Medical Practice Variations in Primary Care

1
Medical Practice Variations in Primary Care

• Professor Azeem Majeed
• University College London

2
Outline of Talk

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

3
National Health Service

• Established in 1948
• Provides health care cradle to grave
• Division between primary care (GPs) secondary
  care (hospital specialists)
• Numerous initiatives in recent years to improve
  efficiency and quality
• More measurement of performance

4
General Practitioners

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

5
Why do variations occur?

• Random variation
• Patient
• Doctor
• General practice
• Local health care system
• National health care system

6
Implications of variation

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

7
Antibiotic prescribing rates in 211 general
practices in 1998
8
Previous Research 1980s

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

9
Previous Research 1990s

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

10
Limitations of Research

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

11
Other types of variation

• Variation between groups of patients
• Variation between areas in the same country
• Variation between different health care systems

12
Annual outpatient referral rates per 1,000 in
males
13
US Health Plans
Patients Referred/Year
UK
14
Some Other Points

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

15
Changing Clinical Practice

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

16
Future issues

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

17
Conclusions

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