Improved availability of specialist consultations in primary health care: impact on physician visits

ORIGINAL PAPER Improved availability of specialist consultations in primary health care: impact on physician visits Aarno Linnala 1, Arpo Aromaa 2 and Kari Mattila 3 1 Research Department of the Social Insurance Institution, Helsinki, 2 National Public Health Institute, Helsinki, 3 University of Tampere, Department of General Practice, Tampere, Finland. Scand J Prim Health Care 2003;21:83 88. ISSN 0281-3432 Results The populations on a GP s list had more physician visits than those not covered by a list system. Persons not on a health Objecti e How do physician visits vary when GPs are given the centre GP s list had fewer visits to the private sector and more visits opportunity to send their patients to private specialists for consulta- to hospital than those covered by a list system. tion rather than simply to hospital outpatient clinics. Conclusion The possibility for a GP to send a patient for consulta- Design An experimental study. tion to a private specialist improves the prerequisites for high-quality Setting and subjects In the City of Turku, 3 populations were care without affecting the total number of physician visits. served over 34 months by different service models. The first model was implemented in municipal health centres by 10 GPs with a list Key words: consultation, continuous care, physician visits, referral, system and an option to consult private specialists. In the second specialist. model, there were four GPs in municipal health centres without a list system or the consultation option. In the third model, there were four Aarno Linnala, Research Department of the Social Insurance Instiprivate GPs with a list system and the consultation option. tution, P.O. Box 450, FIN-00101 Helsinki, Finland. E-mail: Outcome measures Visits to doctors as reported by the population. aarno.linnala@kela.fi Specialist consultations by general practitioners (GPs) are an important element in primary care and help to ensure the quality of services. Finnish GPs working in municipal health centres typically consult hospitals and their resident specialists. The out-of-pocket expenditure of patients sent for consultation to outpatient clinics is small, certainly much smaller than private doctor and laboratory charges. However, the total costs in hospital outpatient departments are high and the patient s waiting time may stretch to weeks or sometimes months. Specialists working in the private sector have the capacity to provide many of the consultations, to speed up diagnoses and to advise, and they can thus reduce the need for hospital outpatient services. Prior to the current experiment, most private physician visits were made on the patient s own initiative. Until the early 1990s there were legislative obstacles to cooperation between municipal primary health care and the private sector. However, since 1993, a reform of the Public Health Act has enabled communes to obtain health services from other communes and from private service providers. Experiences of buying specialist consultations from the private sector have been encouraging and it has been reported that a referral to the private sector has become a noteworthy alternative to a referral to hospital outpatient clinics (1,2). Numerous studies in Finland and elsewhere have analysed the rates of referrals and reasons for referrals by GPs to specialist outpatient clinics (3 7). There has been great variation between referral practices both in different countries and within the same country (8). In Finland, GPs working in a municipal health centre take care themselves of about 95% of visits, with 5% leading to a referral to a specialist (3,6,9). There is little valid research data on how specialists working in the private sector could complement or substitute services of the specialists working in the hospital outpatient clinics. This experimental study is part of the Social Insurance Institution s (SII) Family Doctor Experiment (10) and was conducted by SII and the City of Turku. GPs working in municipal health centres as family doctors with a list system were offered an enhanced possibility to send their patients to private specialists for consultation. The aim was to improve the care given by GPs and the cooperation between GPs and private specialists. This experiment was designed to assess the influence of private sector consultations on physician visits. Hospital referrals are often associated with long waiting times and high costs. Making specialist consultations readily available to GPs improves their work and patient care. Private specialist consultations can replace hospital outpatient visits and improve both the quality and efficiency of health care. DOI 10.1080/02813430310001671

84 A. Linnala et al. We examine how these enhanced specialist consultation possibilities affected the reported visits to physicians and specialists MATERIALS AND METHODS In 1993 the population of Turku was about 164 000 and there were altogether 12 municipal health centres and 56 GPs (11). The experiment was carried out between 1.3.1991 and 31.12.1993, when there were three different models of providing primary health care services: 1. Persons belonging to the experimental group with 10 GPs working in municipal health centres with a list system serving 23 000 residents. The GPs had worked as family doctors for several years and were given an enhanced possibility to send their patients to private specialist consultation. The patients paid the same fixed charge (FIM 100 in 1993) as they would have had they been referred to a specialist working in a hospital outpatient clinic. The remainder of the cost was borne by SII. 2. Persons belonging to the main control group (control A) with four GPs working in municipal health centres without a list system and serving 10 800 residents. These GPs sent their patients to specialist consultation and care, usually to hospital clinics. 3. Persons belonging to another control group (control B) with four private GPs having worked as family doctors with a list system for years, who served 9500 residents and had the same enhanced possibility for private specialist consultation as the health centre doctors with a list system. The data were collected yearly by postal survey. The main questions were about visits to physicians and specialists during the 5 months from August to December (Appendix I). The first questionnaire was sent at the beginning of 1991 and asked respondents about their use of healthcare services before the experiment. The total sample was 21 361 and the average response rate was 81.4% (Table I). The data were analysed using the SAS statistical program (12). Physician visits were standardized by age and sex using a direct method. The means of groups were assessed by the t-test. Table I. Annual total sample (n) and response rate (%) in the experimental and control groups. Experimental group: Persons with a list system in the health centre. Control A: Persons without a list system in the health centre. Control B: Persons with a list system in the private sector. Year/group Total sample Response rate n % 1991 2047 80.5 Control A 1000 81.2 Control B 1992 879 2078 77.6 79.5 Control A 1000 81.7 Control B 864 81.8 1993 2076 81.1 Control A 1000 80.2 Control B 1994 831 81.6 2124 82.0 Control A 1000 79.6 Control B 862 82.5 All 21 361 81.4 Visits to different sectors Every year there were more visits to GPs than to physicians in other sectors (Fig. 1). Also, every year, persons covered by a list system in the private sector (control B) had more visits to GPs than persons with or without a list system in the health centre, though RESULTS All physician isits In each group, the total number of visits declined somewhat, but not consistently during the experiment. Almost throughout the study period, both list populations had more visits than the health centre population without a list system (Fig. 1). Fig. 1. Number of all visits to physicians by sectors (adjusted by age and sex) before (1990) and during intervention in the experimental group and two control groups. Others, Hospital outpatient clinic, Occupational health care, Private sector, GPs.

