General practitioners ending their practice and impact on patients' health, healthcare use and mortality: a protocol for national registry cohort studies in Norway, 2008 to 2021.

INTRODUCTION: Continuous general practitioner (GP) and patient relations associate with positive health outcomes. Termination of GP practice is unavoidable, while consequences of final breaks in relations are less explored. We will study how an ended GP relation affects patient's healthcare utilisation and mortality compared with patients with a continuous GP relation. METHODS AND ANALYSIS: We link national registries data on individual GP affiliation, sociodemographic characteristics, healthcare use and mortality. From 2008 to 2021, we identify patients whose GP stopped practicing and will compare acute and elective, primary and specialist healthcare use and mortality, with patients whose GP did not stop practicing. We match GP-patient pairs on age and sex (both), immigrant status and education (patients), and number of patients and practice period (GPs). We analyse the outcomes before and after an ended GP-patient relation, using Poisson regression with high-dimensional fixed effects. ETHICS AND DISSEMINATION: This study protocol is part of the approved project Improved Decisions with Causal Inference in Health Services Research, 2016/2159/REK Midt (the Regional Committees for Medical and Health Research Ethics) and does not require consent. HUNT Cloud provides secure data storage and computing. We will report using the STROBE guideline for observational case-control studies and publish in peer-reviewed journals, accessible in NTNU Open and present at scientific conferences. To reach a broader audience, we will summarise articles in the project's web page, regular and social media, and disseminate to relevant stakeholders.

Impact of altering referral threshold from out-of-hours primary care to hospital on patient safety and further health service use: a cohort study.

OBJECTIVES: To estimate the impact of altering referral thresholds from out-of-hours services on older patients' further use of health services and risk of death. DESIGN: Cohort study using patient data from primary and specialised health services and demographic data from Statistics Norway and the Norwegian Cause of Death Registry. SETTING: Norway PARTICIPANTS: 491 653 patients aged 65 years and older contacting Norwegian out-of-hours services between 2008 and 2016. ANALYSIS: Multivariable adjusted and instrumental variable associations between referrals to hospital from out-of-hours services and further health services use and death for up to 6 months.Physicians' proportions of acute referrals of older, unknown patients from out-of-hours work were used as an instrumental variable ('physician referral preference') for their threshold of referral for such patients whose clinical presentations were less clear cut. RESULTS: For older patients, whose referrals could be attributed to their physicians' threshold for referral, mean length of stay in hospital increased 3.30 days (95% CI 3.13 to 3.27) within the first 10 days, compared with non-referred patients. Such referrals also increased 6 months use of outpatient specialist clinics and primary care physicians. Importantly, patients with referrals attributable to their physicians' threshold had a substantially reduced risk of death the first 10 days (HR 0.53, 95% CI 0.31 to 0.91), an effect sustaining through the 6-month follow-up period (HR 0.72, 95% CI 0.54 to 0.97). CONCLUSIONS: Out-of-hours patients whose referrals are affected by physician referral threshold contribute substantially to the use of health services. However, the referral seems protective by reducing the risk of death in the first 6 months after the referral. Thus, raising the threshold for referral to lower pressure on overcrowded emergency departments and hospitals should not be encouraged without ensuring the accuracy of the referral decisions, ideally through high-quality randomised controlled trial evidence.

How do busy hospital circumstances affect mortality and readmission within 60 days: A cohort study of 680 000 acute admissions in Norway.

OBJECTIVE: To study mortality and readmissions for older patients admitted during more and less busy hospital circumstances. DESIGN: Cohort study where we identified patients that were admitted to the same hospital, during the same month and day of the week. We estimated effects of inflow of acute patients and the number of concurrent acute inpatients. Mortality and readmissions were analysed using stratified Cox-regression. SETTING: All people 80 years and older acutely admitted to Norwegian hospitals between 2008 and 2016. MAIN OUTCOME MEASURES: Mortality and readmissions within 60 days from admission. RESULTS: Among 294 653 patients with 685 197 admissions, mean age was 86 years (standard deviation 5). Overall, 13% died within 60 days. An interquartile range difference in inflow of acute patients was associated with a hazard ratio (HR) of 0.99, 95% confidence interval (95% CI) 0.98 to 1.00). There was little evidence of differences in readmissions, but a 7% higher risk (HR 1.07, 95% CI 1.06 to 1.09) of being discharged outside ordinary daytime working hours. CONCLUSIONS: Older patients admitted during busier circumstances had similar mortality and readmissions to those admitted during less busy periods. Yet, they showed a higher risk of discharge outside daytime working hours. Despite limited effects of busyness on a hospital level, there could still be harmful effects of local situations.

