peter vedsted, prof., phd frede olesen , prof., drmedsci the research unit for general practice
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Cancer survival and the gatekeeper principle - have we missed some side effects of gatekeeper systems?. Peter Vedsted, Prof., PhD Frede Olesen , Prof., DrMedSci The Research Unit for General Practice Research Centre for Cancer Diagnosis in Primary Care – CaP Aarhus University Denmark. - PowerPoint PPT PresentationTRANSCRIPT
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
Cancer survival and the gatekeeper principle
- have we missed some side effects of gatekeeper systems?
Peter Vedsted, Prof., PhD Frede Olesen, Prof., DrMedSci
The Research Unit for General PracticeResearch Centre for Cancer Diagnosis in Primary Care – CaP
Aarhus UniversityDenmark
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
UNIVERSITY OF AARHUSDENMARK
Frede Olesen, Res. Unit for GP, Univ. of Aarhus, Denmark
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
The Research Unit for General PracticeAarhus University, Denmark
Frede Olesen Research directorProfessor, dr.med.sci, [email protected]
Peter VedstedHead of the CaP centre, vice directorPh.d., [email protected]
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
Outline
The ‘primary care convention’
Cancer survival caused surprise
The ecologic study
The perspectives
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
Primary Care Convention The ’General Practitioner’ doing ’Family Medicine’
a person-centred approach,
a unique consultation process, a relationship over time,
provide longitudinal continuity of care
Position in the healthcare system
first point of contact, open and unlimited access,
makes efficient use of healthcare resources…, managing the interface with other specialities ...
The European Definitions of General Practice /Family Medicine, WONCA EUROPE, 2002
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
’The gatekeeper invention’
Precise point of entry and first contact
Right to refer to specialist treatment
Guidance, continuity and communication
Rationing and efficiency
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
A total health care system- integration:- the GP should be perfect in the inverted T
- quality: balance in the inverted T Vertical – towards the hospital
Horisontal – PHC team
general practice
Hospital
Familie etc. Social care etc.
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
The question- do we fail in the vertical part?
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
About cancer and primary care
Lifetime cancer risk is 35%1
At least >80% are seen in primary care2,3
90% present symptoms
25% of total mortality1
Sources:1. Albreht et al. European Journal of Cancer. 2008;1451–14562: Allgar et al. British Journal of Cancer 2005;92:1959–703: Hansen. Delay in the diagnosis of cancer [Thesis]. University of Aarhus, 2008
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
We were surprised… again…
Møller H et al. British Journal of Cancer. 2009;101, S110–4
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
Have we ignored something? The principle of a strong primary care sector, i.e. with general
practice as gatekeeper, as first point of contact and with a list system, has documented advantages
However, are there adverse consequences?
Is the GP a ‘hostage’ in rationing care and in keeping waiting lists short?
Is it so difficult to refer that the threshold gets too high?
What is the consequence of the relation and repeated contact?Selected sources:Starfield B et al. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502.Walley J et al. Primary health care: making Alma-Ata a reality. Lancet 2008;372:1001-1007.Starfield B. Is primary care essential? Lancet 1994;344:1129-1133.Halm EA et al. Is gatekeeping better than traditional care? A survey of physicians' attitudes. JAMA 1997;278:1677-1681.Freeman GK et al. Continuity of care: an essential element of modern general practice? Fam Pract 2003;20:623-627.Goodwin N. Diagnostic delays and referral management schemes: how "integrated" primary care might damage your health. Int J of Integrated Care 2008; 8
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
The ecologic study
Is there an association between the organisation of general practice and the relative one-year cancer survival?
Data included:
The relative one-year survival for 42 cancers in 19 countries1
The organisation of general practice (gatekeeper, list system, first point of contact)2,3
Analysis:
Median survival, composite survival index1: Møller H et al. A visual summary of the EUROCARE-4 results: a UK perspective. Br J Cancer 2009;101(Suppl 2):S110-4.2: Boerma WG et al. Service profiles of general practitioners in Europe. European GP Task Profile Study. Br J Gen Pract 1997;47:481-6.3: Saltman RB et al. Primary care in the driver's seat? 1 ed. Maidenhead: Open University Press; 2006.
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
Adverse effect of the gatekeeper system?
Relative one-year survival (%)
Countries Median (%) p-value
Gatekeeper No 7 73.40.004
Yes 12 67.8
List system No 9 73.40.004
Yes 10 66.3
First point of
contact
Always 10 66.3
0.001Depends 7 73.4
No 2 73.4
Vedsted P et al. Are the serious problems in cancer survival partly rooted in gatekeeper principles? Submitted
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
Conclusion
Cancer is common, and most patients present with symptoms
Primary care is essential in early cancer diagnosis
Does the organisation with general practice as gatekeeper, as first point of contact and with a list system result in:
5-7% lower one-year survival in cancer?
2,000 lost person-years in Denmark each year?
We need to know! And if so – WHY?
Funded by: Danish Cancer Society | The Novo Nordisk Foundation
Conclusion II: Have we ignored something? Are there adverse consequences of gatekeeping?
Is the GP a ‘hostage’ in rationing care and in keeping waiting lists short?
Is it so difficult to refer that the threshold gets too high?
What is the consequence of the relation and repeated contact?
Even if a strong front line gives the best system
We must investigate side effects
Is gatekeeping the problem – not the strong front line?