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Quality, costs and the role of primary health care
Linköping University, Department of Medical and Health Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Central County Primary Health Care.
2004 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The general aim of this thesis is to describe and analyse the role of primary care in health care systems in terms of health, health care utilisation and costs, and to study the feasibility of retrieval of data from computerised medical records to monitor medical quality.

The thesis includes five studies, a systematic literature review, a register study of utilisation of hospital and primary care, a study based on data from computerised medical records of individual patients cost for primary care, and two studies of management of respiratory infections in primary care based on data from computerised medical records of twelve health centres.

The general findings of the literature review were that an expansion of the primary care component of the health care system would most likely result in better health, lower hospital care consumption and lower expenses for care. The personal physician and continuity of care were core elements to achieve this, and the significance of the way primary care is organised and funded was evident.

In the register study fifty health centres were compared. Age and rates of outpatient hospital visits were the most important factors explaining the variation of rates of hospitalisations between the health centres’ areas. Hospital district also influenced hospitalisation rates in the different health centres’ areas, indicating that the health care structure in the district per se was an important factor. The rates of visits to general practitioners correlated negatively with rates of hospitalisations.

The study of costs in primary care showed that the variation in the costs of the individual patients was substantial, also within age groups and within the diagnosis-related Adjusted Clinical Groups (ACG). Age and gender explained a smaller part of the variation in costs per patient in primary care. Adding the ACG weight had a major influence on improving the ability to explain the variation in costs at patient level. The ACG system might be of value in the calculation of weighted capitation in Swedish primary care, but appears to be sensitive to the thoroughness with which physicians register diagnoses.

The retrieval of data from computerised medical records comprised a total number of 19 965 encounters for respiratory tract infections i.e. 199 per 1000 inhabitants during the year 2001. Most frequent diagnoses were common cold, acute tonsillitis, and acute bronchitis. The number of antibioticprescriptions was 7 961, accounting for 47% of the episodes. The most commonly prescribed antibiotics were phenoxymethylpenicillin (61%), tetracyclines (18%) and macrolides (8%).

A rapid test was performed in 43% of the encounters: for C-reactive protein (CRP) in 31%; for Group A beta-haemolytic streptococci (StrepA) in 22%; and both tests were performed in 10% of the encounters. The findings in the study indicate that StrepA and CRP tests were used too frequently and often with minor contributions to patient management. The frequencies of tests and of antibiotic prescriptions varied greatly between health centres in a way that hardly could be explained by differences in morbidity.

Computerised medical records provided a source of clinical information, which might be a feasible and pragmatic method for studying daily practice, and for follow-up of adherence to guidelines in general practice.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2004. , 72 p.
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 854
Keyword [en]
Drug utilization review methods, Hospitalization statistics and numerical data, Outpatient clinics, hospital utilization, Primary health care, Quality of health care, Respiratory tract infections, drug therapy, Family practice, Cost-benefit analysis, Efficiency, Organizational, Health care costs
National Category
Medical and Health Sciences
Identifiers
URN: urn:nbn:se:liu:diva-5198ISBN: 91-7373-827-1 (print)OAI: oai:DiVA.org:liu-5198DiVA: diva2:21119
Public defence
2004-06-03, Aulan, Hälsans hus, Campus US, Linköpings universitet, Linköping, 13:00 (English)
Opponent
Supervisors
Available from: 2004-06-23 Created: 2004-06-23 Last updated: 2012-01-25Bibliographically approved
List of papers
1. Is general practice effective?: A systematic literature review
Open this publication in new window or tab >>Is general practice effective?: A systematic literature review
2001 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, Vol. 19, no 2, 131-144 p.Article in journal (Refereed) Published
Abstract [en]

Objective - To find evidence of the effectiveness of physicians working in primary care.

Design - Systematic literature search in the Medline and Cochrane databases.

Material - Out of 7223 titles found in the search, 45 studies, comparing, from different aspects, primary care with specialist care, were extracted.