A ailability of specialist consultations in primary health care 85 Every year, persons in a health centre list system (experimental group) had more visits to physicians working in the private sector than did persons served by the health centre but without a list system (control A) and, except in 1993, more than persons on a private sector list system (control B). During the experiment, visits to physicians in the private sector declined in both health centre groups. Visits to physicians working in occupational health care decreased in all groups during the intervention. Persons not covered by a health centre list system had slightly more visits every year to occupational health care than persons in either list system. Fig. 2. Number of all visits to specialists (adjusted by age and sex) before (1990) and during intervention in the experimental group and two control groups. Others, Hospital, Private sector. this difference was statistically significant (p 0.001) only before intervention in 1990. Persons in a health centre list system (experimental group) had more visits, but not significantly, to GPs than persons served by a health centre without a list system (control A). Visits to specialists In every year except 1991, persons in a health centre list system (experimental group) had more visits to specialists than those in the other groups (Fig. 2). Persons served by the health centre but without a list system (control A) had fewer visits to specialists in the private sector than other groups, and when all the years of intervention were combined the difference was statistically significant with the experimental group (p 0.01) and the control B (p 0.001) (Table II). During the experiment, the number of visits to hospital decreased in the experimental group. In all the years of intervention combined, persons in a list system had significantly fewer visits also to hospital than those not in a health centre list system (Table II). Table II. Number of all visits to specialists, visits by each group to specialists working in the private sector, in hospital and in other sectors during August December before intervention in 1990 and during intervention in 1991 1993. Visits are directly standardized by age and sex. Experimental group: Persons with a list system in the health centre. Control A: Persons without a list system in the health centre. Control B: Persons with a list system in the private sector. Specialty/group 1990 1991 1992 1993 1991 1993 Significance 1 Pri ate sector 0.47 0.54 0.40 0.39 0.44 ** Control A 0.44 0.44 0.33 0.25 0.34 Control B Hospital 0.50 0.29 0.48 0.29 0.41 0.28 0.47 0.26 0.45 0.28 *** ** Control A 0.30 0.40 0.22 0.44 0.36 Control B 0.22 0.20 0.23 0.17 0.20 *** Others 0.15 0.12 0.13 0.14 0.13 NS Control A 0.08 0.10 0.08 0.09 0.09 Control B 0.06 0.10 0.05 0.13 0.09 NS All 0.91 0.94 0.81 0.79 0.84 NS Control A 0.82 0.94 0.63 0.77 0.79 Control B 0.78 0.78 0.70 0.77 0.75 NS 1 Compared with control A, when all the years of intervention are combined **p 0.01, ***p 0.001

