1 a study of universal access and separatist primary care systems on the island of ireland

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A study of universal access and A study of universal access and separatist primary care systems separatist primary care systems

on the island of Irelandon the island of Ireland

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Queen’s University BelfastQueen’s University Belfast

• Dr. Dermot O’ReillyDr. Dermot O’Reilly• Dr. Keith SteeleDr. Keith Steele• Dr. Drew GillilandDr. Drew Gilliland• Ms. Karen ThompsonMs. Karen Thompson Trinity College DublinTrinity College Dublin

• Professor Tom O’DowdProfessor Tom O’Dowd• Dr Alan KellyDr Alan Kelly

University College DublinUniversity College Dublin• Professor Gerry BuryProfessor Gerry Bury

NUI GalwayNUI Galway• Professor Andrew W Professor Andrew W MurphyMurphy• Mrs. Ethna ShryaneMrs. Ethna Shryane

University Of UlsterUniversity Of Ulster• Professor Ciaran O’NeillProfessor Ciaran O’Neill

Project TeamProject Team

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OriginalOriginal research questions research questions (N vs S)(N vs S)Question 1.Question 1.Does health status differ between patients ?Does health status differ between patients ?Yes; south are healthierYes; south are healthier

Question 2.Question 2.How do patients view the issue of cost? How do patients view the issue of cost? In south: good idea; in north, not soIn south: good idea; in north, not so

Question 3.Question 3.Does a co-payment effect health seeking behaviour? Does a co-payment effect health seeking behaviour? Yes; very much so in the southYes; very much so in the south

Question 4.Question 4. Does patient satisfaction differ ?Does patient satisfaction differ ?Yes; south are more satisfiedYes; south are more satisfied

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Post hocPost hoc question (south only) question (south only)

Question 5.Question 5.Are primary care services different for those who pay? Are primary care services different for those who pay? i.e. GMS (capitation) vs private patients (FFS)i.e. GMS (capitation) vs private patients (FFS)

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The effects of capitation The effects of capitation and fee for service on and fee for service on

the consultation the consultation process: a cross process: a cross

sectional study and sectional study and associated associated

dissemination issuesdissemination issues

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Background literatureBackground literaturePayment systemsPayment systems– Prospective: Salary and capitationProspective: Salary and capitation– Retrospective: Fee for service (FFS)Retrospective: Fee for service (FFS)– MixedMixed

Market theoriesMarket theories– Supplier Induced Demand (SID)Supplier Induced Demand (SID)– ConsumerismConsumerism

Cochrane review (2000)Cochrane review (2000)– 4 studies of 6, 400 patients; 2 children only4 studies of 6, 400 patients; 2 children only– Concerns regarding generalisability and confounding esp. health Concerns regarding generalisability and confounding esp. health

status and patient satisfactionstatus and patient satisfaction– Need for further standardised and prospective studiesNeed for further standardised and prospective studies

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Study hypothesesStudy hypotheses

1.1. That That GP initiated visitsGP initiated visits will be will be higherhigher in FFS in in FFS in comparison to capitation patientscomparison to capitation patients

2.2. That That prescription, investigation and referralprescription, investigation and referral rates will all be rates will all be higherhigher in FFS in comparison to in FFS in comparison to capitation patientscapitation patients

3.3. That That satisfaction with communicationsatisfaction with communication will be will be higherhigher in FFS in comparison to capitation in FFS in comparison to capitation patientspatients

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Ireland: Ireland: 30%30% free (low income & 70+yrs): free (low income & 70+yrs): CapitationCapitation

70%70% pay (€35-55): pay (€35-55): Fee for Fee for service ‘FFS’service ‘FFS’

The Island of Ireland

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MethodologyMethodology

22ndnd Phase – Audit of consultations (Ireland only) Phase – Audit of consultations (Ireland only) Random selection of up to 200 survey respondents per practiceRandom selection of up to 200 survey respondents per practice Random selection of 1 consultation per patientRandom selection of 1 consultation per patient Up to 4 outcomes categorised per consultation & summarised; Up to 4 outcomes categorised per consultation & summarised;