Main outcome measures - Health indicators, health care costs, quality of health care.

Results - Primary care contributed to improved public health, as expressed through different health parameters, and a lower utilisation of medical care leading to lower costs. Physicians working in primary care, in comparison with other specialists, took care of many diseases without loss of quality and often at lower cost. The organisation of primary care was important in respect of reimbursement by capita tion, more group practices, higher personal continuity, and having generalists as primary care physicians.

Conclusions - To compare the effectiveness of primary care and specialist care is a complex task and there are limitations in all studies. However, we have found evidence that increased accessibility to physicians working in primary care contributes to better health and lower total costs in the health care system. It is also clear that studies with evaluation of how to most effectively organise primary care are far too few. There is an extensive need for future research in this area, a suitable task for collaborative research between the Nordic countries.

Keyword
Primary Health Care; Health Care Costs; Quality Of Health Care; Review
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13652 (URN)10.1080/028134301750235394 (DOI)
Available from: 2004-06-23 Created: 2004-06-23 Last updated: 2009-08-18
2. Determinants of hospitalisation rates: does primary health care play a role?
Open this publication in new window or tab >>Determinants of hospitalisation rates: does primary health care play a role?
2003 (English)In: Scandinavian Journal of Primary Health Care, ISSN 0281-3432, E-ISSN 1502-7724, Vol. 21, no 1, 15-20 p.Article in journal (Refereed) Published
Abstract [en]

Objective - To analyse the influence of rates of general practitioner visits on rates of hospitalisations.

Design  - Ecological cross-sectional study of factors influencing hospitalisation rates. Aggregated data on primary care centre area level.

Setting - The county of Östergötland, Sweden, with 3 hospital districts and 41 primary health care centres, and the hospital district of Jönköping in the county of Jönköping, Sweden, with 11 primary health care centres.

Outcome measure - Hospitalisation rates.

Results  - Age and rates of outpatient hospital visits were the most important factors explaining the variation in rates of hospitalisations between the primary health care centre areas. Hospital districts, socioeconomic factors and rates of GP visits also influenced the rates of hospitalisations.

Conclusion - When evaluating the influence of primary health care on the rates of hospitalisations, both socioeconomic factors and health care structure must be taken into consideration. Doing this, the rates of GP visits correlated negatively with the rates of hospitalisations.

Keyword
Health Care Structure, Hospitalisation, Primary Care, Socioeconomic Factors
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13653 (URN)10.1080/02813430310000500 (DOI)
Available from: 2004-06-23 Created: 2004-06-23 Last updated: 2012-09-17Bibliographically approved
3. The importance of comorbidity in analysing patient costs in Swedish primary care
Open this publication in new window or tab >>The importance of comorbidity in analysing patient costs in Swedish primary care
Show others...
2006 (English)In: BMC Public Health, ISSN 1471-2458, Vol. 36, no 6, 36-42 p.Article in journal (Refereed) Published
Abstract [en]

Background

The objective was to explore the usefulness of the morbidity risk adjustment system Adjusted Clinical Groups® (ACG), in comparison with age and gender, in explaining and estimating patient costs on an individual level in Swedish primary health care. Data were retrieved from two primary health care centres in southeastern Sweden.

Methods

A cross-sectional observational study. Data from electronic patient registers from the two centres were retrieved for 2001 and 2002, and patients were grouped into ACGs, expressing the individual combination of diagnoses and thus the comorbidity. Costs per patient were calculated for both years in both centres. Cost data from one centre were used to create ACG weights. These weights were then applied to patients at the other centre. Correlations between individual patient costs, age, gender and ACG weights were studied. Multiple linear regression analyses were performed in order to explain and estimate patient costs.

Results

The variation in individual patient costs was substantial within age groups as well as within ACG weight groups. About 37.7% of the individual patient costs could be explained by ACG weights, and age and gender added about 0.8%. The individual patient costs in 2001 estimated 22.0% of patient costs in 2002, whereas ACG weights estimated 14.3%.