High ward occupancy, bedspacing, and 60 day mortality for patients with myocardial infarction, stroke, and heart failure.

AIMS: To study the consequences of crowded wards among patients with cardiovascular disease. METHODS AND RESULTS: This is a cohort study among 201 801 patients with 258 807 admissions who were acutely admitted for myocardial infarction (N = 107 895), stroke (N = 87 336), or heart failure (N = 63 576) to any Norwegian hospital between 2008 and 2016. The ward admitting most patients with the given clinical condition was considered a patient's home ward. We compared patients with the same condition admitted when home ward occupancy was different, at the same hospital and during comparable time periods. Occupancy was standardized such that a one-unit difference corresponded to the interquartile range in occupancy in the given month. One interquartile increase in home ward occupancy was associated with 7% higher odds of admission to an alternate ward [odds ratio (OR) 1.07, 95% confidence interval (CI) 1.09 to 1.11], and length of stay was shorter (-0.10 days, 95% CI -0.18 to -0.09). Patients with heart failure had 15% higher odds of admission to alternate wards (OR 1.15, 95% CI 1.08 to 1.23) and increased mortality [hazard ratio (HR) 1.08, 95% CI 1.03 to 1.15]. We found no apparent effect on mortality for patients with myocardial infarction (HR 0.99, 95% CI 0.94 to 1.05) or stroke (HR 1.00, 95% CI 0.96 to 1.05). CONCLUSIONS: Patients with heart failure had higher risk of admission to alternate wards when home ward occupancy was high. These patients may be negatively affected by full wards.

Effects of GP characteristics on unplanned hospital admissions and patient safety. A 9-year follow-up of all Norwegian out-of-hours contacts.

BACKGROUND: There are substantial differences in hospital referrals between general practitioners (GPs); however, there is little research on the consequences for patient safety and further healthcare use. OBJECTIVE: To investigate associations between out-of-hours GP characteristics, unplanned hospital admissions, and patient safety. METHODS: This cohort study included all Norwegian out-of-hours services contacts from 2008 to 2016, linked to registry data on patient characteristics, healthcare use and death, and GP age, sex, specialist status, out-of-hours service experience, and prior admission proportion. We estimated the impact from GP characteristics on (i) immediate unplanned hospital admissions for "all conditions," (ii) immediate unplanned hospital admissions for "critical conditions," (iii) 30-day unplanned hospital admissions, (iv) 30-day hospital costs, and (v) 30-day risk of death. To limit confounding, we matched patients in groups by age, time, and location, with an assumption of random assignment of GPs to patients with this design. RESULTS: Patients under the care of older and male GPs had fewer immediate unplanned hospital admissions, but the effects on cumulative 30-day unplanned hospital admissions and costs were small. The GPs' prior admission proportion was strongly associated with both immediate and 30-day unplanned hospital admissions. Higher prior admission proportion was also associated with admitting more patients with critical conditions. There was little evidence of any associations between GP characteristics and 30-day risk of death. CONCLUSIONS: GPs' prior admission proportion was strongly associated with unplanned hospital admissions. We found little effects on 30-day mortality, but more restrictive referral practices may threaten patient safety through missing out on critical cases.

Referral for specialized health services is a key part of the general practitioner (GP) role. Differences in referrals between primary care physicians have been widely studied, as they represent a target for reducing the use of specialized health services. However, the potential consequences beyond the actual referral have received little attention. Studying associations between physician characteristics and clinical decisions are difficult because physicians often systematically see different patient populations with different morbidity. Previous findings showing large differences in clinical decisions regarding referrals and hospital admissions may suffer from confounding. With our carefully matched study design, we could assume that the assignment of physicians to patients was random. We found substantial differences in referrals associated with GP characteristics. Seeing older and male GPs and specialists in family medicine were associated with fewer immediate unplanned hospital admissions but did not substantially influence unplanned hospital costs within 30 days. However, GPs with a history of admitting many of their recent patients had a substantial higher tendency to admit their future patients and represented a higher use of health services and costs. These GPs also referred more critically ill patients, an essential aspect of patient safety. The differences in referrals had minor impact on the patients' 30-day risk of death.