- Prescription (Yes/No) Prescription (Yes/No) - Investigation (Yes/No) Investigation (Yes/No) - Referral (Yes/No)Referral (Yes/No)

11stst Phase - Baseline survey Phase - Baseline survey 20 practices in Ireland, 20 in N.Ireland (matched)20 practices in Ireland, 20 in N.Ireland (matched)

625 patients randomly selected from lists625 patients randomly selected from lists

Postal survey (Autumn 2003; 2 reminders): RR 52%Postal survey (Autumn 2003; 2 reminders): RR 52%

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Study instrumentsStudy instruments

Health statusHealth status– Limiting long term illness (LLTI)Limiting long term illness (LLTI)– Perceived general healthPerceived general health– Case finding for depressionCase finding for depression

Classification of ‘GP initiated’ or notClassification of ‘GP initiated’ or not

Process outcomeProcess outcome– Prescription; investigation; referralPrescription; investigation; referral

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Study Instruments: Study Instruments: GPGP AAssessment ssessment QQuestionnaire uestionnaire

Dimensions of patient satisfaction:Dimensions of patient satisfaction:

Continuity of CareContinuity of Care Patient / Doctor CommunicationPatient / Doctor Communication Access to servicesAccess to services Overall SatisfactionOverall Satisfaction

ReceptionistsReceptionists NursingNursing

* * © The National Primary Care Research and Development Centre, © The National Primary Care Research and Development Centre, University of Manchester and Safran/NEMCHUniversity of Manchester and Safran/NEMCH

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Questions that form the communication scale of the General Practice Assessment Questionnaire

Thinking about consulting with your doctor, how would you rate the following:1. How thoroughly your doctor asks about your symptoms?2. How well your doctor listens to what you say?3. How well the doctor puts you at ease during your physical examination?4. How much the doctor involves you in decisions about your care?5. How well your doctor explains your problems or treatments you need? 6. The amount of time your doctor spends with you?7. Doctor’s patience with your questions or worries?8. Doctor’s caring and concern for you?

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MethodsMethods

AnalysisAnalysis– Logistic regression with robust confidence Logistic regression with robust confidence

intervals to account for clustering within intervals to account for clustering within practicespractices

Ethical approval from ICGPEthical approval from ICGP

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ResultsResults

1, 668 patients from 20 practices1, 668 patients from 20 practices– Mean age 34.7 (SD 19.5)Mean age 34.7 (SD 19.5)– 62.6% female62.6% female– 28.4% capitation and 70.4% FFS28.4% capitation and 70.4% FFS– EducationEducation

11OO: 24.3%; 2: 24.3%; 2OO: 43.2%;3: 43.2%;3OO 29.8% 29.8%

– Car ownershipCar ownershipNone: 14.7%; One: 39.0%; 2+cars: 45.7%None: 14.7%; One: 39.0%; 2+cars: 45.7%

– 77.4% owner occupier77.4% owner occupier– LLTI: Yes 24.5%LLTI: Yes 24.5%– Depression: Yes 38.4%Depression: Yes 38.4%

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Structure of Data in SouthStructure of Data in South

Survey Survey respondents respondents

(5,291; RR 52%)(5,291; RR 52%)

Random Random Selection (3, Selection (3,

351)351)

Prescription Prescription (993; 59.5%)(993; 59.5%)

InvestigationInvestigation(239; 14.3%)(239; 14.3%)

ReferralReferral(237; 14.2%)(237; 14.2%)

Patients aged 20-69 yrs Patients aged 20-69 yrs who consulted during 12 who consulted during 12

mth periodmth period(2, 584; 77.1%)(2, 584; 77.1%)

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1.1. That That GP initiated visitsGP initiated visits will be will be higherhigher in in the FFS group in comparison to the the FFS group in comparison to the capitation group capitation group TotalTotal mean consultation rate mean consultation rate– Capitation 6.0 (n = 693); FFS 3.6 (n = 548)Capitation 6.0 (n = 693); FFS 3.6 (n = 548)– Mean difference 2.38 (95% CI 1.90-2.87)Mean difference 2.38 (95% CI 1.90-2.87)

