A scope of practice that works 'out here': exploring the effects of a changing medical regulatory environment on a rural New Zealand health service.

INTRODUCTION: In 2008, the Medical Council of New Zealand recognised rural hospital medicine as a vocational scope of practice. The aim was to provide training and professional development standards for medical practitioners working in New Zealand's rural hospitals and to encourage quality systems to become established in rural hospitals. Hokianga Health in New Zealand's far north is an established integrated health service that includes a rural hospital and serves a largely Māori community. The aim of this study was to explore how the new scope had affected health practitioners and the health service at Hokianga Health. METHODS: A case study design was used, employing qualitative methods. Documentary analysis was undertaken tracking change and development at Hokianga Health. Twenty-six documents (10 from within and 16 from outside Hokianga Health) were included in the analysis. Eleven face-to-face semi-structured interviews were conducted with employees of Hokianga Health. The interviews explored participants' views of the rural hospital medicine scope. Interviews were recorded and transcribed. Thematic analysis of the interviews was undertaken using the framework method. The two data sources were analysed separately. RESULTS: Four themes capturing the main issues were identified: (1) 'What I do': articulating the scope of medical practice at Hokianga, (2) 'What we do': the role of the hospital at Hokianga, (3) 'On the fringes', and (4) Survival. With changing regulatory policy an established part of Hokianga Health practice, the hospital aspect was outside the scope of general practice. This mismatch created a vulnerability for individual doctors and threatened the hospital service. The new scope filled the gap, rural hospital medicine together with general practice now covering the whole practice scope at Hokianga Health. With the introduction of the rural hospital medicine scope and the accompanying national definition of a rural hospital came a sense of belonging and increased connectedness, Hokianga Health and its practitioners realigning with the new scope, its policies, processes and language. The new scope brought for the first time a specific focus on the inpatient and emergency care aspects of practice at Hokianga and with this validation of the hospital aspect of the medical practitioners work. The critical importance of a fit-for-purpose scope and rural-specific postgraduate training programs in minimising inequity of care and opportunity for rural communities was emphasised. The importance of benchmarking with its associated costs was also highlighted. The main challenges identified related to the real (as well as potential) increased regulatory requirements of two separate scopes of practice for practitioners and a small rural health service working across primary and secondary care. CONCLUSION: In better equipping medical practitioners for rural hospital work and strengthening hospital systems and standards, the rural hospital medicine scope has met its intentions at Hokianga Health. The rural hospital medicine pathway is a necessary partial solution to rural medical practitioners maintaining a broad skill set. Continued flexibility is required in training programs in order to meet a range of different practitioner and rural health service needs.

Cost-effectiveness of a multicomponent primary care program targeting frail elderly people.

BACKGROUND: Over the last 20 years, integrated care programs for frail elderly people aimed to prevent functional dependence and reduce hospitalization and institutionalization. However, results have been inconsistent and merely modest. To date, evidence on the cost-effectiveness of these programs is scarce. We evaluated the cost-effectiveness of the CareWell program, a multicomponent integrated care program for frail elderly people. METHODS: Economic evaluation from a healthcare perspective embedded in a cluster controlled trial of 12 months in 12 general practices in (the region of) Nijmegen. Two hundred and four frail elderly from 6 general practices in the intervention group received care according to the CareWell program, consisting of multidisciplinary team meetings, proactive care planning, case management, and medication reviews; 165 frail elderly from 6 general practices in the control group received usual care. In cost-effectiveness analyses, we related costs to daily functioning (Katz-15 change score i.e. follow up score minus baseline score) and quality adjusted life years (EQ-5D-3 L). RESULTS: Adjusted mean costs directly related to the intervention were €456 per person. Adjusted mean total costs, i.e. intervention costs plus healthcare utilization costs, were €1583 (95% CI -4647 to 1481) higher in the intervention group than in the control group. Incremental Net Monetary Benefits did not show significant differences between groups, but on average tended to favour usual care. CONCLUSIONS: The CareWell primary program was not cost-effective after 12 months. From a cost-effectiveness perspective, widespread implementation of the program in its current form cannot be recommended. TRIAL REGISTRATION: The study was registered in the ClinicalTrials.govProtocol Registration System: ( NCT01499797 ; December 26, 2011). Retrospectively registered.

Cardiovascular risk factors and frailty in a cross-sectional study of older people: implications for prevention.

