Elsevier

Health Policy

Volume 98, Issues 2–3, December 2010, Pages 131-143
Health Policy

Effect of a French experiment of team work between general practitioners and nurses on efficacy and cost of type 2 diabetes patients care

https://doi.org/10.1016/j.healthpol.2010.06.001Get rights and content

Abstract

Objectives

To assess the efficacy and the cost of a French team work experiment between nurses and GPs for managing type 2 diabetes patients.

Methods

Based on a case control study design we compare the evolution of process (standard follow-up procedures) and final (glycemic control) outcomes, and of cost, between two consecutive periods between type 2 diabetes patients followed within the team work experiment (intervention group) or by “standard” GPs (controlled group).

Results

After a 11 months of follow-up, patients in the intervention group, compared with those in the controlled group, have more chances to remain or to become: correctly followed-up (with OR comprise between 2.1 and 6.8, p  5%) and under glycemic control (with OR comprise between 1.8 and 2.7, p  5%). The latter result is obtained only when a visit for education and counselling has been delivered by a nurse in supplement to systematic electronic patient registry and electronic clinical GPs reminder. All these results are obtained without difference in costs between the intervention and the controlled group.

Conclusions

This experimentation of team working can be considered both effective and efficient. Our findings may have implications in the design of future larger primary care team work experiment to be launched by French health authorities.

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);

References (45)

  • E. Elizabeth Docteur et al.

    No. 9 – Health-care systems: lessons from the reform experience

    Health working papers no. 9

    (2003)
  • M.M. Hofmarcher et al.

    Improved health system performance through better care coordination

    Health working papers no. 30

    (2007)
  • R. Atun

    What are the advantages and disadvantages of restructuring a health care system to be more focused on primary care services?

    Health evidence network report

    (2004)
  • J. Macinko et al.

    The contribution of primary care systems to health outcomes within organization for economic cooperation and development (OECD) countries, 1970–1998

    HSR: Health Services Research

    (2003)
  • R.B. Saltman et al.

    Primary care in the driver's seat? Organizational reform in European primary care. European observatory on health systems and policies series

    (2006)
  • World Health Organization

    The world health report 2008: now more than ever

    (2008)
  • E.H. Wagner

    Chronic disease management: what will it take to improve care for chronic illness?

    Effective Clinical Practice

    (1998)
  • J.M. Grimshaw et al.

    Effectiveness and efficiency of guidelines dissemination and implementation strategies

    Health Technology Assessment

    (2004)
  • C.M. Renders et al.

    Interventions to improve the management of diabetes mellitus in primary care, outpatient and community settings (Cochrane Review)

    The Cochrane Library

    (2003)
  • M. Laurant et al.

    Substitution of doctors by nurses in primary care

    The Cochrane Database of Systematic Reviews

    (2004)
  • J. Buchan et al.

    Skill-mix and policy change in the health workforce: nurses in advanced roles

    Health working papers no. 17

    (2005)
  • M. Zwarenstein et al.

    Interprofessional education: effects on professional practice and health care outcomes (Cochrane Review)

    The Cochrane Library

    (2003)
  • K. Knight et al.

    A systematic review of diabetes disease management programs

    American Journal of Manage Care

    (2005)
  • N. Beaulieu et al.

    The business case for diabetes disease management for managed care organizations

    Forum for Health Economics & Policy

    (2006)
  • L. Tollen

    Physician organization in relation to quality and efficiency of care. A synthesis of recent literature

    The Commonwealth Fund

    (2008)
  • F. Midy

    Efficacité et efficience du partage des compétences dans le secteur des soins primaires, revue de la littérature (1970–2002)

    Question d’économie de la santé no. 65

    (2003)
  • B. Sibbald

    Skill mix in primary care – the UK experience. Oral communication during the international conference Politiques et organisation des soins primaires: concepts, outils et pratiques en Europe et aux Etats-Unis

    (2009 Octobre)
  • Agence Nationale de l’Evaluation en Santé

    Efficacité des méthodes de mise en œuvre des recommandations médicales

    (2000)
  • Haut conseil pour l’avenir de l’assurance maladie. Rapport du haut conseil pour l’avenir de l’Assurance Maladie. Paris;...
  • Haut conseil pour l’avenir de l’assurance maladie. Rapport du haut conseil pour l’avenir de l’Assurance Maladie 2009....
  • Cour des Comptes. Les actions sur les comportements des professionnels de santé et des assurés sociaux in Rapport sur...
  • P.L. Bras et al.

    Improving the care of the chronically ill: lessons from foreign disease management experience

    Pratiques et Organisation des Soins

    (2006)
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