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Inequality in provider continuity for children by Australian general practitioners

Inequality in provider continuity for children by Australian general practitioners Background: There is little published on provider continuity in Australian general practice and none on its effect on inequality of care for children. Method: Questionnaire administered to parents of the ACT Kindergarten Health Screen asking the name of their child’s usual GP and practice address between 2001 and 2008. Results: Parents of 30,789 children named 433 GPs and 141 practices. In each year, an average of 77% of parents could name both the GP and the practice, an average of 11% of parents could name only the practice, and an average of 12% of parents could name neither. In each year, 25% of parents could not name a usual GP for children of Aboriginal or Torres Straight Islander descent, or children born outside of Australia, compared to 10% of all other children (p = < 0.0001). The frequency of GPs displaying continuity of care varied over time with 19% of GPs being present in the ACT in only one year and 39% of GPs being present in every year over the eight years of study. GPs displayed two different forms of transience either by working in more than one practice in each year (5% of GPs), or by not being present in the ACT region from one year to the next (15% of GPs). Fewer parents nominated transient GPs as their child’s GP compared to choosing GPs who displayed continuity (p < 0.001). Conclusions: Many GPs (39%) were reported to provide continuity of care for in the ACT region and some GPs (20%) displayed transient care. Indigenous children or children born outside of Australia had less equity of access to a nominated GP than all other children. Such inequity might disappear if voluntary registration of children was adopted in Australian general practice. Background In Australia, there is no formal process where patients The story of the GP who remained in one location mana- voluntarily register with individual GPs or their practices ging the many health problems people present over time and thereby create administrative registries. There are a is a story unique to general practice. The theme of conti- number of indirect methods of counting GPs used by nuity of care was first described in Holland [1] and more DOHA from an analysis of Medicare data producing recently weaves through stories of Australian general paradoxical results [5,6]. For example, the full-time practices published on the RACGP website [2]. A recent equivalent method of counting individual GPs produces a systematic review defined continuity of care as a three decrease in numbers of GPs between 2004 and 2008 in dimensional description of health care which included the ACT, but the headcount method produces a small informational, longitudinal, and personal continuity of increase. None of these methods result in a published care [3]. Each of these dimensions have been adopted in account of individual GPs or individual general practices the 2010 RACGP standards for general practice as an over time. Our study aims to address this gap by analys- achievable standard in Australia [4], but do not comment ing systematically gathered names of GPs and their prac- on how provider continuity might be achieved by GPs. tice addresses. Our first null hypothesis was that similar proportions of GPs display continuity and transient care over time. * Correspondence: marjan.kljakovic@anu.edu.au A principle policy goal of Medicare is to provide equal Academic Unit of General Practice and Community Health in the School of General Practice, Rural and Indigenous Health, at the Australian National care for equal need to all Australian people, for all ages. University Medical School, PO Box 11 Woden, ACT 2606, Australia Nevertheless, previous research has shown that Medicare Full list of author information is available at the end of the article © 2011 Kljakovic et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kljakovic et al. BMC Family Practice 2011, 12:106 Page 2 of 8 http://www.biomedcentral.com/1471-2296/12/106 does not guarantee equity of health care for health same when the first name was missing. The matching was related outcomes [7]. Our second study aim was to also visually assessed to correct any mismatching GPs. describe the equity of access to GP care for children in The accuracy of the matching was critical to the results. the ACT. Our second null hypothesis was there are no The matching of practices was reliable due to the use of disparities in equity of access to GPs for Indigenous chil- the phone number for matching. The GP matching was dren (who are of Aboriginal or Torres Strait Islander