Going the extra mile? General practitioners' upcoding of fees for home visits.

General practitioners' (GPs') income often relies on self-reported activities and performances. They can therefore 'game the system' to maximize their remuneration. We investigate whether Danish GPs game their travel fees for home visits. Combining administrative and geographical data, we measure the difference between GPs' traveled and billed distances. We exploit a rise in the fees for home visits. If there is a link between the rise in fees and upcoding, we interpret this finding as indicative of gaming behavior. We find that upcoding occurs slightly more often than downcoding (16% vs. 13% of visits) for visits that can be both upcoded and downcoded. Using linear probability models with GP fixed effects, we find that the fee rise is associated with a reduction in upcoding of 0.6% of home visits (2.8% for visits where upcoding is feasible) and no change in downcoding. Importantly, we find no statistically significant differences in the reduction in upcoding across distance bands despite large differences in their fee rises. We therefore conclude that there is no causal evidence of GPs gaming their fees.

GP preferences for discussing statin deprescribing: a discrete choice experiment.

BACKGROUND: Deprescribing (planned, supervised discontinuation) of statins may be considered in some older persons. This should be carefully discussed between patients and GPs. METHODS: We examined GPs' preferences for discussing statin deprescribing by conducting a discrete choice experiment (DCE) sent to a stratified random sample of 500 Danish GPs. Attributes were discussion topics (goals of therapy, evidence on statin use in older persons, adverse effects, uncertainty), and levels were the depth of the discussion topics (none, brief, detailed). We used mixed logistic regression for analysis. RESULTS: A total of 90 GPs (mean age 48, 54% female, mean 11 years in practice) completed the DCE. There was substantial variability in which topics GPs felt were most important to discuss; however, GPs generally preferred a brief discussion of topics to detailed ones. The most important discussion topic appeared to be goals of therapy. GPs felt a brief discussion of evidence was important but not a detailed one, while adverse effects and uncertainty were felt to be less important to discuss. CONCLUSION: GPs prefer brief discussions on a range of topics when discussing statin deprescribing but have differing views on which topics are most important. For deprescribing communication tools to be useful to GPs in clinical practice, they may need to focus on brief coverage of the range of relevant topics. Future work should evaluate patient preferences, and opportunities for education and training for GPs on deprescribing communication.

Quality clusters in general practice: associations between cluster organization and general practitioners' self-reported benefits.

BACKGROUND: Quality clusters were introduced as a quality improvement concept in Danish general practice in 2018. This new concept anchored quality improvement in local clusters managed by general practitioners (GPs). OBJECTIVES: To describe the cluster organization and GPs' self-reported benefits of participating in them and explore the associations between cluster organization and self-reported benefits. METHODS: A national survey in Danish general practice gathering information about cluster organization (cluster size, cluster meetings, participants, and content) and GPs' self-reported benefits (overall benefit, internal changes in the clinic, and improved external collaboration). RESULTS: One hundred and eight (95%) clusters and 1,219 GPs (36%) were included. Cluster size varied from 10 to 68 GPs (34 GPs on average). Approximately 70% of GPs reported moderate to very high overall benefit from cluster participation. Most GPs experienced changes in their clinic organization (68%), drug prescriptions (78%), and patient care (77%). Collaboration was reported improved between the GPs (86%), municipality (50%), and hospital (36.2%). GPs in clusters with 3-6 planned meetings per year (odds ratio [OR] 1.9; confidence interval [CI] 1.3-2.9), mixed meeting types (OR 1.7; CI 1.2-2.4), group work (OR 1.7; CI 1.1-2.5), and use of guidelines in their meetings (OR 1.8; CI 1.3-2.4) had statistically significantly higher odds for reporting overall benefit of participating in clusters compared with GPs in clusters without these characteristics. CONCLUSIONS: Frequent and active meetings with a relevant meeting content are positively related to GPs' perceived benefits and with improved collaboration between GPs in the clusters. There seems to be a potential for developing collaboration with other healthcare providers.