Conclusion

ACGs was an important factor in explaining and estimating individual patient costs in primary health care. Costs were explained to only a minor extent by age and gender. However, the usefulness of the ACG system appears to be sensitive to the accuracy of classification and coding of diagnoses by physicians.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13654 (URN)10.1186/1471-2458-6-36 (DOI)
Available from: 2009-02-22 Created: 2009-02-22 Last updated: 2009-03-10Bibliographically approved
4. Data from electronic patient records are suitable for surveillance of antibiotic prescriptions for respiratory tract infections in primary health care
Open this publication in new window or tab >>Data from electronic patient records are suitable for surveillance of antibiotic prescriptions for respiratory tract infections in primary health care
Show others...
2004 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, Vol. 36, no 2, 139-143 p.Article in journal (Refereed) Published
Abstract [en]

Diagnoses and antibiotic treatments were analysed in relation to respiratory tract infections (RTI). A 1-y retrospective study was made of electronic patient records (EPR) for encounters concerning RTIs in primary health care in Sweden. The study covered a registered population of 102,050 individuals at 12 primary health care centres in 3 counties. Data were recorded on number of episodes, encounters, diagnostic codes and antibiotic prescriptions. The yearly number of episodes of RTIs was 16,964 or 166 per 1000 inhabitants per y. The total number of encounters was 19,965. The most frequent diagnoses were common cold (40%), acute tonsillitis (18%), and acute bronchitis (15%). The yearly number of antibiotic prescriptions was 7961, accounting for 47% of the episodes or 78 per 1000 inhabitants per y. The most frequently prescribed antibiotics were phenoxymethylpenicillin (61%), tetracyclines (18%) and macrolides 8%). Standard EPRs provide a feasible source of clinical information which, taking limitations into consideration, could be used for the follow-up of trends in antibiotic prescribing and of adherence to guidelines with regard to RTIs.

Keyword
electronic patient records, respiratory tract infections, primary health care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13655 (URN)10.1080/00365540410019011 (DOI)
Available from: 2004-06-23 Created: 2004-06-23 Last updated: 2009-08-18
5. Excessive use of rapid tests in respiratory tract infections in Swedish primary health care
Open this publication in new window or tab >>Excessive use of rapid tests in respiratory tract infections in Swedish primary health care
Show others...
2004 (English)In: Scandinavian Journal of Infectious Diseases, ISSN 0036-5548, Vol. 36, no 3, 213-218 p.Article in journal (Refereed) Published
Abstract [en]

A 1-y retrospective study of problem oriented electronic patient records, for encounters concerning respiratory tract infection, was performed. The aim was to analyse the management of respiratory tract infections in primary health care in terms of diagnostic coding, tests and antibiotic treatment using data from electronic patient records. 12 primary health care centres with a registered population of 102,050 residents in 3 counties in southeast Sweden participated. Data were retrieved electronically from records of patient encounters concerning respiratory tract infections. The data were: patient age and gender, date of contact, diagnostic code, CRP and GABHS tests and results, as well as antibiotic prescriptions. In a total of 19,965 encounters, the most frequent diagnoses were common cold (40%), acute tonsillitis (18%), and acute bronchitis (15%). A total of 4445 GABHS tests (in 22% of encounters) and 6141 CRP tests (31%) were performed, and both tests were done in 1910 encounters (10%). A total of 7934 antibiotic prescriptions were registered. The proportion of patients tested and prescribed an antibiotic varied greatly between centres. We found an excessive, and much varying, use of rapid tests in encounters for respiratory tract infections. Data retrieval from electronic patient record systems was a feasible method to study the use of laboratory tests in relation to pharmacological treatment.

Keyword
rapid tests, respiratoty tract infections, primary health care
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:liu:diva-13656 (URN)10.1080/00365540310018842 (DOI)
Available from: 2004-06-23 Created: 2004-06-23 Last updated: 2009-08-18

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