A Systems Approach to Continuity of CarePatient Attitude

A/Prof JP SturmbergUniversity of NSW

A/Prof F CarinciMonash Institute of Health Services Research

RACGP-conference, Perth 2002

Health Care System

Consultation(Outcomes)

Doctor Patient

Consultation(Process)

Systems-based Concept of Continuity of Care

Doctor-Patient Stability

Patient Satisfaction

+

ACCESSto care

Healthfinancing

+

The Need For a Systems Approach

MORBIDITY Psycho-social

-

Method

Health Care System

Low Attitude

Univariate OR (95%CI)

Time dedicated by GP – not always enough 1.77 (1.29-1.86)

Funding for health care – mix of private/public 0.69 (0.52-0.93)

Delay to get an appointment ns

Practice size ns

Billing by this doctor ns

Doctor

Low Attitude

Univariate OR (95%CI)

Knowledge about the patient ns

Consultation difficulty ns

Doctor’s holistic attitude ns

Patient

Low Attitude

Univariate OR (95%CI)

Gender – male 1.38 (1.03-2.41)

Age 65 2.40 (1.67-3.45)

Employment Status (RC=employed)

- Unemployed

- Social support pension

- Retired

1.75 (1.08-2.84)

1.79 (1.17-2.75)

2.28 (1.60-3.25)

Social problem – present 1.71 (1.26-2.32)

Health Status – poor health 1.46 (1.07-2.00)

Psychological problem ns

Patient’s knowledge about the doctor ns

Expecting a script ns

Consultation - Process

Low Attitude

Univariate OR (95%CI)

Communication – poor 1.45 (1.07-1.98)

Patient sent for investigations – no 0.71 (0.51-0.99)

Doctor requested this visit – no ns

Doctor-patient stability - low ns

Consultation length – 11-15 min

Consultation length – 11-10 min

ns

ns

Patient sent for secondary care – no ns

Consultation - Outcome

Low Attitude

Univariate OR (95%CI)

Patient Satisfaction – low 1.66 (1.17-2.36)

Enablement - moderate ns

Would you see this doctor again - no ns

Received a script for old and new medication - yes 1.87 (1.28-2.73)

Outcome = Low Patients’ Attitude towards medical careEvents = 259/1069Category* OR 95% CI

Pat

ien

tH

ealt

hS

yste

mC

on

su

lta

tio

n

(Pro

ce

ss)

Low 1.71 1.14-2.56Old and new medicine 2.26 1.55-3.28

Effect in aged 65 1.02 0.97-1.08Effect in aged 40, 65 0.99 0.92-1.06

Effect in aged 40 1.09 1.01-1.17Effect in aged 65 0.46 0.23-0.90

Effect in aged 40, 65 2.19 0.96-5.00Effect in aged < 40 1.75 0.69-4.44

Effect in aged 65 0.96 0.92-0.99Effect in aged 40, 65 1.03 1.00-1.07

Effect in aged < 40 0.98 0.93-1.03 0.92 0.86-0.98

Unknown in aged < 40 0.18 0.05-0.59Effect in aged 65 1.01 0.91-1.13

Effect in aged 40, 65 1.15 1.04-1.27Effect in aged < 40 0.89 0.79-0.99Effect in aged 65 1.02 0.58-1.79

Effect in aged 40, 65 1.27 0.70-2.29Effect in aged < 40 0.66 0.35-1.25

Unknown 0.48 0.31-0.75Private or mix 0.69 0.50-0.95

No 1.80 1.26-2.58Low 1.52 1.03-2.23

Missing 3.37 1.71-6.64Yes 2.31 1.37-3.88Yes 0.66 0.47-0.93

Administrative/None 2.00 1.21-3.32Social only 1.69 1.03-2.77

Yes 1.77 1.06-2.95Effect in aged 65 1.03 1.01-1.06

Effect in aged 40, 65 0.96 0.94-0.99Effect in aged <40 1.01 0.98-1.04

Effect in aged 65 0.98 0.59-1.64Effect in aged 40, 65 1.65 0.93-2.92

Effect in aged < 40 2.05 1.09-3.87

ODDS RATIO

0.25 0.50 1.00 2.00 5.00

Co

ns

ult

ati

on

(Ou

tco

me

)

Males (RC:females)

Age

Unemployment (RC:no)Self-reported morbidity(RC:physical only or complex)Psychological symptoms (RC:no)

Social symptoms (RC:no)

Practice Seize (RC: 1-3 GPs)

Patient knowledge of doctor (RC:high)Always enough time by GP (RC:yes)Financing for health (RC:public)Charging system (RC:known)

Doctor-patient stability

Doctor-patient communication

Length of consultation

Referral to secondary care (RC:yes)

Patient enablement

Patient satisfaction (RC:high)Prescription (RC: other)

Increased RiskDecreased Risk* red: significant increased risk; green: significant decreased risk.

When reference category is not indicated, effect is unit increase

Variable

Results of Multivariate Logistic Regression

Global correlates of low attitude

INCREASED RISK• Social Problem• Administrative Problem• Social Symptom• Not Knowing the Doctor• Not Having Enough Time with the Doctor• Receiving a Script for an Old and New Problem• Dissatisfaction

DECREASED RISK

• Psychological Symptoms• Mixed Funding of Health

Care• Better Communication

Age-specific correlates of low attitude

< 40 40, <65 65

Gender – Male

Increasing Age

Increasing Patient Enablement

Increasing Doctor-Patient Stability

Increasing Consultation Length

Referral – Not referred

Conclusions (1)

• Being young, middle-aged or old modifies the sense and strength of the association between gender, age, doctor-patient stability, length of consultation, patient enablement

• The effect of age itself changes:

“getting older” in middle aged is associated to better attitudes,

in old patients to lower attitude

Age is an important

effect modifier

Conclusions (2)

Vulnerable Groups• Patients presenting with issues of a social nature – frank social

problems or indirect social problems, eg. Related to DSS, Workers Compensation

• Patients who have not omitted to social problems

Stigma, Guilt, Shame

Somatisation

Lack of Coping

Lack of Social Support

Low self-esteem

Bad experienceswith family

doctors institutions

Dissatisfaction

Conclusions (3)

Not Knowing the Doctor

Experiential Reasons for not seeing the same doctor

Wanting to maintain anonymity

Difficulties accessing the same doctor

Communication Difficulties

Missing psychosocial dimensions

High prescribing rates

More investigations

Dissatisfaction

Lack of tacit knowledge

Conclusions (4)

Systems Effects

Doctor does not have enough time for

patient

Mixed funding for health care

Doctor too busy

• Patient too demanding• Complex Morbidity ?

Conclusions (5)

Practice Size

TREND (NS):Young patients with a holistic

attitude seem to prefer large

practices

Do they seek anonymity?

Do they more easily find the doctor that suits their needs?

Conclusions (6)

Paradoxes

Middle-aged patients who are NOT referred have low holistic attitude

Old patients who are NOT referred have high holistic attitude

Young patients seeking stable doctor-patient relationship

Middle-aged patients avoiding a stable doctor-patient relationship

Summary

• Multivariate logistic regression identifies factors associated to a target outcome

• Sophisticated strategy is needed to increase precision of the final model

• Sense and strength of association between different characteristics and holistic attitudes changes across different age groups

• A systems approach is needed to explain the complex relationships between different dimensions and component variables