Transition project data on inter-doctor variation

1. Jean Karl Soler MIPC Transition project data on inter-doctor variation

2. Presentation plan • Inter-doctor and inter-practice variation • Maltese context • What do we know? • Transition project data • Summary • Reflection

3. The personal doctor • 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

4. The personal doctor • 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

5. Inter-doctor/practice variation • 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

6. Presentation plan • Inter-doctor and inter-practice variation • Maltese context • What do we know? • Transition project data • Summary • Reflection

7. Maltese context • 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?

8. Maltese context • 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.

9. Maltese context • 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

10. Maltese context • 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

11. Presentation plan • Inter-doctor and inter-practice variation • Maltese context • What do we know? • Transition project data • Summary • Reflection

12. What do we know? • 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 systems De Jong J, Groenewegen PP, Westert GP. Mutual influences of general practitioners in partnerships. Social Science and Medicine 2003; 57:1515-1524

13. What do we know? • 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.

14. What do we know? • 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.

15. Presentation plan • Inter-doctor and inter-practice variation • Maltese context • What do we know? • Transition project data • Summary • Reflection

16. Transition project data

17. Episodes of care

18. The Netherlands

19. The Netherlands

21. Malta

22. Malta

23. Malta

25. Reasons for encounter

26. The Netherlands

27. The Netherlands

29. Malta

30. Malta

32. Interventions

33. The Netherlands

34. The Netherlands

36. Malta

37. Malta

39. Prevention / No disease

43. Presentation plan • Inter-doctor and inter-practice variation • Maltese context • What do we know? • Transition project data • Summary • Reflection

44. Summary • 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

45. Presentation plan • Inter-doctor and inter-practice variation • Maltese context • What do we know? • Transition project data • Summary • Reflection

46. Reflection • 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