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Medical Practice Variations in Primary Care. Professor Azeem Majeed University College London. Outline of Talk. Structure of NHS Role of general practitioners Gatekeeping in the NHS Previous research Current research Implications for policy and clinical practice. National Health Service.
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Medical Practice Variations in Primary Care Professor Azeem Majeed University College London
Outline of Talk • Structure of NHS • Role of general practitioners • Gatekeeping in the NHS • Previous research • Current research • Implications for policy and clinical practice
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
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
Why do variations occur? • Random variation • Patient • Doctor • General practice • Local health care system • National health care system
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
Antibiotic prescribing rates in 211 general practices in 1998
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
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
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
Other types of variation • Variation between groups of patients • Variation between areas in the same country • Variation between different health care systems
US Health Plans % Patients Referred/Year UK
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
Changing Clinical Practice • Clinical practice guidelines • Educational interventions • Feedback of comparative data • Systematic reviews suggest these interventions have only limited effects
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
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