Barriers to assessing vulnerability in pregnant women. A cross-sectional survey in Danish general practice.

BACKGROUND: Undetected vulnerability in pregnancy contributes to inequality in maternal and perinatal health and is associated with negative birth outcomes and adverse child outcomes. Nationwide reports indicate important barriers to assessing vulnerability among Danish general practitioners. OBJECTIVE: To explore general practitioners perceived barriers to vulnerability assessment in pregnant women and whether the barriers are associated with practice organization of antenatal care, general practitioner, and practice characteristics. METHODS: The questionnaire was sent to all Danish general practitioners (N = 3,465). Descriptive statistics described the barriers to assessing vulnerability in pregnant women. Analytical statistics with ordered logistic regression models were used to describe the association between selected barriers to vulnerability assessment and antenatal care organization, and general practitioner and practice characteristics. RESULTS: 760 general practitioners (22%) answered. Barriers to vulnerability assessment were related to lacking routines for addressing vulnerability, lacking attention to and record-keeping on vulnerability indicators, an insufficient overview of vulnerable pregnant women, and perceived insufficient remuneration for antenatal care consultations. Not prioritizing extra time when caring for vulnerable pregnant women was associated with experiencing more barriers. Always prioritizing continuity of care was associated with experiencing fewer barriers. General practitioners of either young age, male gender, or who did not prioritize extra time to care for vulnerable pregnant women experienced more barriers. CONCLUSION: Barriers to vulnerability assessment among pregnant women do exist in general practice and are associated with organizational characteristics such as lacking prioritization of extra time and continuity in antenatal care consultations. Also, general practitioner characteristics like male gender and relatively young age are associated with barriers to vulnerability assessment.

Identifying vulnerability in pregnant women is essential to prevent pregnancy-related depression or problems of mother-child attachment, and these women need extra support during pregnancy. In Denmark, all pregnant women are offered pregnancy care by their general practitioner (GP). However, identifying vulnerable pregnant women is challenging for the GPs. This questionnaire study among 760 GPs explores whether the GPs perceived barriers to identifying vulnerable pregnant women are lack of attention to and overview of vulnerable women in their clinic, insufficient record-keeping of vulnerability indicators, and insufficient communicative routines in addressing vulnerability. Additionally, lack of monetary incentives, i.e. not getting paid for spending extra time to talk about vulnerability, was perceived as a barrier. These barriers to identifying vulnerable pregnant women are related to e.g. characteristics of the GP, the practice, and the antenatal care organization in general practice. Young GPs, male GPs, and GPs who did not spend as much time caring for vulnerable pregnant women experienced the most barriers. Contrary, GPs who always prioritized continuity of care experienced fewer barriers. Continuity of care and extra time is important for improving the care of vulnerable pregnant women. Health commissioners may consider supporting the GPs in mobilizing extra time and resources to enhance their care for vulnerable pregnant women.

Physicians' experiences, attitudes, and beliefs towards medical cannabis: a systematic literature review.

BACKGROUND: An increasing number of countries legalise the use of medical cannabis or allow it for a narrow range of medical conditions. Physicians, and often the patients' general practitioner, play a major role in implementing this policy. Many of them, however, perceive a lack of evidence-based knowledge and are not confident with providing patients with medical cannabis. The objectives of this review are to synthesise findings about hospital physicians' and GPs' experiences, attitudes, and beliefs towards the use of medical cannabis with the purpose of identifying barriers and facilitators towards providing it to their patients. METHODS: Peer-reviewed articles addressing hospital physicians' and GPs' experiences, attitudes, and beliefs towards the use of medical cannabis were searched systematically in PubMed, Scopus, EMBASE, and the Cochrane Library. RESULTS: Twenty-one articles were included from five different countries in which the medical cannabis laws varied. The studied physicians experienced frequent inquiries about medical cannabis from their patients (49-95%), and between 10 and 95% of the physicians were willing to prescribe and/or provide it to the patients, depending on setting, specialty and experience among the physicians. This review found that physicians experienced in prescribing medical cannabis were more convinced of its benefits and less worried about adverse effects than non-experienced physicians. However, physicians specialized in addiction treatment and certain relevant indication areas seemed more sceptical compared to physicians in general. Nevertheless, physicians generally experienced a lack of knowledge of clinical effects including both beneficial and adverse effects. CONCLUSION: This review indicates that GPs and hospital physicians from various specialties frequently experience patient demands for medical cannabis and to some degree show openness to using it, although there was a wide gap between studies in terms of willingness to provide. Hospital physicians and GPs' experienced in prescribing are more convinced of effects and less worried of adverse effects. However, most physicians experience a lack of knowledge of beneficial effects, adverse effects and of how to advise patients, which may comprise barriers towards prescribing. More research, including larger studies with cohort designs and qualitative studies, is needed to further examine facilitators and barriers to physicians' prescribing practices.