86 A. Linnala et al. There was no clear difference between the three groups between specialties. Most of the visits to specialists were made to surgeons and gynaecologists (Table III). Visits to gynaecologists and ophthalmologists declined every year in the experimental group. DISCUSSION The aim of this evaluation study was to assess the effects of GPs enhanced possibility to consult private specialists. An experiment was set up to assess the effects of the private sector consultation scheme. The experiment was not a fully randomised one, which is a drawback, but was necessary for practical reasons. The effects were estimated by analysing the data obtained by annual questionnaires. The response rates were high. Population level questionnaire data may be slightly crude and lead to an underestimate of the difference between the groups. A specific reason for this is that a minority of visits leads to a referral to specialists in the private sector or in public hospitals. Our hypothesis was that the intervention could reduce visits to the specialists working in hospital outpatient clinics. This is also what we found in the comparison of the experimental and the control groups. However, this difference was not consistent through all years. Persons with a family doctor make more visits to physicians than those without (13 15). This was the case also in this study. Before the intervention, people belonging to a list system and having a family doctor had significantly more visits to physicians than people without a list system. During the intervention, the differences between our study groups decreased. This questionnaire study was unable to provide a definitive answer concerning the reasons for the decrease in visits to physicians among people with a family doctor list system and in the health centre. In the intervention, GPs were given a facilitated possibility to send their patients to a specialist consultation to private doctors. However, the private family doctors with a list system already had that possibility before the intervention and yet their populations visits to physicians also declined during the experiment. In Finland, on the average about 5% of visits to GPs lead to a referral to a specialist (9). During our intervention, GP referral rate in the experimental group increased from 5.7% to 6.8% and the share of specialist referrals to the private sector from 5% to 35% (16). In this study, we asked about visits during the previous 5 months. The number of referred patients was relatively small and may explain why no differences in physician visits were found on the population level. We might have noted differences in the share of visits to specialists made on the basis of a referral, but the questionnaires were not suited for offering such data. Visits to physicians working in occupational health care decreased in all groups during the intervention. The most likely explanation was the rapid rise in unemployment in the City of Turku, from 4.2% in 1990 to 21.4% in 1993. However, persons who did not Table III. Number of visits (per 100 persons) in each group to selected specialist categories during August December before (1990) and during intervention (1991 1993). Visits are directly standardized by age and sex.experimental group: Persons with a list system in the health centre.control A: Persons without a list system in the health centre.control B: Persons with a list system in the private sector. Specialty/group 1990 1991 1992 1993 Surgeon 12.1 14.8 11.8 11.9 Control A 14.5 14.3 8.4 16.0 Control B 9.4 11.9 11.6 12.5 Gynaecology 13.9 13.0 11.3 10.0 Control A 12.9 10.7 11.5 14.6 Control B 13.1 14.4 11.6 8.6 Internist 11.7 11.4 9.5 11.7 Control A 14.7 17.2 8.2 13.1 Control B 9.5 10.6 9.8 12.0 Ear, nose and throat 13.2 10.7 10.8 11.1 Control A 8.1 12.8 9.3 5.4 Control B 11.5 10.9 11.4 11.1 Ophthalmologist 9.4 8.1 7.2 5.7 Control A 4.4 7.9 6.9 3.9 Control B 5.1 7.1 7.2 6.8

A ailability of specialist consultations in primary health care 87 belong to a list system had more occupational healthcare visits than those with a list system. It has been found previously that continuity of care is better in the list system and that this greatly influences the number of visits to other physicians (15). Although the distribution of referrals changed dramatically between private and hospital outpatient clinic specialists, the effect on the total number of visits was smaller. This suggests that a major effect of our experiment during its 2-year duration was the provision of better care and earlier diagnosis and treatment. We believe that the availability of consultation services resulted in improved access and enhanced quality of care rather than merely substituting for hospital outpatient visits or hospital inpatient care. In addition, it is important to note that a big proportion of hospital visits are due to acute serious conditions, which are unlikely to be influenced by any primary care arrangements. In addition to this population level short-term macro approach, it would be important to study each of the effects in greater detail. We also believe that only if the experiment had lasted longer would it have been possible to estimate any permanent effects that the changes in health care and the financial incentives possibly might have. We did not observe major differences on changes in the total volume of physician visits between our experimental and control groups. Taking together these and our own earlier findings (16,17), we conclude that the experiment resulted in improved access and quality of care without increasing the volume of ambulatory care and its costs. In fact, it is likely that the costs were reduced due to more rational use of public and private resources. REFERENCES 1. Ehrnstöm B-O. Lähete yksityiselle on sairaalalähetteen varteenotettava vaihtoehto (Referral to a private doctor is a relevant alternative to referral to hospital). Suom Lääkäril 1994;49:2787 91. 2. Virtanen P, Rintanen H. Yksityislääkäreiltä ostetut konsultaatiot laajentavat terveyskeskuksen palvelukirjoa (Consultations bought from private physicians extend the selection of the services in health centres). Suom Lääkäril 2001;56:3857 61. 3. Vehviläinen AT, Kumpusalo EA, Takala JK. Reasons for referral from general practice in Finland. Scand J Prim Health Care 1997;15:43 7. 4. Coulter A, Noone A, Goldacre M. General practitioners referrals to specialist outpatient clinics. I. Why general practitioners refer patients to specialist outpatient clinics. BMJ 1989;299:304 6. 5. Coulter A, Noone A, Goldacre M. General practitioners referrals to specialist outpatient clinics. II. Locations of specialist outpatient clinics to which general practitioners refer patients. BMJ 1989;299:306 8. 6. 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88 A. Linnala et al. Appendix I. The questions put to respondents in the annual questionnaire regarding their visits to a doctor. Did you visit a doctor because of your own illness, injury or some symptom during August December? no yes Who were these doctors and how many times did you see them during August December? a. GP with a list system working in the private sector or municipal centre b. GP without a list system working in a municipal health centre c. private doctor d. doctor working in occupational health care e. doctor working in a hospital outpatient clinic f. some other doctor Did you visit a specialist during August December? no yes How many times and where did you visit a specialist during August December and what was his/her specialty? a specialist working in the private sector a specialist working in the outpatient clinic of the University Central Hospital of Turku a specialist working in the outpatient clinic of the Health Centre Hospital of Turku a specialist working somewhere else