des- dependent on text fields and therefore the level of confi- cent), or overseas born, compared to all other children. dence for accurate matching was reduced. In 2008, six general practices (named Index General Practices) from the ACT region agreed to measure the Methods Each year, all 4 to 6 year old primary school-entry children concordance between parents naming a GP and practice take part in the ACT Kindergarten Health Screen for a in the Kindergarten screen and whether the child’s name population-based school health assessment, which had been recorded in the named practice records. includes a survey completed by parents (delivery and We undertook descriptive statistics of continuity for the structure described elsewhere [8]). Since 1998, this survey named GPs and their practices between 2001 and 2008. has comprised a general health questionnaire that includes Statistical comparisons were made using chi-squared tests questions asking the name of the child’sGPand the and T-tests for categorical and continuous outcomes address of the general practice. Response rates of 85% to respectively. All analysis was undertaken using SAS 89% to the questionnaire are achieved each year. The dis- version 9.1.3. tribution of all the 105 private and government funded Ethical approval was obtained from the Australian kindergartens match the spread of general practices across Nation University Human Ethics Committee and the the ACT region increasing the likelihood that most GPs ACT Health Human Research Ethics Committee. and general practices are named each year. Results Defining the naming of GPs Parents of 30,789 children responded to the questionnaire 1. ‘Naming a GP ’ was defined when parents between 2001 and 2008. The mean age of the children was responded yes to the question “Does your child have 5.7 years, 50.5% were male, 1.8% were Indigenous children, a usual medical practitioner?” and provided the name and 6.3% were children were born outside of Australia. of the GP and a practice address. There was an average of 31.3 (95% CI 29.0 to 33.7) chil- 2. Parents who could not name a GP were defined as dren in each general practice named by parents, with a ‘Not Naming a GP’. range of 1 to 283 children per practice. 3. A ‘New GP’ was defined as a GP who was not Significantly more parents of children born outside of named in any of the previous years. Australia could not name a usual GP for their child 4. A ‘GP left the area’ was defined as a GP who was compared to parents of all other Canberra children not named in a current year and never again. (27% versus 10% Chi squared = 514.9, df = 1, p = < 5. A ‘GP displayed transient care’ was defined as a 0.001). Table 1 shows that this result was consistent in GP who was not named in a current year but was each year over the eight years of study. The proportions named in subsequent years. varied from one year to the next for parents of Indigen- ous children. However overall, significantly more parents Data were collected from parents in each year from 2001 of Indigenous children could not name a usual GP for until 2008 inclusive. The data entered into the screening their child compared to all other children in Canberra database are cleaned and checked. Each year, a list of when the results of eight years of study were combined. names of new GPs and any new practice address (includ- (17% versus 11%, Chi squared = 19.7, df = 1, p = < ing phone number) is produced by the local General Prac- 0.001). When the parents of Indigenous children and tice Liaison Unit in the Canberra Hospital. This list is the parents of children born outside of Australia were checked against ACT’s telephone book for accuracy. Prac- combined, significantly more parents of the combined tices were deemed to match against the list if the phone groups could not name a usual GP for their child com- number was the same or the name and address was the pared to all other Canberra children (25% versus 10%, same each year. The matching was also visually assessed Chi squared = 498.9, df = 1, p = < 0.001). to correct any mismatching practices. GPs were deemed Parents named 433 individual GPs and 141 practice to match if the full name was the same or last name and addresses between 2001 and 2008. An average of 77% first initial were the same. Or the first three characters of (95% CI 76.5-77.5) of parents could name both the GP thelastnameand firstnamewerethesame.Orthefirst and the practice, an average of 11% (95% CI 10.6-11.3) of three characters of the last name and practice were the parents could name only the practice address, and an Kljakovic et al. BMC Family Practice 2011, 12:106 Page 3 of 8 http://www.biomedcentral.com/1471-2296/12/106 Table 1 The percent of parents of