Prescribing antibiotics: the use of diagnostic tests in general practice. A register-based study.

OBJECTIVE: To assess (i) the pattern of antibiotic prescribing in Danish general practice, (ii) the use of diagnostic tests [point-of-care (POC) and tests analysed at the hospital laboratory (laboratory tests)], and (iii) the frequency of diagnostic testing in relation to antibiotic prescriptions. DESIGN: Retrospective cross-sectional register-based study. SETTING: General practice in a geographical area of Denmark covering 455,956 inhabitants. SUBJECTS: We studied redeemed antibiotic prescriptions and performed diagnostic tests in general practice from 2013 to 2017 among inhabitants in nine selected municipalities. MAIN OUTCOME MEASURES: Frequency of antibiotic courses. Frequency and type of diagnostic testing performed in relation to types of antibiotics. RESULTS: A total of 783,252 antibiotic courses were redeemed from general practice with an overall decrease of 19% during 2013-2017. Diagnostic testing increased by 6% during this period. POC tests comprised the majority of performed diagnostic tests (83%) with C-reactive protein (CRP) as the most frequently used test. A 27% increase in the use of laboratory tests was observed. Tests were performed in relation to 43% of all antibiotic courses; most in relation to prescriptions for sulphonamide and trimethoprim (57%) and rarely when prescribing tetracyclines (10%). Conflicting with national guidelines, Danish GPs prescribed fluoroquinolones without performing any kind of diagnostic testing in 48% of the cases. CONCLUSIONS: This study provides an overview of the use of diagnostic tests in relation to antibiotics and creates basis for further research into the variability between types of antibiotics. The study indicates that there is room for improvement to use diagnostic tests as an aid to promote prudent antibiotic use.KEY POINTSDiagnostic tests (point-of-care or tests analysed at the hospital laboratory), can increase diagnostic certainty and lead to a reduction in antibiotic use in general practice.A decrease in antibiotic courses in general practice in Denmark was observed during 2013-2017, while the use of diagnostic tests increased.A diagnostic test was performed in relation to 43% of antibiotic courses.Only 52% of prescribed fluoroquinolones was related to a diagnostic test, conflicting with national guidelines.

Patient preferences for preventive health checks in Danish general practice: a discrete choice experiment among patients at high risk of noncommunicable diseases.

