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The impact of interaction and interdependence within a multi- professional primary care group practice on general practitioners’ clinical behavior and.

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Presentation on theme: "The impact of interaction and interdependence within a multi- professional primary care group practice on general practitioners’ clinical behavior and."— Presentation transcript:

1 The impact of interaction and interdependence within a multi- professional primary care group practice on general practitioners’ clinical behavior and on quality of care Patrizio Armeni, Amelia Compagni, Stefano Tasselli and Francesco Longo. CERGAS, Università Bocconi, Milano 1

2 2 J OINT M EDICAL P RACTICES IN P RIMARY C ARE IN I TALY Joint medical practices with spontaneous membership Associations Networks Group Primary care center E.g. Spain, Finland… ONE REGION HAS INTRODUCED A MANDATED FORM OF JOINT MEDICAL PRACTICE COMPRISING GPs and OTHER PROFESSIONS: Primary Care Unit Strong reduction of endogeneity Solo practice

3 favorPCUs favor interaction and collaboration between GPs and between GPs and other professionals BUT each PCU can decide how much to “activate” these opportunities GPs can “activate” their PCU over several dimensions (CFA) Interaction Peer-interaction = PCU meetings and degree of partecipation (GPs) Inter-professional interaction = participation of nurses, specialists, others Interdependence Peer-interdependence = GPs assisting other GPs’ patients Inter-professional interdependence = care processes managed together with specialists and nurses Extra services Extra-clinical services = therapeutic education, technology etc. Extension to LHA services = blood drawings, reservation of consultations, drug distribution Out-of-office = PCU office opened during holydays and nights PCU S AS O PPORTUNITY 3

4 Research questions Variability of behaviors (prescription of diagnostic exams and referral for specialist contultations)  Reduction of variability due to gradual creation of shared knowledge through interaction and to enhanced social control through interdependence  Increase of variability due to enhanced ability to discriminate different patients’ needs (effect fueled by heterogeneity in patients) H1: Interaction and interdependence show ambiguous impacts on the variability of behaviors Quality of care (adherence to guidelines for diabetes)  Interaction “per se” may not be sufficient to motivate GPs to change and enhance their approach to chronic diseases management  Interdependence without steering and monitoring may generate confusion and dispersion of information (e.g. peer interdependence  dispersion of information; IP-ID  under-organized division of labor)  Interaction and interdependence, if developed together, can promote information sharing (applied to a shared pool of patients), organized multidisciplinar management of diseases H2.a: Interaction and interdependence “per se” should not show signifincant impact (negative, if any) on management of diabetes H2.b: Positive complementarities should emerge between interaction and interdependence Perception of responsiveness (patients’ inappropriate accesses to ED)  Patients evaluate responsiveness on the basis of visible processes and on the lack of confusion H3: Peer -interdependence is perceived as better responsiveness; Inter-professional interdependence is coupled with a perception of better responsiveness only if the process is organized and monitored 4 RESEARCH QUESTIONS THE IMPACT OF INTERACTION AND INTERDEPENDENCE ON :

5 DATA AND METHODS THE HEALTHCARE SYSTEM IN EMILIA ROMAGNA: KEY FIGURES Data from the Emilia-Romagna Region Observatory on Primary Care millions inhabitants 7.9 billion € for healthcare spending in 2008: 4.5% prevention 41.8% hospital services 53.7% district & primary care 17 Public Local Health Authorities: 11 Local Health Authorities (L.H.A.) 4 Teaching Hospitals (T.H.) 1 Hospital Trust 1 IRCCS 61,000 employees (14.1 per 1,000 inhabitants) 3,100 GPs (+ 600 pediatricians) 2.0 MD per 1,000 inhabitants 6.1 Nurses per 1,000 inhabitants 19,800 private and public hospital beds (4.5 per 1,000 inhabitants)

6 DATA AND METHODS: the models H1: fixed effects 2-levels regression H2 and H3: Impact analysis based on a mixed-effect multilevel (3) regression Fixed effectsRandom effects 6

7 RESULTS (1)(2)(3)(4)(5)(6)(7)(8)(9) VARIABLESATCNuclearEcographyECDEMGEndoscopyMR Overall diagnostics Referral Peer – interaction *** Inter-professional interaction * Peer - interdependence ** * ** Inter-professional interdependence * Out of office * LHA’s services * Extra-clinical services ** p.interaction x i.interaction * * p.interaction x p.interdep ** p.interaction x inter-prof interd ** ** i.interaction x p.interdependence i.interaction x inter-prof interd ** * p.interdependence x inter-prof id Vc GPs’ Age ** Vc Female GP * Vc Number of patients ** ** Vc proportion of female pat *0.868***0.642*0.549** ***0.083 Vc proportion ov over 65yo pat.0.252**0.280** * Location dummiesYES Constant0.163***0.192***0.152***0.163***0.325***0.166***0.208***0.106***0.092*** Observations214 R-squared Number of lha11 H1.a 7