Initiation: GP 11.1% and Patient 85.8%Initiation: GP 11.1% and Patient 85.8%– FFS 9.6%FFS 9.6%– Capitation 14.6%Capitation 14.6%

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Logistic regression determinant Logistic regression determinant of having a GP initiated visitof having a GP initiated visit

Adjusting for sex, age, general health, Adjusting for sex, age, general health, LLTI, Depression, GMS eligibility, LLTI, Depression, GMS eligibility, household income and geographyhousehold income and geography

Only Only GMS eligibilityGMS eligibility significant: significant:– Capitation Capitation 1.001.00– FFSFFS 0.56 (95% CI 0.37-84)0.56 (95% CI 0.37-84)

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1.1. That That GP initiated visitsGP initiated visits will be will be higherhigher in in the FFS group in comparison to the the FFS group in comparison to the capitation group capitation group

2.2. That That prescription, investigation and prescription, investigation and referralreferral rates will all be rates will all be higher higher in FFS in FFS patients in comparison to capitation patients in comparison to capitation patientspatients

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Prescription, investigation and Prescription, investigation and referral rates by referral rates by ageage

0

10

20

30

40

50

60

70

Prescriptions (p=ns) Investigations(p<0.001)

Referrals (p<0.001)

% 0-19 20-44 45-69

2020

Prescription, investigation and Prescription, investigation and referral rates referral rates self-reported self-reported

general healthgeneral health

0

10

20

30

40

50

60

70

Prescriptions(p=0.002)

Investigations(p=0.044)

Referral (p=0.036)

%

Excellent Very Good Good Fair/Poor

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Prescription, investigation and Prescription, investigation and referral rates by referral rates by payment statuspayment status

0

10

20

30

40

50

60

70

Prescription(p<0.001)

Investgation(p<0.001)

Referral (p=ns)

%

Captiation (GMS) Fee for service (Non-GMS)

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Logistic regression determinants Logistic regression determinants of being issued a of being issued a RxRx

General General healthhealth

Adj ORAdj OR CI’sCI’s P valueP value

ExcellentExcellent 1.001.00

Very goodVery good 1.601.60 1.27-2.021.27-2.02 < 0.001< 0.001

GoodGood 1.591.59 1.22-2.101.22-2.10 0.0010.001

Fair/PoorFair/Poor 1.311.31 0.94-1.820.94-1.82 0.1090.109

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Logistic regression determinants Logistic regression determinants of being issued a of being issued a RxRx

GMS GMS statusstatus


CapitationCapitation 1.001.00

FFSFFS 0.750.75 0.66-0.850.66-0.85 < 0.001< 0.001

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Logistic regression determinants Logistic regression determinants of being of being investigatedinvestigated




FFSFFS 2.262.26 1.50-3.401.50-3.40 0.0010.001

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Logistic regression determinants Logistic regression determinants of being of being referredreferredAdj ORAdj OR CI’sCI’s P valueP value

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1.1. That That GP initiated visitsGP initiated visits will be will be higherhigher in the in the FFS group in comparison to the capitation FFS group in comparison to the capitation group group

2.2. That That prescription, investigation and referralprescription, investigation and referral rates will all be rates will all be higherhigher in FFS patients in in FFS patients in comparison to capitation patientscomparison to capitation patients

3.3. That That satisfaction with communicationsatisfaction with communication will be will be higherhigher in FFS patients in comparison to in FFS patients in comparison to capitation patientscapitation patients

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Logistic regression determinants Logistic regression determinants of a of a high communication scorehigh communication score

AgeAge Adj ORAdj OR CI’sCI’s P valueP value

20-2920-29 1.001.00

30-3930-39 0.700.70 0.53-0.930.53-0.93 0.0140.014

40-4940-49 0.570.57 0.42-0.780.42-0.78 < 0.001< 0.001

50-5950-59 0.640.64 0.44-0.930.44-0.93 0.0200.020

60-6960-69 0.860.86 0.59-1.250.59-1.25 0.4330.433

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General General healthhealth