BACKGROUND: Preventive health checks targeted at the at-risk population can be a way of preventing noncommunicable diseases. However, evidence on patient preferences for preventive health checks is limited, especially among patients with a high risk of noncommunicable diseases. OBJECTIVE: To examine patient preferences for preventive health checks in Danish general practice, targeting persons at high risk of a noncommunicable disease. METHODS: The method used in this study was a discrete choice experiment (DCE) with five attributes: assess, advice, agree, assist and arrange. The attributes were inspired by the 5A model for behaviour change counselling but was altered for the purpose of this study to grasp the entirety of the general practice-based intervention. Moreover, the attribute levels were defined to resemble daily clinical practice. The experimental design of the DCE was an efficient Bayesian main effects design and the results were analysed using a random utility theory framework. RESULTS: A total of 148 patients completed the DCE. Patients at high risk of a noncommunicable disease have positive preferences for: giving brief explanations about own lifestyle, practicing shared decision-making with the general practitioner (GP), follow-up counselling with the GP after the preventive health check and scheduling a new appointment right after the preventive health check. CONCLUSIONS: The results provide Danish GPs with evidence on their patients' preferences towards preventive health checks which will enable the GPs to tailor these consultations. Moreover, the results suggest that pre-appointment measures, such as a health profile, may mediate a preference for more action-oriented attributes. TRIAL REGISTRATION: Registered at Clinical Trial Gov (Unique Protocol ID: TOFpilot2016, https://clinicaltrials.gov/ct2/show/NCT02797392?term=TOFpilot2016&rank=1). Prospectively registered on the 29th of April 2016.

Targeted prevention in primary care aimed at lifestyle-related diseases: a study protocol for a non-randomised pilot study.

BACKGROUND: The consequences of lifestyle-related disease represent a major burden for the individual as well as for society at large. Individual preventive health checks to the general population have been suggested as a mean to reduce the burden of lifestyle-related diseases, though with mixed evidence on effectiveness. Several systematic reviews, on the other hand, suggest that health checks targeting people at high risk of chronic lifestyle-related diseases may be more effective. The evidence is however very limited. To effectively target people at high risk of lifestyle-related disease, there is a substantial need to advance and implement evidence-based health strategies and interventions that facilitate the identification and management of people at high risk. This paper reports on a non-randomized pilot study carried out to test the acceptability, feasibility and short-term effects of a healthcare intervention in primary care designed to systematically identify persons at risk of developing lifestyle-related disease or who engage in health-risk behavior, and provide targeted and coherent preventive services to these individuals. METHODS: The intervention took place over a three-month period from September 2016 to December 2016. Taking a two-pronged approach, the design included both a joint and a targeted intervention. The former was directed at the entire population, while the latter specifically focused on patients at high risk of a lifestyle-related disease and/or who engage in health-risk behavior. The intervention was facilitated by a digital support system. The evaluation of the pilot will comprise both quantitative and qualitative research methods. All outcome measures are based on validated instruments and aim to provide results pertaining to intervention acceptability, feasibility, and short-term effects. DISCUSSION: This pilot study will provide a solid empirical base from which to plan and implement a full-scale randomized study with the central aim of determining the efficacy of a preventive health intervention. TRIAL REGISTRATION: Registered at Clinical Trial Gov (Unique Protocol ID: TOFpilot2016 ). Registered 29 April 2016. The study adheres to the SPIRIT guidelines.

Patient preferences for treatment of low back pain-a discrete choice experiment.

BACKGROUND: Back pain imposes a substantial economic and social burden, and treatment decisions are distorted by conflicting evidence. Thus, it is important to include patient preferences in decision making and policy making. OBJECTIVE: To contribute to the understanding of patient preferences in relation to the choice of treatment for low back pain. METHODS: A discrete choice experiment was conducted with consecutive patients referred to a regional spine center. The respondents (n = 348) were invited to respond to a choice of two hypothetical treatment options and an opt-out option. The treatment attributes included the treatment modality, the risk of relapse, the reduction in pain, and the expected increase in the ability to perform activities of daily living. In addition, the wait time to achieve the treatment effect was used as a payment vehicle. Mixed logit models were created to perform analysis. Subgroup analysis, dividing respondents into sociodemographic and disease-related categories, further explored the willingness to wait. RESULTS: Respondents assigned positive utilities to positive treatment outcomes and disutility to higher risks and longer waits for effects of treatment and to surgical interventions. The model captured significant heterogeneity within the sample for the outcomes of pain reduction and the ability to pursue activities of daily living and for the treatment modality. The subgroup analysis revealed differences in the willingness to wait, especially with regard to treatment modality, the level of pain experienced at the time of data collection, and the respondents' preferences for surgery. CONCLUSIONS: The majority of the respondents prefer nonsurgical interventions, but patients are willing to wait for more ideal outcomes and preferred interventions. The results show that health care professionals have a very important task in communicating clearly about the expected results of treatment and the basis of their treatment decisions, as patients' preferences are highly individual.