Objective: to examine the associations of cardiovascular disease (CVD) and cardiovascular risk factors with frailty. Design: a cross-sectional study. Setting: the Irish Longitudinal Study on Ageing (TILDA). Participants: frailty measures were obtained on 5,618 participants and a subset of 4,330 participants with no prior history of CVD. Exposures for observational study: cardiovascular risk factors were combined in three composite CVD risk scores (Systematic Coronary Risk Evaluation [SCORE], Ideal Cardiovascular Health [ICH] and Cardiovascular Health Metrics [CHM]). Main outcome measures: a frailty index (40-items) was used to screen for frailty. Methods: the associations of CVD risk factors with frailty were examined using logistic regression. Results: overall, 16.4% of participants had frailty (7.6% at 50-59 years to 42.5% at 80+ years), and the prevalence was higher in those with versus those without prior CVD (43.0% vs. 10.7%). Among those without prior CVD, mean levels of CVD risk factors were closely correlated with higher frailty index scores. Combined CVD risk factors, assessed using SCORE, were linearly and positively associated with frailty. Compared to low-to-moderate SCOREs, the odds ratio (OR) (95% confidence interval, CI) of frailty for those with very high risk was 3.18 (2.38-4.25). Conversely, ICH was linearly and inversely associated with frailty, with an OR for optimal health of 0.29 (0.21-0.40) compared with inadequate health. Conclusions: the concordant positive associations of SCORE and inverse associations of ICH and CHM with frailty highlight the potential importance of optimum levels of CVD risk factors for prevention of disability in frail older people.

Introducing a GP copayment in Australia: Who would carry the cost burden?

Recent policy changes designed to contain unsustainable health expenditure growth imply that many more Australians may soon be charged a copayment to consult a GP. We explore the distributional consequences associated with a range of hypothetical GP copayment scenarios using nationally-representative Australian survey data. For each scenario, we estimate the cost burden that individuals and households across the income distribution would need to absorb to maintain their current GP service utilisation. Even when concessional patients are charged a third or a quarter of the non-concessional copayment rate, the average estimated cost burden in the lowest income quartile is typically between three and six times that of the highest, and the average cost burden for women is significantly higher than for men within every income quartile. These disparities are intensified for those with a chronic illness. We conclude that the widespread implementation of GP copayments would disproportionately burden lower-income families, who experience higher rates of chronic illness, higher demand for GP services, and lower capacity to absorb price increases. The regressive nature of GP copayments is reduced when concessional and child patients are exempted entirely, highlighting the importance of supporting GPs-particularly in disadvantaged areas-to maintain bulk-billing arrangements for vulnerable patient groups.

Variation in outpatient consultant physician fees in Australia by specialty and state and territory.

OBJECTIVES: To determine the mean, median and 10th and 90th percentile levels of fees and out-of-pocket costs to the patient for an initial consultation with a consultant physician; to determine any differences in fees and bulk-billing rates between specialties and between states and territories. DESIGN, PARTICIPANTS AND SETTING: Analysis of 2015 Medicare claims data for an initial outpatient appointment with a consultant physician (Item 110) in 11 medical specialties representative of common adult non-surgical medical care (cardiology, endocrinology, gastroenterology, geriatric medicine, haematology, immunology/allergy, medical oncology, nephrology, neurology, respiratory medicine and rheumatology). MAIN OUTCOME MEASURES: Mean, median, 10th and 90th percentile levels for consultant physician fees and out-of-pocket costs, by medical specialty and state or territory; bulk-billing rate, by medical specialty and state/territory. RESULTS: Bulk-billing rates varied between specialties, with only haematology and medical oncology bulk-billing more than half of initial consultations. Bulk-billing rates also varied between states and territories, with rates in the Northern Territory (76%) nearly double those elsewhere. Most private consultations require a significant out-of-pocket payment by the patient, and these payments varied more than fivefold in some specialties. CONCLUSION: Without data on quality of care in private outpatient services, the rationale for the marked variations in fees within specialties is unknown. As insurers are prohibited from providing cover for the costs of outpatient care, the impact of out-of-pocket payments on access to private specialist care is unknown.

Prescription Patterns and the Cost of Migraine Treatments in German General and Neurological Practices.