Indigenous children, parents of children born outside Australia, and parents of both groups compared to the percent of parents of all other children in the ACT who did not name a usual GP for their child between 2001 and 2008 Year Parents of Indigenous children Parents of children born outside Australia Both groups of parents of Indigenous children or children born outside Australia Yes No# p-value* Yes No# p-value* Yes No# p-value* 2001 19% 12% 0.0983 28% 10% < .0001 26% 10% < .0001 2002 20% 10% 0.0116 27% 9% < .0001 26% 9% < .0001 2003 13% 11% 0.6895 28% 10% < .0001 24% 10% < .0001 2004 13% 10% 0.2693 23% 9% < .0001 21% 9% < .0001 2005 19% 10% 0.0051 25% 9% < .0001 24% 9% < .0001 2006 16% 10% 0.1536 29% 9% < .0001 27% 9% < .0001 2007 17% 11% 0.1064 25% 10% < .0001 24% 9% < .0001 2008 20% 14% 0.1882 29% 13% < .0001 27% 13% < .0001 Total 17% 11% < .0001 27% 10% < .0001 25% 10% < .0001 *Chi squared test. # Parents of all other children in the ACT Kljakovic et al. BMC Family Practice 2011, 12:106 Page 4 of 8 http://www.biomedcentral.com/1471-2296/12/106 average of 12% (95% CI 11.8-12.5) of parents could not Discussion name either the child’s GP, nor the child’s general practice The provision of continuity of care is considered an address. achievable standard in Australian general practice by the Parents named an average of 2.68 (95% CI 2.55 to 2.81) RACGP [4]. To the best of our knowledge, this is the first GPs per practice per year. There was a 15% decline in the study to describe how general practitioners achieved this number of practices named by parents from 118 in 2001 standard by providing continuity of provider care over to 100 in 2008. There was a 13% point decline in solo time. We rejected our first hypothesis to find a greater practitioners named by parents from 42% (n = 49) in proportion of GPs displayed continuity of provider care, 2001 to 29% (n = 29) in 2008. There was a 4% point rise rather than transient care, but that only 39% of GPs in large general practices (defined as six or more GPs per appeared to have been present in the ACT for the full practice) named by parents from 9% (n = 11) in 2001 to eight years of the study. 13% (n = 13) in 2008. Our study also described for the first time how GPs DOHA, AIHW, and Medicare use different methods to displayed two different forms of transience -either by measure the number of GPs in the ACT region as listed working in more than one practice in each year or by in Table 2. Our method of counting GPs found 130 fewer not being present in the ACT region from one year to GPs each year if compared with DOHA’sheadcount the next. From the parents’ perspective such GPs ran method described in Table 2 [a] and we found 100 more the risk of impairing longitudinal and personal continu- GPs each year if compared with DOHA’s FTE method ity of care for children. described in Table 2 [c]. The long-term lack of GPs within the ACT region has In the 2008, 171 parents nominated one of the six Index been documented [9]. Our study indicated that GP attri- general practices as their child’s practice: two practices tion was an unlikely cause of transient because in each had 100% concordance with 22 and 16 parents, one prac- year we found slightly more GPs arrived in the ACT (22), tice had 99% concordance with 75 parents, one practice compared to leaving (21). Furthermore, the different had 88% concordance with 26 parents, one practice had methods of counting GPs within the ACT (Table 2) all 77% concordance with 26 parents, and one practice had agreed that the number of GPs remained constant over 67% concordance with 6 parents respectively. The overall time. However, the small level of GP turnover would give mean concordance found matching a child listed in the the appearance of transience. Those parents who were practice records and the parent having named the practice used to seeing only one GP for their care, would perceive was 89%, (Chi squared = 24.041, df = 5, p < 0.001). transience as a threat to longitudinal continuity of care Figure 1 shows the frequency of GPs displaying continu- when forced to see a range of GPs over time. Further- ityof carevaried overtimewith 19% ofGPs named in more, the 15% attrition in the numbers of general prac- only one year and 39% of GPs were named in each of the tices was due to the loss in the number of solo or small eight years studied. An average of 324 GPs (92%) were GP practices in the ACT. Our study found small prac- reported by parents to be working in one general practice tices were less likely to have GPs who displayed transient over the eight years of this study. An average of 26 GPs provider care. Therefore their loss would add to the par- (7%) were reported to be working in two general practices, ental