The link between physician motivation and care.

Studies report an unexplained variation in physicians' care. This variation may to some extent be explained by differences in their work motivation. However, empirical evidence on the link between physician motivation and care is scarce. We estimate the associations between different types of work motivation and care. Motivation is measured using validated questions from a nation-wide survey of Danish general practices and linked to high-quality register data on their care in 2019. Using a series of regression models, we find that more financially motivated practices generate more fee-for-services per patient, whereas practices characterised by greater altruistic motivation towards the patient serve a larger share of high-need patients and issue more prescriptions for antibiotics per patient. Practices with higher altruism towards society generate lower medication costs per patient and prescribe a higher rate of narrow-spectrum penicillin, thereby reducing the risk of antimicrobial resistance in the population. Together, our results suggest that practices' motivation is associated with several dimensions of healthcare, and that both their financial motivation and altruism towards patients and society play a role. Policymakers should, therefore, consider targeting all provider motivations when introducing organisational changes and incentive schemes; for example, by paying physicians to adhere to clinical guidelines, while at the same time clearly communicating the guidelines' value from both a patient and societal perspective.

Mapping GPs' motivation ­ it's not all about the money: a nationwide cross-sectional survey study from Denmark.

BACKGROUND: Understanding physicians' motivation may be essential for policymakers if they are to design policies that cater to physicians' wellbeing, job retention, and quality of care. However, physicians' motivation remains an understudied area. AIM: To map GPs' work motivation. DESIGN AND SETTING: A cross-sectional analysis using registry and survey data from Denmark. METHOD: Survey data were used to measure four types of motivation: extrinsic motivation, intrinsic motivation, user orientation, and public service motivation. These were combined with register data on the characteristics of the GP, practice, and area. Using latent profile analysis, the heterogeneity in GPs' motivation was explored; the associations between GPs' motivation and the GP, practice, and area characteristics were estimated using linear regression analyses. RESULTS: There was substantial heterogeneity in GPs' motivations. Five classes of GPs were identified with different work motivations: class 1 'it is less about the money' - probability of class membership 53.2%; class 2 'it is about everything' - 26.5%; class 3 'it is about helping others' - 8.6%; class 4 'it is about the work' - 8.2%; and class 5 'it is about the money and the patient' - 3.5%. Linear regression analyses showed that motivation was associated with GP, practice, and area characteristics to a limited extent only. CONCLUSION: GPs differ in their work motivations. The finding that, for many GPs, 'it is not all about the money' indicated that their different motivations should be considered when designing new policies and organisational structures to retain the workforce and ensure a high quality of care.

Do general practitioners know patients' preferences? An empirical study on the agency relationship at an aggregate level using a discrete choice experiment.

OBJECTIVES: This study investigated whether general practitioners (GPs) know patients' preferences regarding a number of organizational characteristics in general practice (i.e., waiting time on the telephone, opening hours, waiting time to the appointment, distance to the general practice, waiting time in the waiting room, consultation time, and whether the GP or assisting personnel performs routine tasks) to examine whether there is a basis for improving the agency relationship at an aggregate level. DATA: A total of 698 respondents from the Danish population and 969 GPs answered the questionnaire in May and September 2010. METHODS: In a discrete choice experiment, GPs and patients made both forced and unforced choices, allowing us to explore the congruence of preferences 1) when patients must choose a new GP and 2) when they can stay with their current GP. RESULTS: Results show that in the forced choice, preferences are seen to differ. In the unforced choice also, preferences differ--mainly because GPs overestimate their own importance to the patients. Rank orders, however, are similar for both GPs and patients. CONCLUSIONS: It is concluded that GPs do not have a precise knowledge of patients' preferences. However, in the unforced choice, GPs do know on which attributes to compete although they underestimate the necessity of competition. The overall conclusion is that there is room for improving the agency relationship in the organization of general practice.