OBJECTIVES: The aim of this study was to analyze prescription patterns and the cost of migraine treatments in general practices (GPs) and neurological practices (NPs) in Germany. METHODS: This study included 43,149 patients treated in GPs and 13,674 patients treated in NPs who were diagnosed with migraine in 2015. Ten different families of migraine therapy were included in the analysis: triptans, analgesics, anti-emetics, beta-blockers, antivertigo products, gastroprokinetics, anti-epileptics, calcium channel blockers, tricyclic antidepressants, and other medications (all other classes used in the treatment of migraine including homeopathic medications). The share of migraine therapies and their costs were estimated for GPs and NPs. RESULTS: The mean age was 44.4 years in GPs and 44.1 years in NPs. Triptans and analgesics were the 2 most commonly prescribed families of drugs in all patients and in the 9 specific subgroups. Interestingly, triptans were more commonly prescribed in NPs than in GPs (30.9% to 55.0% vs. 30.0% to 44.7%), whereas analgesics were less frequently given in NPs than in GPs (11.5% to 17.2% vs. 35.3% to 42.4%). Finally, the share of patients who received no therapy was higher in NPs than in GPs (33.9% to 58.4% vs. 27.5% to 37.9%). The annual cost per patient was €66.04 in GPs and €94.71 in NPs. Finally, the annual cost per patient increased with age and was higher in women and in individuals with private health insurance coverage than in men and individuals with public health insurance coverage. CONCLUSION: Triptans and analgesics were the 2 most commonly prescribed drugs for the treatment of migraine. Furthermore, approximately 30% to 40% of patients did not receive any therapy. Finally, the annual cost per patient was higher in NPs than in GPs.

Effectiveness and cost-effectiveness of a proactive, goal-oriented, integrated care model in general practice for older people. A cluster randomised controlled trial: Integrated Systematic Care for older People--the ISCOPE study.

BACKGROUND: older people often experience complex problems. Because of multiple problems, care for older people in general practice needs to shift from a 'problem-based, disease-oriented' care aiming at improvement of outcomes per disease to a 'goal-oriented care', aiming at improvement of functioning and personal quality of life, integrating all healthcare providers. Feasibility and cost-effectiveness of this proactive and integrated way of working are not yet established. DESIGN: cluster randomised trial. PARTICIPANTS: all persons aged ≥75 in 59 general practices (30 intervention, 29 control), with a combination of problems, as identified with a structured postal questionnaire with 21 questions on four health domains. INTERVENTION: for participants with problems on ≥3 domains, general practitioners (GPs) made an integrated care plan using a functional geriatric approach. Control practices: care as usual. OUTCOME MEASURES: (i) quality of life (QoL), (ii) activities of daily living, (iii) satisfaction with delivered health care and (iv) cost-effectiveness of the intervention at 1-year follow-up. TRIAL REGISTRATION: Netherlands trial register, NTR1946. RESULTS: of the 11,476 registered eligible older persons, 7,285 (63%) participated in the screening. One thousand nine hundred and twenty-one (26%) had problems on ≥3 health domains. For 225 randomly chosen persons, a care plan was made. No beneficial effects were found on QoL, patients' functioning or healthcare use/costs. GPs experienced better overview of the care and stability, e.g. less unexpected demands, in the care. CONCLUSIONS: GPs prefer proactive integrated care. 'Horizontal' care using care plans for older people with complex problems can be a valuable tool in general practice. However, no direct beneficial effect was found for older persons.

Characteristics, disease burden and costs of COPD patients in the two years following initiation of long-acting bronchodilators in UK primary care.

BACKGROUND: To assess the symptomatic and cost burden among patients initiating long-acting bronchodilator (LABD) therapy and impact of adherence on healthcare resource use and costs. METHODS: This retrospective cohort study identified patients with COPD who were newly prescribed a LABD (long-acting muscarinic antagonist [LAMA], long-acting beta2-agonist [LABA], a combination of LABA+LAMA or combination of LABA with inhaled corticosteroid [ICS]/LABA) between January 1, 2009 and November 30, 2013 from the UK Clinical Practice Research Datalink. Health care resource use, costs and symptom burden up to 24 months after treatment initiation were estimated. Adherence in the follow-up period was assessed using the medication possession ratio (MPR ≥ 80%). RESULTS: The cohort comprised 8283 LABD initiators (16% LABA, 81% LAMA and 3% LABA+LAMA) and 9246 LABA+ICS initiators with generally similar baseline characteristics; prior exacerbation rate was higher in the LABA+ICS cohort. Less than half the patients (LAMA:42%; LABA:34% and LABA+ICS:34%) were adherent to their index medication. Among adherent patients, the total annual per patient cost of COPD was £3008 for LAMA initiators, £2783 for LABA initiators and £3376 for LABA+ICS initiators; primarily due to general practitioner interactions. Among patients with a Medical Research Council dyspnea score recorded during 24 months follow-up, a substantial proportion of adherent patients (LAMA: 41%; LABA: 45%; LABA+ICS 44%) had clinically significant dyspnoea (MRC ≥ 3). CONCLUSION: Cost and symptomatic burden of COPD was high among patients initiating maintenance treatment, including patients adherent with their initial treatment. General practitioner interactions were the primary driver of costs. Further, real world studies are required to address unmet needs and optimize treatment pathways to improve COPD symptom burden and outcomes.

Perceptions of Indonesian general practitioners in maintaining standards of medical practice at a time of health reform.