High volumes of recent surgical admissions, time to surgery, and 60-day mortality.

AIMS: Few studies have investigated potential consequences of strained surgical resources. The aim of this cohort study was to assess whether a high proportion of concurrent acute surgical admissions, tying up hospital surgical capacity, may lead to delayed surgery and affect mortality for hip fracture patients. METHODS: This study investigated time to surgery and 60-day post-admission death of patients 70 years and older admitted for acute hip fracture surgery in Norway between 2008 and 2016. The proportion of hospital capacity being occupied by newly admitted surgical patients was used as the exposure. Hip fracture patients admitted during periods of high proportion of recent admissions were compared with hip fracture patients admitted at the same hospital during the same month, on similar weekdays, and times of the day with fewer admissions. RESULTS: Among 60,072 patients, mean age was 84.6 years (SD 6.8), 78% were females, and median time to surgery was 20 hours (IQR 11 to 29). Overall, 14% (8,464) were dead 60 days after admission. A high (75th percentile) proportion of recent surgical admission compared to a low (25th percentile) proportion resulted in 20% longer time to surgery (95% confidence interval (CI) 16 to 25) and 20% higher 60-day mortality (hazard ratio 1.2, 95% CI 1.1 to 1.4). CONCLUSION: A high volume of recently admitted acute surgical patients, indicating probable competition for surgical resources, was associated with delayed surgery and increased 60-day mortality. Cite this article: Bone Joint J 2021;103-B(2):264-270.

Hospitals´ Discharge Tendency and Risk of Death - An Analysis of 60,000 Norwegian Hip Fracture Patients.

PURPOSE: A reduction in the length of hospital stay may threaten patient safety. This study aimed to estimate the effect of organizational pressure to discharge on 60-day mortality among hip fracture patients. PATIENTS AND METHODS: In this cohort study, hip fracture patients were analyzed as if they were enrolled in a sequence of trials for discharge. A hospital's discharge tendency was defined as the proportion of patients with other acute conditions who were discharged on a given day. Because the hospital's tendency to discharge would affect hip fracture patients in an essentially random manner, this exposure could be regarded as analogous to being randomized to treatment in a clinical trial. The study population consisted of 59,971 Norwegian patients with hip fractures, hospitalized between 2008 and 2016, aged 70 years and older. To calculate the hospital discharge tendency for a given day, we used data from all 5,013,773 other acute hospitalizations in the study period. RESULTS: The probability of discharge among hip fracture patients increased by 5.5 percentage points (95% confidence interval (CI)=5.3-5.7) per 10 percentage points increase in hospital discharges of patients with other acute conditions. The increased risk of death that could be attributed to a discharge from organizational causes was estimated to 3.7 percentage points (95% CI=1.4-6.0). The results remained stable under different time adjustments, follow-up periods, and age cut-offs. CONCLUSION: This study showed that discharges from organizational causes may increase the risk of death among hip fracture patients.

The effect of emergency department delays on 30-day mortality in Central Norway.

OBJECTIVE: To assess whether prolonged length of stay in the emergency department was associated with risk of death. METHODS: We analysed data from 165,183 arrivals at St. Olav's University Hospital's emergency department from 2011 to 2018, using an instrumental variable method. As instruments for prolonged length of emergency department stay, we used indicators measured before arrival of the patient. These indicators were used to study the association between prolonged length of emergency department stay and risk of death, being discharged from the emergency department and length of hospitalisation for those who were hospitalised. RESULTS: Mean length of stay in the emergency department was 2.9 hours, and 30-day risk of death was 3.4%. Per hour prolonged length of stay in the emergency department, the overall change in risk of death was close to zero, with a narrow 95% confidence interval of -0.5 to 0.7 percentage points. Prolonged emergency department stay was associated with a higher probability of being discharged from the emergency department without admission to the hospital. We found no substantial differences in length of hospitalisation for patients who were admitted. CONCLUSION: In this study, prolonged emergency department stay was not associated with increased risk of death.

Employees' drug purchases before and after organizational downsizing: a natural experiment on the Norwegian working population (2004-2012).