ExcellentExcellent 1.001.00

Very goodVery good 0.760.76 0.56-1.030.56-1.03 0.7400.740

GoodGood 0.480.48 0.34-0.680.34-0.68 < 0.001< 0.001

Fair/PoorFair/Poor 0.520.52 0.35-0.770.35-0.77 0.0010.001

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FFSFFS 0.790.79 0.66-0.950.66-0.95 0.0140.014

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ProcessProcess Adj ORAdj OR CI’sCI’s P valueP value

Not Ix’edNot Ix’ed 1.001.00

Ix’edIx’ed 1.291.29 1.01-1.651.01-1.65 0.0380.038

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DiscussionDiscussionLimitationsLimitations– Cross sectional study: ‘Association, not causation’Cross sectional study: ‘Association, not causation’– Retrospective determination of consultation initiationRetrospective determination of consultation initiation– Long term, not acute, health statusLong term, not acute, health status– All GP’s receive mixed paymentsAll GP’s receive mixed payments

StrengthsStrengths– Mixed is reflective of international practiceMixed is reflective of international practice– Clustering accounted for during analysisClustering accounted for during analysis– Relatively large (n=1, 668) study in nationally Relatively large (n=1, 668) study in nationally

representative samplerepresentative sample– Disaggregated consultation data with potential Disaggregated consultation data with potential

confounders includedconfounders included

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1.1. That That GP initiated visitsGP initiated visits will be will be higherhigher in FFS in in FFS in comparison to capitation patientscomparison to capitation patients FFSFFS OR 0.75OR 0.75 95%CI 0.66-0.8595%CI 0.66-0.85

2.2. That That prescription, investigation and referralprescription, investigation and referral rates will all rates will all be be higherhigher in FFS vs capitation in FFS vs capitation

Rx: Rx: FFSFFS OR 0.75OR 0.75 95%CI 0.66-0.8595%CI 0.66-0.85 Ix:Ix: FFSFFS OR 2.26OR 2.26 95%CI 1.50-3.4095%CI 1.50-3.40 Referral:Referral:

3. That 3. That satisfaction with communicationsatisfaction with communication will be will be higherhigher in in FFS in comparison to capitationFFS in comparison to capitation FFSFFS OR 0.79OR 0.79 95%CI 0.66-0.9595%CI 0.66-0.95

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Why so ?Why so ?

Madden and Nolan (2005)Madden and Nolan (2005)

Use of Rx and Ix by GP’sUse of Rx and Ix by GP’s

Omission of confounders from previous Omission of confounders from previous work, Scott (1995)work, Scott (1995)

Stable Irish system vs US ‘before + after’Stable Irish system vs US ‘before + after’

Uni-dimensional economical approach – Uni-dimensional economical approach – ‘businessman with licences’- insufficent‘businessman with licences’- insufficent

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Incentivisation vs professionalismIncentivisation vs professionalism

Timmins, 2005Timmins, 2005– ‘‘the professionalism of the professionalism of

GP’s will have to be GP’s will have to be played off against their played off against their financial self interest’financial self interest’

Marshall, 2005Marshall, 2005– ‘‘crowding out’crowding out’

0

20

40

60

80

100

120

0 1 2 3 4 5 6

Score

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ConclusionsConclusions

Prescription and investigation patterns indicate Prescription and investigation patterns indicate that the method of GP remuneration does impact that the method of GP remuneration does impact upon the process of the consultation. upon the process of the consultation.

SID does not appear to explain the differences SID does not appear to explain the differences between payment status; rather GPs may be between payment status; rather GPs may be more concerned with their patients’ ability to pay, more concerned with their patients’ ability to pay, than with opportunities for income generation. than with opportunities for income generation.