BACKGROUND: There is little research on how GPs experience the demands of maintaining standards of medical practice in developing countries and what strategies might improve their capability to provide high-quality primary health care (PHC). OBJECTIVE: This study aims to explore the underlying factors, which shape GPs' experience within the Indonesian PHC system and impact on their experience of professional practice. METHODS: A grounded theory approach was applied using semi-structured interviews of 25 purposively selected GPs in West Sumatra, Indonesia. The interviews were analysed inductively through an iterative process of the interplay between empirical data, emerging analysis and theory development. RESULTS: Three major health care systems attribute shaped GPs' experiences of professional practice, including (i) a restricted concept of the PHC system, (ii) lack of regulation of private primary care practice conducted by GPs, midwives, nurses and specialists and (iii) low coverage and inappropriate policy of the health insurance system. CONCLUSION: The findings indicate that a major revision of current health care system is required with a focus on promoting the concept of PHC services to the population, redefining the role of the GP to deliver recognised best practice within available resources, changing the way GPs are remunerated by the public health system and the health insurance industry, policing of the regulations related to the scope of practice of other health care professionals, particularly midwives and nurses, and regulation of prescribing. GPs can be the champions of the PHC service that Indonesia needs, but it requires sustained systematic change.

Getting the balance right between generalism and specialisation - does remuneration matter?

BACKGROUND: Remuneration has been cited as a factor influencing the distribution of doctors between generalist and specialist roles. OBJECTIVE: To review the evidence on earnings differentials between specialists and GPs, and suggest possible policy responses. DISCUSSION: Specialists earn almost twice as much as GPs but only half of this difference can be explained by differences in their characteristics. Evidence suggests that expected future earnings, together with a range of other factors, influence specialty choice. Directly altering relative earnings may be difficult, but greater targeted investment in primary care is more achievable to help shift the balance.

Are pharmacy-based minor ailment schemes a substitute for other service providers? A systematic review.

BACKGROUND: Pharmacy-based minor ailment schemes (PMASs) have been introduced throughout the UK to reduce the burden of minor ailments on high-cost settings, including general practice and emergency departments. AIM: This study aimed to explore the effect of PMASs on patient health- and cost-related outcomes; and their impact on general practices. DESIGN AND SETTING: Community pharmacy-based systematic review. METHOD: Standard systematic review methods were used, including searches of electronic databases, and grey literature from 2001 to 2011, imposing no restrictions on language or study design. Reporting was conducted in the form recommended in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and checklist. RESULTS: Thirty-one evaluations were included from 3308 titles identified. Reconsultation rates in general practice, following an index consultation with a PMAS, ranged from 2.4% to 23.4%. The proportion of patients reporting complete resolution of symptoms after an index PMAS consultation ranged from 68% to 94%. No study included a full economic evaluation. The mean cost per PMAS consultation ranged from £1.44 to £15.90. The total number of consultations and prescribing for minor ailments at general practices often declined following the introduction of PMAS. CONCLUSION: Low reconsultation and high symptom-resolution rates suggest that minor ailments are being dealt with appropriately by PMASs. PMAS consultations are less expensive than consultations with GPs. The extent to which these schemes shift demand for management of minor ailments away from high-cost settings has not been fully determined. This evidence suggests that PMASs provide a suitable alternative to general practice consultations. Evidence from economic evaluations is needed to inform the future delivery of PMASs.

Acupuncture in Australian general practice: trends in reimbursed acupuncture services from 1995 to 2011.

OBJECTIVES: To ascertain the extent of and trends in the use of acupuncture in Australian general practice and the characteristics of patients receiving publicly subsidised acupuncture services from general practitioners (GPs). DESIGN: Secondary analysis of national patient Medicare data for claims by all non-specialist medical practitioners for Medicare Benefits Schedule items for an attendance where acupuncture was performed by a medical practitioner from 1995 to 2011. MAIN OUTCOME MEASURES: Use of acupuncture by GPs, patients' sex and age and the socioeconomic disadvantage index of GP's practice. RESULTS: There has been a 47.7% decline in the number of acupuncture claims by GPs per 100 000 population in the period from 1995 to 2011. Acupuncture claims were made by 3.4% of GPs in 2011. Women were almost twice as likely to receive acupuncture from a GP as men, and patients in urban areas were more than twice as likely to receive acupuncture from a GP as patients in rural areas. Acupuncture claims were highest in areas that were socioeconomically advantaged. CONCLUSIONS: Claims for reimbursement for acupuncture by GPs have declined significantly in Australian general practice even though the use of acupuncture by the Australian public has increased. This may be due to increased use of referrals or use of non-medical practitioners, barriers to acupuncture practice in general practice or non-specific factors affecting reimbursement for non-vocationally registered GPs.