8 8 H2 (1)(2)(3) VARIABLES% patients with 4 exams Virtual exams (ln) Inappropriate accesses to Emergency dept (ln) Peer – interaction Inter-professional interaction Peer - interdependence-0.192***-0.138** *** Inter-professional interdependence Out of office LHA’s services-0.083* Extra-clinical services p.interaction x i.interaction p.interaction x p.interdep0.348***0.262*59.706** p.interaction x inter-prof interd ** i.interaction x p.interdependence i.interaction x inter-prof interd p.interdependence x inter-prof interd PCU Patients PCU Diabetics % of female GPs % of GPs in group0.067**0.058** Average patients’ age-0.042**-0.056*** PCU’s proportion of female patients * PCU’s proportion of over 65yo patients Location dummiesYES GP’s diabetic patients GP’s Age-0.038*-0.056*** Female GP0.032*0.049***3.537** GP’s number of patients *** GP’s proportion of female patients ** *** GP’s proportion of over 65yo patients0.000*** *** GP in group Between level interactionsYES Other activation interactionsYES Constant3.064**4.504*** Observations2,810 Number of groups11 ? H2.a H2.b H3

9 Activating collaboration through interaction and interdependence does not reduce the variability of GP’s behaviors: – However further research should explore if this is due to social control + better discrimination of patient needs  more efficient variability Peer interdependence reduces the variability of prescription of diagnostic exams (not surprisingly) Interaction and interdependence should be developed together for a better managment of chronic diseases (diabetes) 9 DISCUSSION (1)

10 Patients’ perception of the responsiveness of their GP is more sensible to peer-interdependence alone and actually reduced by the complementarity with peer-interaction. – This may depend from the fact that peer-interdependence is visible while peer-interaction (i.e meetings and more organizational joint activities) is not but the latter may subtract time from the GPs’ routine clinical activities and this might be perceived by the patients that therefore tend to go more to the emergency room for non-urgent matters Inter-professional interdependence enhances the perceived quality of care only if coupled to a good level of interaction among GPs – Interaction is not visible but probably allows GPs to coordinate and organize better the work and avoid confusion  “I am treated by an organized multidisciplinar team” 10 DISCUSSION (2)

11 11 T HANK Y OU

12 12 E XTRA SLIDES

13 13 P RIMARY C ARE : T HE I TALIAN M ODEL GP and GP practices 1.General practitioners are independent contractors paid on a capitation basis; additional payments for fee for service and results 2. GPs as gatekeepers – responsible for referring patients to hospital and specialist care (also diagnostics) and for pharmaceutical prescriptions 3. GPs can work in solo practices or in joint medical practices with the assistance of secretaries for administrative tasks and nurses for triaging and simple clinical tasks Nurses, secretary Simple technologies Hospital and secondary care Referral and gatekeepig

14 14 T HE I TALIAN SYSTEM OF P RIMARY C ARE GPs: 46,661 ; Pediatricians: 7,621 μ=51.6μ=55.4 Maximum 1,500 patients (roster list) Freedom of choice of GPs There is a certain degree of competition for patients Multilevel negotiation for GPs’ contracts Capitation rate covers approx 52.4% of GPs’ compensation (47.6: FFS, incentives, reimbursement for nurses, etc.) Age Activities Source: FIMMG

15 15 J OINT M EDICAL P RACTICES IN P RIMARY C ARE IN I TALY Joint medical practices with spontaneous membership Associations Networks Group Primary care center E.g. Spain, Finland… ONE REGION HAS INTRODUCED A MANDATED FORM OF JOINT MEDICAL PRACTICE COMPRISING GPs and OTHER PROFESSIONS THE CASE OF EMILIA ROMAGNA Solo practice

16 16 P RIMARY C ARE U NITS (PCU – N UCLEI DI C URE P RIMARIE ) Joint medical teams Associations Networks Groups Primary care center E.g. Spain, Finland… Mandated PCU Primary care unit (PCU) ~ patients AND GPs per PCU Coordinator appointed by GPs Professional integration between GPs, paediatricians, nurses and specialists: Management of minor urgent medical problems Chronic disease management Clinical audit Integration with Health Care District and Local Health Authority for planning and service delivery purposes 216 PCU in Emilia-Romagna

17 17 V ARIABLES AND D IMENSIONS ( VALIDATED THROUGH CFA)

18 Research questions Variability of behaviors (prescription of diagnostic exams and referral for specialist contultations)  Reduction of variability due to gradual creation of shared knowledge through interaction and to enhanced social control through interdependence  Increase of variability due to enhanced ability to discriminate different patients’ needs (effect fueled by heterogeneity in patients) H1.a: Interaction and interdependence show ambiguous impacts on the variability of behaviors H1.b: higher patients’ heterogeneity is reflected in higher variability of behaviors Quality of care (adherence to guidelines for diabetes and patients’ inappropriate accesses to ED)  Interaction “per se” may not be sufficient to motivate GPs to change and enhance their approach to chronic diseases management  Interdependence without steering and monitoring may generate confusion and dispersion of information (e.g. peer interdependence  dispersion of information; IP-ID  under-organized division of labor) but can be positively perceived by patients as a proxy for collaboration among GPs  Interaction and interdependence, if developed together, can promote information sharing (applied to a shared pool of patients), organized multidisciplinar management of diseases and a perception of better quality of care. H2.a: Interaction and interdependence “per se” should not show signifincant impact (negative, if any) on management of diabetes and on patients-perceived quality H2.b: Positive complementarities should emerge between interaction and interdependence 18 RESEARCH QUESTIONS


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