Effect of a French experiment of team work between general practitioners and nurses on efficacy and cost of type 2 diabetes patients care
Introduction
Both the improvement of the quality of the care delivered by health professionals and the strengthening of primary care organisation are seen as two key elements for increasing the performance of health care systems in a context of increasing demand and constraints in resources [1], [2], [3], [4], [5], [6]. Thus, numerous countries have undertaken reforms that aim at improving medical practices or organizing in a different way the provision of primary or ambulatory care and services, especially for chronic patient. This requires the production of medical practice guidelines and the implementation of “evidence based medicine” in daily practice through policy intervention close to doctors and the implementation of primary care and services organisational innovations: chronic care and/or disease management, performance based economic incentives, group practice and team work [7].
Numerous systematic literature reviews are henceforth available [8], [9], [10], [11], [12], [13], [14], [15]. Passive intervention policy, which includes the simple provision of educational material and standard education activities (e.g. conferences, congresses,…) are considered to be little effective. On the contrary, more active policy interventions have proved to be more effective. These include more advanced continuing medical education strategies (e.g. academic detailing); therapeutic information systems, audit and feedback as well as computing reminders; and finally all “organisational-oriented” policies. Within the latter, our concern is specifically about policies focused on team work and cooperation between GPs and nurses, when nurses substitute or supplement physician workforce. Most of the works converge in their conclusions: nurses trained adequately for specific actions (e.g. prevention, first contact, follow-up of a chronic patient…) can deliver care and services at least from a same level of outcome in terms of quality – indeed superior when the nurse act in complement – and with a greater level of outcome in terms of satisfaction, than of primary care doctors [10], [16], [17]. The magnitude of cost saving and of efficiency gains, depends on salary and productivity differentials between nurses and GPs and possible duplication.
In France, in spite of a public debate on the levers for performance improvement at the professional or organisational levels [18], [19], [20], [21], [22] the recent reforms conserve an “embryonic character”. Our health system still combines a relative free and comprehensive access to care and services for insured [23], [24] with a weak regulation both of professional practices and ambulatory care organisations. One can observe that French health care system have a fragmented ambulatory care system, more than a formal primary care organisation. Most of ambulatory care professionals are self-employed and work in solo practice paid on a fee-for-services basis. They are historically not subject to constraint by any strict mandatory quality regulation and it is only recently that both continuing medical education and the evaluation of professional practice have become mandatory.
As a consequence several signs of inefficiency in health care delivery have come to light; especially for chronically ill patients for whom there has been no dramatic improvement in the care delivery – e.g. for diabetes patients [25], [26], [27], [28], [29] – despite their growing place in the burden of disease and the fact that they currently consume an increasing share of the French health care system's resources [30], [31].
After all, some experiments of network, GP group practices, skill mix and team work (e.g. between GPs and nurses), are supported by an increasing number of stakeholders (sickness funds, state, local representatives…) and professionals’ representatives [32], [33]. A national policy experiment in cooperation and skill mixing was carried out between 2004 and 2008 [33], [34]. This policy authorized ten experiments which involved mainly the transfer of: technical procedures, follow-up of chronic patients with hepatitis, prevention. Only two of them are related to ambulatory care, and only one general practice: the ASALEE experiment (Action de Santé Libérale en Equipe1).
Our general objective is to assess the efficacy and the cost of the ASALEE team work experiment regarding the management of type 2 diabetes patients, defined by the fact that they are treated by at least one oral antidiabetic medication, which represent the bulk of the nurse working time.2 The ASALEE experiment began in 2004 with 3 practices clustering 12 GPs and 3 nurses. In 2007, 18 practices involving 41 GPs and 8 nurses participated in the experiment. All the GPs and nurses stayed with the experiment from the beginning.
Our specific objectives are: first, to assess the efficacy both regarding process (adequacy of follow-up procedures) and final (glycemic control) outcomes; second, to assess the difference of impact between two levels of nurses intervention in supplement to the GP: systematic electronic patient registry and electronic clinical reminder (level 1) combine or not with patient education and counselling (level 2); third, to assess the impact on direct costs for the National Health Insurance Funds, including additional cost generated by the experiment for ASALEE (i.e. nurses’ wages,…).
Section snippets
Materials and methods
For the type 2 diabetes patients, the activity provided by the nurses complements that of the GP at two levels. The first level (level 1) of intervention by the nurses is a systematic electronic patient registry of type 2 diabetes patients. This list was made up on the basis of the GPs’ electronic patient records. For all these patients, the nurses log specific information (mainly requested biological results for the follow up). If require, the nurses can introduce electronic reminders inside
Results
Descriptive statistics show that type 2 diabetes patients included in the experiment ASALEE are significantly better followed than others control patients, for all the process outcomes retained at the two consecutive periods, and that the improvement between the two periods is greater for them (Cf. Table 2).
Logistics models confirm this fact (see Table 3) and we therefore observe, ceteris paribus, that a type 2 diabetes patient followed up in the ASALEE experiment has, depending on procedures,
Discussion and conclusions
The main purpose of this study was to provide some empirical evidence about the efficacy and the efficiency of the French team work experiment ASALEE – mixing GPs and nurses skills – regarding the management of type 2 diabetes patients. More specifically, following a general design of a controlled before-and-after study, some logistic and linear models were estimated to assess: first, the efficacy according to process (adequacy of follow-up procedures) and final outcomes (glycemic control);
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