Physicians under Pressure: Evidence from Antibiotics Prescribing in England.

BACKGROUND: Many physicians are experiencing increasing demands from both their patients and society. Evidence is scarce on the consequences of the pressure on physicians' decision making. We present a theoretical framework and predict that increasing pressure may make physicians disregard societal welfare when treating patients. SETTING: We test our prediction on general practitioners' antibiotic-prescribing choices. Because prescribing broad-spectrum antibiotics does not require microbiological testing, it can be performed more quickly than prescribing for narrow-spectrum antibiotics and is therefore often preferred by the patient. In contrast, from a societal perspective, inappropriate prescribing of broad-spectrum antibiotics should be minimized as it may contribute to antimicrobial resistance in the general population. METHODS: We combine longitudinal survey data and administrative data from 2010 to 2017 to create a balanced panel of up to 1072 English general practitioners (GPs). Using a series of linear models with GP fixed effects, we estimate the importance of different sources of pressure for GPs' prescribing. RESULTS: We find that the percentage of broad-spectrum antibiotics prescribed increases by 6.4% as pressure increases on English GPs. The link between pressure and prescribing holds for different sources of pressure. CONCLUSIONS: Our findings suggest that there may be societal costs of physicians working under pressure. Policy makers need to take these costs into account when evaluating existing policies as well as when introducing new policies affecting physicians' work pressure. An important avenue for further research is also to determine the underlying mechanisms related to the different sources of pressure.JEL-code: I11, J28, J45. HIGHLIGHTS: Many physicians are working under increasing pressure.We test the importance of pressure on physicians' prescribing of antibiotics.The prescribed rate of broad-spectrum antibiotics increases with pressure.Policy makers should be aware of the societal costs of pressured physicians.[Formula: see text].

Prescribing antibiotics: Factors driving decision-making in general practice. A discrete choice experiment.

BACKGROUND: Antimicrobial resistance is a threat to human health. We need to strive for a rational use of antibiotics to reduce the selection of resistant bacteria. Most antibiotics are prescribed in general practice, but little is known about factors influencing general practitioners' (GPs) decision-making when prescribing antibiotics. AIM: To 1) assess the importance of factors that influence decisions by GPs to prescribe antibiotics for acute respiratory tract infections (RTIs) and 2) identify segments of GPs influenced differently when deciding to prescribe antibiotics. METHODS: A questionnaire survey including a discrete choice experiment was conducted. Danish GPs were asked to indicate whether they would prescribe antibiotics in six hypothetical choice sets with six variables: whether the GP is behind schedule, patient's temperature, patient's general condition, lung auscultation findings, C-reactive protein (CRP) level, and whether the patient expects antibiotics. Error component and latent class models were estimated and the probabilities of prescribing in different scenarios were calculated. RESULTS: The questionnaire was distributed to every Danish GP (n = 3,336); 1,152 (35%) responded. Results showed that GPs were influenced by (in prioritised order): CRP level (Relative importance (RI) 0.54), patient's general condition (RI 0.20), crackles at auscultation (RI 0.15), and fever (RI 0.10). Being behind schedule and patient expectations had no significant impact on antibiotic prescription at the aggregate level. The latent class analysis identified five classes of GPs: generalists, CRP-guided, general condition-guided, reluctant prescribers, and stethoscopy-guided. For all classes, CRP was the most important driver, while GPs were heterogeneously affected by other drivers. CONCLUSION: The most important factor affecting Danish GPs' decision to prescribe antibiotics at the aggregate level, in subgroups of GPs, and across latent classes was the CRP value. Hence, the use of CRP testing is an important factor to consider in order to promote rational antibiotic use in the battle against antimicrobial resistance.

Factors associated with C-reactive protein testing when prescribing antibiotics in general practice: a register-based study.