perception of transient GPs working in the ACT. and an average of 3 GPs (< 1%) were reported to be work- Various combinations of GP work patterns will influ- ing in three general practices in the ACT region. ence how Australians conceive continuity of care. More Table 3 shows that in each year, an average of 22 GPs research is needed to determine whether a GP who (8%) were categorised as new GPs, an average of 21 GPs works two sessions a week in one practice, or a GP who (8%) were categorised as GP left area, and an average of works two sessions a week in two different practices, is 13 GPs (5%) were categorised as displaying transient perceivedasproviding thesamekindofcontinuityof care. care as the GP who works full time in one practice. Table 4 shows the number of general practices worked Recent surveys of the Australian GP suggest that the per GP over the eight-year period. A total of 64 GPs future GP is unlikely to want to work in one place, full (15%) displayed transient care and fewer parents nomi- time, for a lifetime [10]. A 100-year history of continuity nated them as their child’sGPcomparedtoGPs who of care in New Zealand found that a minority of GPs pro- displayed continuity (mean 3.5 versus 11.3 children per vided longitudinal continuity of care, as did a minority of GP, t-value = 11.71, df = 2312, p < 0.001). Furthermore, general practices (with only 2.8 percent of practices more GPs displayed transient care if parented nomi- remaining at one address for 30 years or more) [11]. The nated them as working in large practices compared to RACGP standards for general practice unfortunately do small practices (mean 3.3 versus 2.1 GPs per practice, not comment on how provider continuity might be t-value = -3.81, df = 132 p < 0.001). achieved in practice [4]. The lack of comment on Kljakovic et al. BMC Family Practice 2011, 12:106 Page 5 of 8 http://www.biomedcentral.com/1471-2296/12/106 Table 2 Comparing the estimates of the number of general practitioners in the ACT from seven sources with the number of GPs and general practices obtained from the ACT Kindergarten Screen between 2001 and 2008 Year Methods used to count numbers of GPs in the ACT Headcount Headcount Full-Time Full-Time Workload Primary Care FTE GPs and GPs [a] [b] Equivalent [c] Equivalent [d] Practitioner [e] Primary Care Other Medical named in ACT Kindergarten Practitioner Practitioners Health Screen [f] [g] 2001 395 387 201 219 283 2002 382 376 196 212 271 2003 386 383 191 203 269 2004 374 370 187 198 398 350 253 2005 375 373 190 200 255 2006 379 381 194 208 391 274 2007 374 373 205 226 408 281 2008 383 383 208 232 371 317 413 289 [a] Source: DOHA [5]. Number of GPs (major specialty at 30 June) who provided at least one MBS service (Non-referred attendance) during the year at a location within the ACT. [b] Source: DOHA [5]. Number of GPs (major specialty at 30 June) who provided at least one MBS service (Non-referred attendance) during the year with their main practice location within the ACT division of GP. [c] Source: DOHA [5]. Number of FTE GPs calculated as the proportion of MBS billing at a location in the ACT divided by the average MBS billing of full-time doctors, capped at 1. [d] Source: DOHA [5]. Number of FEW GPs calculated as the proportion of MBS billing at a location in the ACT divided by the average MBS billing of full-time doctors, not capped at 1, such that an individual GP who bills above average is counted as > 1. [e] Source AIHW [6]. Number primary care practitioners whose main field of work is clinician (includes those whose main job is not in private rooms, e.g. Acute Care Hospital, Defence, which may not be reflected in Medicare data) Note, these data are based on medical registration rather than MBS claims. AIHW compares these data with column [a] [f] Source AIHW [6]. Number FTE primary care practitioners whose main field of work is clinician (includes those whose main job is not in private rooms). Note, AIHW compares these data with column [d] http:// www.aihw.gov.au/publications/index.cfm/title/10723 [g] Source Medicare Australia [19]. Number of GPs (major specialty at 30 June) providing category 1 services (Professional Attendance) during the 3 months ending 30 June (Q2) who generate > = $1000 in fees for the quarter (Q2) with their main practice location within the ACT division of GP. Kljakovic et al. BMC Family Practice 2011, 12:106 Page 6 of 8 http://www.biomedcentral.com/1471-2296/12/106 Figure 1 Percent of GPs named by parents in each year from 2001 to 2008 in the ACT region n = 433 GPs. provider continuity in the RACGP standards impedes [16]. The observed decline in the number of solo or small academic and policy development on what it means for practices and the concomitant