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Dissemination issuesDissemination issues

JE Pirkis, GA Blashki, A W Murphy, JC JE Pirkis, GA Blashki, A W Murphy, JC Richards, IB Hickie, L Ciechomski.Richards, IB Hickie, L Ciechomski. The The contribution of general practice based contribution of general practice based research to the development of national research to the development of national policy: Two international case studies. policy: Two international case studies. Submitted Submitted AusNZ Health Policy JournalAusNZ Health Policy Journal

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Publishing recordPublishing recordQuestion 1.Question 1.Does health status differ between patients ?Does health status differ between patients ?Rejected:Rejected: Eur J Pub Hlth, Soc Sci Med Eur J Pub Hlth, Soc Sci Med CurrentlyCurrently: IJMS: IJMS

Question 2.Question 2.How do patients view the issue of cost? How do patients view the issue of cost? RejectedRejected: Health Affairs : Health Affairs CurrentlyCurrently: Hth : Hth EconomicsEconomics Question 3.Question 3.Does a co-payment effect health seeking behaviour? Does a co-payment effect health seeking behaviour? RejectedRejected: BMJ, Family Practice : BMJ, Family Practice CurrentlyCurrently: EJGP: EJGP

Question 4.Question 4. Does patient satisfaction differ ?Does patient satisfaction differ ?CurrentlyCurrently: Family Practice: Family Practice

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Research into policyResearch into policyLavis, 2003 Lavis, 2003 – ‘‘producer-push’producer-push’

(where producers of research actively push (where producers of research actively push research knowledge out to users of research), research knowledge out to users of research),

– ‘‘user-pull’user-pull’(where users of research actively pull in research (where users of research actively pull in research when faced with a decision that they believe could when faced with a decision that they believe could be informed by research knowledge) and be informed by research knowledge) and

– ‘‘knowledge exchange’ knowledge exchange’ (where producers and users of research are jointly (where producers and users of research are jointly responsible for transferring and facilitating the responsible for transferring and facilitating the uptake of research knowledge, and elements of uptake of research knowledge, and elements of ‘producer push’ and ‘user pull’ approaches occur)‘producer push’ and ‘user pull’ approaches occur)

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DisseminationDisseminationInnvaer (2002): systematic review of of policy-makers’ views Innvaer (2002): systematic review of of policy-makers’ views on using research evidence for policy decisions. on using research evidence for policy decisions. Facilitators x7Facilitators x7– personal contact between researchers and policy-makerspersonal contact between researchers and policy-makers– timeliness and relevance of the researchtimeliness and relevance of the research– summary with clear recommendationssummary with clear recommendations– good quality researchgood quality research – confirmed current policy or endorsed self-interestconfirmed current policy or endorsed self-interest– community pressure or client demand for research community pressure or client demand for research – included effectiveness dataincluded effectiveness data

Barriers x6Barriers x6– absence of personal contact between researchers and policy-absence of personal contact between researchers and policy-

makersmakers– lack of timeliness or relevancelack of timeliness or relevance– mutual mistrust, including perceived political naivety of scientists mutual mistrust, including perceived political naivety of scientists

and scientific naivety of policy-makersand scientific naivety of policy-makers– power and budget strugglespower and budget struggles– poor quality of researchpoor quality of research– political instability or high turnover of policy-makerspolitical instability or high turnover of policy-makers

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FFS vs capitation paperFFS vs capitation paper

Where to send to ? Where to send to ? – Probably a secondary issue, for us ?Probably a secondary issue, for us ?

Have decided Have decided notnot to wait for publication to wait for publication– attempted to get HRB to sponsor meetingattempted to get HRB to sponsor meeting– will persist with some prior dissemination will persist with some prior dissemination

Sustenance from Int Cmmttee Med Sustenance from Int Cmmttee Med – http://http://www.icmje.orgwww.icmje.org//

The The idealideal is Lomas, 2000 is Lomas, 2000– ‘‘linkage and exchange’, that routine and ongoing involvement of linkage and exchange’, that routine and ongoing involvement of

policy-makers in the activities of research organisations will policy-makers in the activities of research organisations will improve the likelihood of research influencing policy.improve the likelihood of research influencing policy.

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AcknowledgementsAcknowledgements

HRBHRB

Participating GP’s and practicesParticipating GP’s and practices

1 a study of universal access and separatist primary care systems on the island of ireland

Documents

capitation patients

island of ireland slide

safrannemch slide

satisfied slide

south question

capitation retrospective

effects of capitation

healthier question