BACKGROUND: The use of C-reactive protein (CRP) tests has been shown to safely reduce antibiotic prescribing for acute respiratory tract infections (RTIs). The aim of this study was to explore patient and clinical factors associated with the use of CRP testing when prescribing antibiotics recommended for RTIs. METHODS: A nation-wide retrospective cross-sectional register-based study based on first redeemed antibiotic prescriptions issued to adults in Danish general practice between July 2015 and June 2017. Only antibiotics recommended for treatment of RTIs were included in the analysis (penicillin-V, amoxicillin, co-amoxicillin or roxithromycin/clarithromycin). Logistic regression models were used to estimate odds ratios for patient-related and clinical factors on performing a CRP test in relation to antibiotic prescribing. RESULTS: A total of 984,149 patients redeemed at least one antibiotic prescription during the two-year period. About half of these prescriptions (49.6%) had an RTI stated as the indication, and a CRP test was performed in relation to 45.2% of these scripts. Lower odds of having a CRP test performed in relation to an antibiotic prescription was found for patients aged 75 years and above (OR 0.82, 95CI 0.79-0.86), with a Charlson Comorbidity Index of more than one (OR 0.93, 95CI 0.91-0.95), unemployed or on disability pension (OR 0.84, 95CI 0.83-0.85) and immigrants (OR 0.91, 95CI 0.88-0.95) or descendants of immigrants (OR 0.90, 95CI 0.84-0.96). Living with a partner (OR 1.08, 95CI 1.07-1.10), being followed in practice for a chronic condition (OR 1.22, 95CI 1.18-1.26) and having CRP tests performed in the previous year (OR 1.78, 95CI 1.73-1.84) were associated with higher odds of CRP testing in relation to antibiotic prescribing. CONCLUSIONS: Differences were observed in the use of CRP tests among subgroups of patients indicating that both sociodemographic factors and comorbidity influence the decision to use a CRP test in relation to antibiotic prescriptions in general practice. Potentially, this means that the use of CRP tests could be optimised to increase diagnostic certainty and further promote rational prescribing of antibiotics. The rationale behind the observed differences could be further explored in future qualitative studies.

Burnout of intrinsically motivated GPs when exposed to external regulation: A combined panel data survey and cluster randomized field experiment.

Burnout among general practitioners (GPs) is a problem in many countries. Research indicates that burnout is less likely to occur among intrinsically motivated employees. Based on self-determination theory, we investigate 1) whether intrinsically motivated GPs are less burned out than their colleagues, and 2) whether the most intrinsically motivated GPs are more likely to burn out when exposed to an external regulatory accreditation programme. General practices in Denmark were cluster randomized to mandatory accreditation in 2016, 2017 or 2018. We measure GPs' intrinsic motivation and burnout levels one and two years into the accreditation process. We use a balanced panel of GPs (n = 846) to estimate mixed effects ordered logit models. We find that GPs with high intrinsic motivation are less burned out than their colleagues. However, the most intrinsically motivated GPs are significantly more burned out when exposed to accreditation compared to their colleagues. We conclude that being intrinsically motivated may not shield from burnout when external regulation is imposed.

Home sweet home: GPs' response to an increase in the fee size for home visits.

In many health care systems GPs receive fees for their services. Policymakers may use the size of these fees to try to incentivise GPs to provide more care. However, evidence is mixed on whether and how GPs respond to an increase in the fee size. This study investigates how GPs respond to an average increase of 150% in the fee for a high-effort and infrequent service such as a home visit due to patients' illness. We consider Danish GPs' provision of these visits to enlisted patients living outside of nursing homes. Using linear regressions with general practice fixed effects and a rich number of control variables, we estimate the association between GPs' provision of these home visits and the fee rise. On average, we find no association between the fee rise and GPs' provision of home visits. However, we find that GPs who previously provided the fewest home visits to eligible patients increase their provision by 13% after the fee rise compared to other GPs. This increase in visits is driven by more patients receiving multiple visits after the fee rise. We conclude that a fee rise may not yield a strong response in GPs' provision of high-effort and infrequent services such as home visits.

