Group versus single handed primary care: A performance evaluation of the care delivered to chronic patients by Italian GPs
Introduction
Changes in demographic structure of the population and in the type of family relationships as well as medical technology advances are quickly modifying the relationship between health needs and health care services supply. Current estimates forecast that by 2020 chronic diseases will cause 73% of overall deaths and will be responsible for 60% of the global burden of disease [1], [2]. There is widespread agreement on the fact that primary care can represent an effective tool for dealing with the future health care needs of the population [3]. Accessibility, comprehensiveness, coordination, continuity and accountability are all features of primary care which can contribute to an improved management of disease and in particular of chronic disease.
Team practice is one of the features of primary care organization which is often considered effective in managing chronic disease and in offering high quality services to patients. Starting from the early 1970s team practice was adopted in many countries as an important part of the primary health care (PHC) promotion process and currently represents the base of modern health care systems [4].
Nevertheless, recent developments have made it an imperative to support changes in the organization of health care delivery with sound performance measurement and reporting management. A recent publication by the European Observatory on Health Systems and Policies highlighted the role of information and its dissemination in enhancing decision-making by various stake-holders seeking to steer health systems towards better outcomes [5]. Improved governance of the system and increased accountability are the key elements which enable stakeholders to make informed decisions.
Several methods have been suggested in developing and applying quality indicators in primary care [6], [16]. While it may never be possible to produce an error free measure of quality, measures should adhere, as far as possible, to some fundamental a priori characteristics (acceptability, feasibility, reliability, sensitivity to change, and validity). Adherence to these characteristics will help maximize the effectiveness of quality indicators in quality improvement strategies [7].
During the last decade, the comparison between team practice and single handed general practitioners (GPs) has been widely studied and has focused on the impact on different effects. The scientific literature provides contrasting evidence on the effectiveness of team practice compared with “solo” practice [8], [9], [10], [11].
Particularly, when considering adherence to clinical guideline recommendations, some authors found a greater adherence in team practice than single handed practice [12], [13], [14] while others found no differences [15], [16].
Performance evaluation and monitoring are slowly entering the Italian health care policy arena and primary care represents one of the areas where less has been done in this sense. Although team practice within the Italian primary care system is rapidly expanding, no evaluation of its effectiveness has ever been carried across regions, and available evidence is restricted to single regions or health districts [17], [18], [19], [20], [21], [22]. More generally, limited experience exists on the evaluation of GPs performance in chronic disease management in national health systems, in particular using record linkage of different administrative database.
In 2010 the Italian National Agency for Regional Health Services (Agenas) launched the VALORE project. This study was the first to consider more than one region in evaluating the impact of GPs team practice on chronic disease management process indicators (i.e. the mean number of recommended clinical exams performed and drugs prescribed in one year) under the assumption that adherence to clinical recommendations is a proxy for good quality of care [23]. In particular the study analyzed the relationship between GPs organization (team vs. single handed practice) and adherence to recommendations for specific diseases: ischaemic heart disease, congestive heart failure and diabetes.
Italy's health care system is a regionally based national health service (Servizio Sanitario Nazionale – SSN) that provides universal coverage free of charge at the point of service with financing mainly based on taxation. The system is organized into three levels: national, regional and local. The national level is responsible for ensuring the general objectives and fundamental principles of the national health care system. Regional governments, through the regional health departments, are responsible for ensuring the delivery of a benefits package through a network of population-based health management organizations (Local Health Authorities – LHA). LHAs provide care directly through their own facilities or through services supplied by independent hospital trusts, research hospitals and accredited private providers (acute and rehabilitation hospitals, diagnostic laboratories, nursing homes, outpatient specialists). Primary care is provided, free of charge, by GPs and paediatricians, self-employed and independent physicians working under a government contract paid through a capitation fee based on the number of people belonging to their own list.
Coordination of GPs activity is a responsibility of health districts. Health districts are geographical subunits of LHAs responsible for coordinating and providing primary care, non-hospital-based specialist medicine and residential and semi-residential care to their assigned populations. The number of districts in each LHA depends on its size and on other geographical and demographic characteristics.
Reforms of the system adopted during the 90s introduced significant changes in primary health care. Team practice was reinforced along with the introduction of economic incentives for general practitioners to share clinic premises with their colleagues. Also, integration between primary care physicians and district services (social care, home care, health education and environmental health) was actively promoted.
The current law allows general practitioners to work in a team in three ways:
- (a)
Medicina in associazione (base group): between 3 and 10 GPs working in their own offices but sharing clinical experience, adopting guidelines and organizing workshops for quality and appropriate prescribing assessment; each GP is paid an additional 2.58 € for each patient on his/her list;
- (b)
Medicina in rete (network group): same characteristics as previous type; in addition, GPs share a common patient electronic health record system and each GP is paid an additional 4.7 € for each patient on his/her list;
- (c)
Medicina di gruppo (group practice): 3–8 GPs share the same office and the patient electronic health record system. They also provide primary care to patients belonging to the list of patients of the colleagues working in the same group; each GP is paid an additional 7 € for each patient on his/her list [24].
According to the National Collective Agreement, the capitated payment that GPs receive for participating in a team implies adherence to clinical guidelines and promotion of clinical audits. Moreover, based on regional planning decisions, additional financial incentives might be provided locally for the participation in chronic disease management programmes.
Neither specialists nor other professionals participate in these teams.
Section snippets
Study design
Three analysis were performed, one for each chronic condition. They were observational, cross-sectional studies. In each study the impact of team vs. “solo” practices was approximated through performance comparison of GPs who had chosen to adhere or not to a group in the previous years. Exposure and covariates (characteristics of the GPs, of their patients and of the health districts) were measured at baseline (1st January 2008), and performance (composite score taking into account the number
Results
Overall, 1,962,137 inhabitants (7.9% of the total population of the 6 regions) and 2082 GPs were considered for the analysis. The algorithms in Table 2 identified 164,267 as having one or more of the selected chronic conditions. The average age of chronic patients was 71.9 years, with 47.1% being females; 81.3% of the patients were identified as having only one of the considered conditions. Diabetes was the most frequent (45.0%), followed by ischaemic heart disease (31.3%) and congestive heart
Discussion
Available evidence on the impact of GPs working in teams on quality of care and on effective management of chronic patients reports mixed results [12], [16], [34], [35], [36], [37]. Nevertheless, GPs working in association with other colleagues, when compared to solo practices, appear to have favourable results: teams of GPs generally allow extended accessibility to health care services leading to an improved outcome in terms both of acute care and chronic care management. Evidence for the
Conclusions
The study concluded that, in the selected health districts, there appears to be no significant difference between performance of team practice and solo practice on chronic disease management. As Fattore and Salvatore pointed out Italian GPs groups are still uniprofessional organizational forms created with little attention to the context necessary to allow networking to have an impact on professional work [22]. It is thus time for re-organization of primary care system based on
Funding
Funding for this study was provided by the Italian Ministry of Health (310,000 €).
Conflict of interest
No conflicts of interest declared.
Acknowledgments
The authors would like to thank all those involved in data collection activities and Paolo Rodelli, Remo Piroli, Giuseppina Rossi (Emilia-Romagna Region), Fabio Michelotti, Ettore Giustini Saffi, Alessandro Bussotti (Toscana Region) for their extremely useful comments on the preliminary results of our study. The authors wish to thank Niek Klazinga and Gerrard Abi-Aad for insightful comments on a previous version of the manuscript. The authors are extremely grateful to Professor Elio Guzzanti
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- 1
On behalf of the VALORE group. See Appendix A.