Objectives This study investigated the association between organizational downsizing and purchases of prescribed drugs by private sector employees in Norway. Methods A natural experiment was constructed using individual-level employer and employee data linked to the national prescription database for the period 2004-2012. The study population comprised 144 089 employees who had been exposed to major downsizing in the same period. Random effects logistic regression models were used to investigate relative changes in drug purchases (antidepressants, hypnotics/sedatives, anxiolytics, and anti-psychotics, as well as anti-obesity, anti-diabetic, cardiovascular, and thyroid drugs, anti-inflammatory drugs, opioids, and analgesics/antipyretics) in the five-year-period before and after exposure to downsizing. Results Compared with the situation three years before exposure, the odds ratios (OR) of purchasing psychotropic drugs one year after exposure increased for antidepressants (OR 1.44, 95% CI 1.34-1.55), hypnotics/sedatives (OR 1.39, 95% CI 1.29-1.49), anxiolytics (OR 1.32, 95% CI 1.22-1.43), and antipsychotics (OR 1.34, 95% CI 1.19-1.52). Similar associations were found for cardiovascular, anti-diabetic, and thyroid drugs. Stratified analyses showed that the odds of purchasing psychotropic, anti-diabetic, and cardiovascular drugs in the years around downsizing was more pronounced in men compared with women. Elevated odds were also found for employees in the oldest age group and those with less than tertiary education. Conclusions Exposure to organizational downsizing increased the odds of purchasing prescribed psychotropic, cardiovascular, anti-diabetic, and thyroid drugs. The clinical implications of these results might be systematic involvement from medical personnel and occupational health services in workforce reduction processes.

The relationship between educational attainment and waiting time among the elderly in Norway.

We investigate whether educational attainment affects waiting time of elderly patients in somatic hospitals. We consider three distinct pathways; that patients with different educational attainment have different disease patterns, that patients with different levels of education receive treatments at different hospitals, and that patient choice and supply of local health services within hospital catchment areas explain unequal waiting time of different educational groups. We find evidence of an educational gradient in waiting time for male patients, but not for female patients. Conditional on age, male patients with tertiary education wait 45% shorter than male patients with secondary or primary education. The first pathway is not quantitatively important as controlling for disease patters has little effect on relative waiting times. The second pathway is important. Relative to patients with primary education, variation in waiting time and education level across local hospitals contributes to higher waiting time for male patients with secondary education and female patients with secondary or tertiary education and lower waiting time for male patients with tertiary education. These effects are in the order of 15-20%. The third pathway is also quantitatively important. The educational gradients within catchment areas disappear when we control for travel distance and supply of private specialists.

Waiting times and socioeconomic status. Evidence from Norway.

We investigate whether socioeconomic status, measured by income and education, affects waiting time when controls for severity and hospital-specific conditions are included. We also examine which aspects of the hospital supply (attachment to local hospital, traveling time, or choice of hospital) matter most for unequal treatment of different socioeconomic groups. The study uses administrative data from all elective inpatient and outpatient stays in somatic hospitals in Norway. The main results are that we find very little indication of discrimination with regard to income and education when both severity and aspects of hospital supply are controlled for. This result holds for both men and women.

Maternal education and risk of offspring death; changing patterns from 16 weeks of gestation until one year after birth.

BACKGROUND: The social disparity in perinatal mortality may vary by the age of the offspring. We studied offspring mortality from pregnancy week 16 until 1 year after birth by maternal educational level. METHODS: We included all births in Norwegian women during the years 1999-2004 (n = 297 663). The Medical Birth Registry of Norway was linked to the Norwegian Education Registry to obtain individual information on maternal education at the time of delivery. Information on infant mortality was obtained by linkage to the Norwegian Central Person Registry. RESULTS: In pregnancy weeks 37 through 43 and in the first week after birth, there was little difference in offspring mortality by maternal education. Before pregnancy week 37, the excess offspring mortality associated with compulsory school only was >60% using university/college education as the reference. During the 2nd through 12th month after birth, the excess mortality was 132% in offspring of mothers with compulsory school only. CONCLUSION: The social disparity in offspring mortality was lowest in pregnancies at term and in the first week after birth. In this period, all women living in Norway and their infants use the public health care service extensively. Our results may suggest that health care that is equally available to all citizens, reduces social disparities in mortality.

Changes in fetal and neonatal mortality during 40 years by offspring sex: a national registry-based study in Norway.