Time to retire? A register-based study of GPs' practice style prior to retirement.

In many healthcare systems a large share of general practitioners (GPs) is retiring. The literature has shown a negative correlation between physicians' age and their quality of care. However, little is known about whether GPs exhibit different practice styles in the years prior to retirement. This study investigates whether GPs who are closer to retirement make different professional choices than GPs who are not as close to retirement. Using detailed administrative data on 555 Danish GPs and their patients from 2005 to 2017, we study GPs' practice styles across a ten-year period prior to retirement and compare these with GPs who retire at a later date ('non-retiring GPs'), while controlling for age differences as well as exogenous factors affecting healthcare provision. We focus on the GPs' number of enlisted patients, revenue, provision of consultations, and treatment behaviour in consultations. We find no differences between retiring and non-retiring GPs for key outcomes such as 'revenue per patient' and 'consultations per patient'. However, we find that retiring GPs have fewer enlisted patients in their final years of practicing. This finding is driven by more patients leaving rather than fewer patients joining their lists. We also find that retirement is associated with other dimensions of GPs' practice style, e.g. their provision of home visits, prescribing, and referral rates. Overall, we find a modest association between GPs' retirement and their practice style.

Does accreditation of general practice promote patient-reported quality of care? A natural cluster randomised experiment.

OBJECTIVE: To investigate whether accreditation of general practice in Denmark promotes patient-reported quality of care and patient satisfaction. DESIGN: A national cluster randomised case control study based on an online version of the Danish Patients Evaluate Practice questionnaire. Mixed effects ordered logit regression models taking account of clustering of patients in different municipalities were used in the analyses. SETTING: General practice in Denmark. PARTICIPANTS: A representative sample of the Danish population. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was patient-reported quality of care, and patient satisfaction with general practice and patient satisfaction with the general practitioner served as secondary outcome measures. RESULTS: In total, 3609 respondents answered the survey. We found no statistically significant relationships between patient-reported quality of care and practice accreditation (2016: OR=0.89, 95% CI 0.73 to 1.07 and 2017: OR=0.85, 95% CI 0.71 to 1.02) and between patient satisfaction with the general practitioner and accreditation (2016: OR=0.93, 95% CI 0.76 to 1.13 and 2017: OR=0.86, 95% CI 0.70 to 1.04). However, there was a statistically significant negative relationship between patient satisfaction with the general practice and recent practice accreditation compared with satisfaction with practices not yet accredited (OR=0.81, 95% CI 0.67 to 0.97) but no significant relationship between patient satisfaction with the general practice and previous accreditation (OR=0.91, 95% CI 0.76 to 1.09). CONCLUSION: Accreditation does not promote patient-reported quality of care or patient satisfaction. On the contrary, patient satisfaction with the general practice decreases when general practice is recently accredited.

Does accreditation affect the job satisfaction of general practitioners? A combined panel data survey and cluster randomised field experiment.

A critical question for policy makers in health care is whether external interventions have unintended consequences such as lowering professionals' job satisfaction. We investigate whether a non-monetary incentive, in the form of mandatory accreditation, affects the job satisfaction of Danish GPs. Accreditation of general practice in Denmark was introduced as a cluster randomised stepwise implementation from 2016 to 2018. We measure job satisfaction at three time points: before the randomisation took place, one year into the accreditation process and two years into the accreditation process. We use a balanced panel of GPs who have completed all three waves of the survey (n = 846) and estimate a series of random and mixed effects ordered logit models. Despite many GPs having negative attitudes towards accreditation, we find no evidence of accreditation affecting GP job satisfaction. However, there are negative associations between job satisfaction and perceiving accreditation as a tool for external control. Policy makers are therefore encouraged to carefully inform about new interventions and identify barriers to diminish pre-existing negative perceptions about the incentive.