counselling/listening

*41 Diagnostic radiology/imaging

Primary care reform presents opportunities and challenges

Patients may gain accessibility to care, but the quality of care may change (less continuity)

Maltese GPs welcome change, but are wary of the challenges

Various practice styles exist Circumstances are a moulding force Working together will change the way

we practice

Doctors may take different approaches Disease oriented, tests, treatment, referral Symptom oriented, advising and counselling Various other patterns

Patients will choose doctors on the basis of their approach

Think about how your patients will perceive you

jean karl soler mipc. inter-doctor and inter-practice variation maltese context what do we know? ...

Documents

continuity of care

public care

hours care

personal care

chronic disease care

different styles of

doctors access

change registration