BACKGROUND: There has been a considerable decline in fetal and neonatal mortality in the Western world. The authors hypothesized that this decline has been largest for boys, since boys have a higher risk of fetal and neonatal death. METHODS: The authors used data from the Medical Birth Registry about all births in Norway to study changes during 1967-2005 in mortality for boys and girls from the 23rd week of pregnancy until one month after birth. Absolute and relative yearly changes in fetal and neonatal death rates were estimated separately for boys and girls. RESULTS: From 1967 to 2005, the average annual reduction in the overall death rate was greater for boys: 0.47 per 1000 boys (95% CI: 0.45, 0.48) and 0.37 per 1000 girls (95% CI: 0.35, 0.39). These estimates were not affected by adjustments made for changes over time in maternal characteristics. The convergence in death rates by sex was strongest for the first week after birth: average annual reduction in the early neonatal death rate was 0.24 per 1000 boys (95% CI: 0.23, 0.25) and 0.17 per 1000 girls (95% CI: 0.16, 0.18). The death rates for boys and girls also converged during pregnancy and from one week to one month after birth. The relative reduction in death rates was quite similar for boys and girls: the overall death rate fell annually by 4.4% (95% CI: 4.3, 4.6%) for boys and by 4.2% (95% CI: 4.0, 4.4%) for girls. CONCLUSIONS: During the period 1967-2005, the absolute reduction in fetal and neonatal death rates was greatest for boys. The relative reduction in mortality was about the same for both sexes, but the absolute reduction was greatest for boys since the mortality for boys began at a higher level. The convergence of death rates was not due to changes in the composition of mothers, suggesting that convergence has been caused by technological progress.

Norwegian priority guidelines: estimating the distributional implications across age, gender and SES.

OBJECTIVE: Targeting hospital treatment at patients with high priority would seem to be a natural policy response to the growing gap between what can be done and what can be financed in the specialist health care sector. The paper examines the distributional consequences of this policy. METHOD: 450000 elective patients are allocated to priority groups on the basis of medical guidelines developed by one of the regional health authorities in Norway. Probit models are estimated explaining priority status as a function of age, gender and socioeconomic status. RESULTS: Women and older people are overrepresented among patients with low priority. Conditional on age, women with low priority have lower income and less education than women with high priority. Among men below 50 years, patients with low priority have less education than patients with high priority. CONCLUSION: Targeting hospital treatment at patients with high priority, though sensible from a pure medical perspective, may have undesirable distributional consequences.

[Population satisfaction with health care and physicians' job satisfaction]. / Befolkningens tilfredshet med helsetjenesten og legers tilfredshet med arbeidssituasjonen.

BACKGROUND: To assess whether development of health services in Norway has been well balanced in terms of satisfaction; time series variation has been compared for population satisfaction with health services and physician job satisfaction. MATERIAL AND METHODS: Data were retrieved from the following sources and years: the reference panel of The Research Institute of the Norwegian Medical Association on physician job satisfaction in the years 1994, 2000, 2002 and 2006; the municipal surveys of TNS Gallup on population satisfaction with health care (primary) in the years 1995 - 2000, 2003 and 2005 and in 1999, 2000 and 2003 for satisfaction with hospitals, and from the Norwegian part of the International Social Survey Program (ISSP) on population willingness to allocate resources to public health care (in 1990 and 2006). Time series of physician satisfaction were computed from changes in satisfaction between consecutive surveys. Time series of population satisfaction were computed from annual regression-adjusted means that control for the association between satisfaction and observable personal characteristics. RESULTS: On a scale from 10 to 70, hospital doctors' job satisfaction increased from 50.2 in 1994 to 52.3 in 2006. General practitioners' job satisfaction increased from 52.3 to 55.5 in the same period. From 1995 to 2005, consumer satisfaction with primary care increased from 4.43 to 4.54 and with hospital services from 4.23 to 4.47 (on a scale from 1 to 6). The proportion of the population who believes more public resources should be spent on health care increased from 82.7 % in 1990 to 85.2 % in 2006. INTERPRETATION: The development in the health care sector seems to be balanced in the sense that views of the population and health personnel have followed parallel trajectories. A large and increasing share of the population is willing to allocate more resources to health care.

Services production and patient satisfaction in primary care.

