Medical Practice Variations in Primary Care

1. Medical Practice Variations in Primary Care Professor Azeem Majeed University College London

2. Outline of Talk • Structure of NHS • Role of general practitioners • Gatekeeping in the NHS • Previous research • Current research • Implications for policy and clinical practice

3. National Health Service • Established in 1948 • Provides health care ‘cradle to grave’ • Division between primary care (GPs) & secondary care (hospital specialists) • Numerous initiatives in recent years to improve efficiency and quality • More measurement of performance

4. General Practitioners • Provide primary (first contact) care • Around 75% of all medical contacts • Act as gatekeepers to other NHS services • Prescriptions, investigations, outpatient referrals, hospital admissions • Government views gatekeeping as more important than do many GPs or patients

5. Why do variations occur? • Random variation • Patient • Doctor • General practice • Local health care system • National health care system

6. Implications of variation • Patients may be denied access to appropriate care • Patients may be at risk of iatrogenesis • Doctors may not be practising ‘evidence-based’ medicine • May be a marker of inefficient use of resources

7. Antibiotic prescribing rates in 211 general practices in 1998

8. Previous Research: 1980s • Very limited research before 1980s • 1980s research very descriptive in nature • 20-fold variation in many areas of practice • Little attempt to understand reasons for variation

9. Previous Research: 1990s • More analytical in nature, using techniques such as multiple regression • First major attempts to ‘explain’ variation • Use ‘patient’ and ‘general practice’ characteristics as explanatory variables • Mixed results but typically only a small percentage of variation explained

10. Limitations of Research • Methods often flawed, e.g. small numbers • No information on clinical case-mix • Often used ecological measures of socio-economic status & ethnicity • Limited information on clinician & health service characteristics • No information on psychological factors

11. Other types of variation • Variation between groups of patients • Variation between areas in the same country • Variation between different health care systems

12. Annual outpatient referral rates per 1,000 in males

13. US Health Plans % Patients Referred/Year UK

14. Some Other Points • Large variations also present among specialists and hospitals • Very little research on variations among other clinical professions, e.g., nurses, midwives, therapists • Similar principles apply to these other groups

15. Changing Clinical Practice • Clinical practice guidelines • Educational interventions • Feedback of comparative data • Systematic reviews suggest these interventions have only limited effects

16. Future issues • New GP contract • Increased monitoring of performance • Quality payments to general practices • New resource allocation formula (Carr-Hill formula) • Understanding variations important • More data available for research

17. Conclusions • Practice variations important to many different groups • Previous research has many limitations • Understanding reasons for variations important if interventions to change clinical practice are to be implemented • Patients and government also want to be reassured about the care given by doctors