CONTEXT: The institutional setting for the study was the primary physician service in Norway, where there is a regular general practitioner scheme. Each inhabitant has a statutory right to be registered with a regular general practitioner. There are large differences between physicians in service production. OBJECTIVE: We studied whether difference in services production between physicians has an effect on how satisfied patients are with the services that are provided. METHODOLOGY: Data about patient satisfaction were obtained from a survey of a representative sample of the population. We obtained data about how satisfied the respondents were with: waiting time to get an appointment, amount of time the physician spent with them, and to what extent they perceived that the physician took their medical problems seriously. The survey data were merged with data on service production for the primary physician that the respondent was registered with. Service production was measured as the number of consultations per person on the list. RESULTS: There was a positive and relatively strong association between the level of service production of the general practitioners and patient satisfaction with waiting time for a consultation. There was no association between the level of service production and the two other measures of patient satisfaction. CONCLUSION: The results provide evidence about one of several factors that should be taken into account when deciding on future health manpower policies with respect to primary physician services in Norway.

Primary physicians' response to changes in fees.

The study examines how the service production of primary physicians in Norway is influenced by changes in fees. The data represent about 2,650 fee-for-service physicians for the years 1995--2000. We constructed a variable that made it possible to estimate income effects of fee changes on service levels. Service production was measured by the number of consultations per physician, the number of laboratory tests per consultation and the proportion of consultations lasting more than 20 min. Our main finding is that fee changes have no income effect on service production. Our results imply that fee regulation can be an effective means of controlling physicians' income, and therefore government expenditure, on primary physician services.

Better primary physician services lead to fewer hospital admissions.

The aim of the study was to examine whether improved quality of primary physician services, measured by patient satisfaction, leads to fewer admissions to somatic hospitals. We studied differences in hospital admissions at the municipality level in Norway. In addition to the standard explanatory variables for use of hospitals--gender, age, socio-economic status and travelling distance to the nearest hospital--we also included a measure of patient satisfaction with primary physician services in the municipality. Data on patient satisfaction was obtained from an extensive questionnaire survey of 63,798 respondents. We found a statistically significant negative relationship between patient satisfaction and the number of hospital admissions. This conclusion was robust with regard to the empirical specification, and the effect was large.

[Population's satisfaction with hospitals before and after a hospital reform in Norway]. / Befolkningens tilfredshet med sykehusene før og etter sykehusreformen.

BACKGROUND: We investigated patients' satisfaction with availability and quality of hospital services in 2000 and 2003, that is before and after the Norwegian hospital reform. MATERIAL AND METHODS: The data were collected from two national surveys in 2000 and 2003. The participants were asked about their satisfaction with availability (choice and waiting time for an appointment) and quality (result of treatment, professional skills, service-mindedness, punctuality, information and available time). For each question, changes in mean satisfaction from 2000 to 2003, corrected for changes in the composition of the sample, were estimated. RESULTS: A clear and statistically significant improvement in patient satisfaction with the availability and quality of hospital services took place from 2000 to 2003. In general, patients were more satisfied with the quality than with the availability of hospital services. INTERPRETATION: The hospital reform may have contributed to improved satisfaction with hospitals, though other factors may also have played a part.

[Patient satisfaction with general practice services before and after the list patient reform]. / Brukertilfredshet i allmennlegetjenesten før og etter fastlegereformen.

BACKGROUND: The aim of this study was to investigate how satisfied people are with general practitioners' (GPs') services before and after the introduction of a list patient system in Norway. MATERIAL AND METHODS: Data were collected from two national questionnaire surveys carried out in 2000 and 2003. Satisfaction was measured on two dimensions: satisfaction with access and satisfaction with the physician and the actual treatment. RESULTS: The level of satisfaction with GPs' services was high before the reform. This was particularly the case with regard to the second dimension: satisfaction with the GP and the actual treatment (for example, evaluation of the GP's competence). There were only small changes in these indicators from 2000 to 2003, but the changes were for the better. The changes in the indicators for the first dimension (those with the lowest scores before the reform): satisfaction with access (e.g. physicians-to-population ratio in the district and waiting time for an appointment)--were greater and also positive. Respondents in large and medium-sized municipalities reported the highest increase in satisfaction with access. There were no changes with regard to emergency services. The proportion of people who had used more than one physician during the last year was down from 38% to 29%. INTERPRETATION: Higher satisfaction with GPs' services has occurred after the introduction of a list patient system and the associated improvement in the GPs-to-population ratio. That fewer people changed their GP may be the result of more stability in physician posts. It may also be associated with greater satisfaction with people's access to their own GP after the reform.