rise in the number of large Australian GPs to provide health care over the long term practices had no effect on the constant proportion of par- and how such care shapes our understanding of general ents reporting disparities over time. This indicates that practice [12-15]. changes on the structure of practices did not affect the We rejected our second hypothesis to find disparities in overall rate of nominating a GP or equity of access to equity of access to GP services by children. There were a general practices in the ACT. However, it might be con- constant 12% of children in each year whose parents jectured that the small, but constant, proportion of provi- reported their child did not have a usual medical practi- dertransiencebyGPs may havehad arippleeffecton tioner. There was a doubling in the proportion of parents access in the ACT. One study in New Zealand has shown (25%)who couldnot nameaGPfor theirchild if they that the size of a general practice was influenced by word were of Aboriginal or Torres Strait Islander descent or of mouth [17,18]. Parents might report on their experi- their child was born overseas. This disparity has been ence of transient GPs to other parents who might then found in linguistic studies of provider care in Australia choose not to nominate that practice for their child. Table 3 Comparing the total number of GPs with the number of new GPs, GPs who left the area, and GPs displaying discontinuity of care between 2001 and 2008 Year Total number of GPs New GP GP left area GP displayed discontinuity of care n% n % n % 2001 283 NA1* NA1 NA1 NA1 NA1 NA1 2002 271 28 10% 25 9% 13 5% 2003 269 16 6% 13 5% 14 5% 2004 253 11 4% 20 8% 13 5% 2005 255 15 6% 14 6% 12 5% 2006 274 41 15% 21 8% 16 6% 2007 281 19 7% 21 8% 9 3% 2008 289 22 8% 30 11% NA2* NA2 NA1* Means not applicable as a GP can only be counted in this category if their status in 2000 is known. NA2* Means not applicable as a GP can only be counted in this category if their status in 2008 is known Kljakovic et al. BMC Family Practice 2011, 12:106 Page 7 of 8 http://www.biomedcentral.com/1471-2296/12/106 Table 4 The number of general practices worked per GP during each year between 2001 and 2008 in the ACT Year Number of Practices per GP Total GP worked in one practice during the GP worked in two practices during the GP worked in three practices during the year year year n% n % n % n 2001 319 94% 19 6% 2 1% 340 2002 315 92% 23 7% 3 1% 341 2003 307 91% 27 8% 4 1% 338 2004 307 91% 27 8% 4 1% 338 2005 317 91% 29 8% 4 1% 350 2006 346 92% 29 8% 2 1% 377 2007 356 92% 30 8% 3 1% 389 2008 378 92% 30 7% 3 1% 411 Equivalent; FTE: Full-Time Equivalent; GP: General Practitioner; MBS: Medical Evidence on such social effects requires qualitative stu- Benefits Scheme; PracNet: a Primary Health Care research network in the dies of why parents choose a new practice or to leave a ACT region; RACGP: Royal Australian College of General Practitioners practice. Acknowledgements The first limitation in this study was the parental bias Acknowledgement is given to ACT Health for supporting the administration in naming GPs and their practices. This limitation was of the ACT Kindergarten Health Screen since 1999. Further offset by our systematic method of checking names, by acknowledgement is given to the six index general practices that work with PracNet for their contribution. the high whole-of-population response rate (89%) achieved each year, and by the distribution of kindergar- Author details tens matching the spread of general practices across the Academic Unit of General Practice and Community Health in the School of General Practice, Rural and Indigenous Health, at the Australian National whole of the ACT region. Secondly, our method was University Medical School, PO Box 11 Woden, ACT 2606, Australia. less likely to identify those GPs who work part-time, or Department of Paediatrics at the Canberra Hospital, Australian National work in more than three general practices, or choose University Medical School, PO Box 11 Woden, ACT 2606, Australia. Biostatistics, Covance Pty Ltd Level 3, 4 Research Park Drive, North Ryde, not to care for children. DOHA’s headcount method NSW 2113, Australia. indicted that we might have underestimated the counts by 130 GPs each year. However, Medicare data may Authors’ contributions GR helped conceive of the study and helped to draft the manuscript. SC lead to overestimates of headcounts because an indivi- contributed to the design of the study and performed the statistical analysis. dual GP can have many provider numbers, one for each CS participated in data collection and helped to draft the manuscript. MK state and one for each practice where they work [19]. conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final Finally, this study has not described directly the full manuscript. complexity of equity of access to GP services for chil- dren. However, the data points towards a disparity in Competing interests The authors declare that they have no competing interests. equity of access suggesting further policy research is needed to identify possible causes and consequences of Received: 20 June 2011 Accepted: 30 September 2011 such inequality. Published: 30 September 2011 References Conclusions 1. Huygen FJA: Family Medicine. The medical life history of families New York: The ACT is a wealthy region of Australia and yet it has Brunner/Manzel; 1978. a low number of GPs compared to other States and Ter- 2. RACGP | History. [http://www.racgp.org.au/history]. 3. Saultz JW: Defining and measuring interpersonal continuity of care. Ann ritories [20]. Many GPs provide continuity of care while Fam Med 2003, 1(3):134-143. some display transient care. Children of Aboriginal or 4. Royal Australian College of General Practitioners: Standards for general Torres Strait Islander descent or children born outside practice. Melbourne: The Royal Australian College of General Practitioners;, 4 2010, 149. of Australia appear to experience inequality in provider 5. General Practice Statistics. [http://www.health.gov.au/internet/main/ continuity from their GP. This might disappear if a sys- publishing.nsf/Content/General+Practice+Statistics-1]. tem of voluntary registration of children was adopted in 6. Medical labour force. [http://www.aihw.gov.au/publications/index.cfm/title/ 10723]. Australian general practice. 7. Korda RJ, Butler JR, Clements MS, Kunitz SJ: Differential impacts of health care in Australia: trend analysis of socioeconomic inequalities in avoidable mortality. Int J Epidemiol 2007, 36(1):157-165. Abbreviations 8. Phillips CBYR, Glasgow NJ, Ciszek K, Attewell R: Improving response rates ACT: Australian Capital Territory; AIHW: Australian Institute of Health and to primary and supplementary questionnaires by changing response Welfare; DOHA: Department of Health and Aging; FEW: Full-Time Workload Kljakovic et al. BMC Family Practice 2011, 12:106 Page 8 of 8 http://www.biomedcentral.com/1471-2296/12/106 and instruction burden: cluster randomised trial. Australian and New Zealand Journal of Public Health 2005, 29(5):457-460. 9. ACT GP Taskforce, Kljakovic M: General Practice and Sustainable Primary Health Care - The Way Forward. Canberra: ACT Health; 2009, 41. 10. About one in ten doctors plan to quit over the next 5 years. [https:// mabel.org.au/Media/23042009-results.htm]. 11. Kljakovic M: Continuity of care provided by general practice in Wellington over 100 years. New Zealand Family Physician 2008, 35(1):16-21. 12. Dammery D: Fledgling general practice in Australia. Aust Fam Physician 2001, 30(8):808-809. 13. Gandevia B: A history of general practice in australia. Can Fam Physician 1971, 17(10):51-61. 14. Leavesley J: A history of general practice. Med J Aust 1984, 141(2):107-109. 15. Strasser R: The origins of general practice. Med J Aust 1991, 155(9):609-611. 16. Ou L, Chen J, Hillman K: Health services utilisation disparities between English speaking and non-English speaking background Australian infants. BMC Public Health 2010, 10:182. 17. Pilotto LS, McCallum J, Raymond C, McGilchrist C, Veale BM: Sequential continuity of care by general practitioners: which patients change doctor? Med J Aust 1996, 164(8):463-466. 18. Tracey J, Barham P: Survey of North Shore residents’ views of general practice. New Zealand Family Phisician 2001, 28(1):1-8. 19. Statistics. [http://www.medicareaustralia.gov.au/about/stats/index.jsp]. 20. Australian Government: General Practice in Australia: 2004. First edition. Canberra: GP Communications and Business Improvement Unit. Primary Care Division. Department of Health and Aging; 2005. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2296/12/106/prepub doi:10.1186/1471-2296-12-106 Cite this article as: Kljakovic et al.: Inequality in provider continuity for children by Australian general practitioners. BMC Family Practice 2011 12:106. 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Inequality in provider continuity for children by Australian general practitioners

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Springer Journals
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Copyright © 2011 by Kljakovic et al; licensee BioMed Central Ltd.
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Medicine & Public Health; General Practice / Family Medicine; Primary Care Medicine
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Abstract

Background: There is little published on provider continuity in Australian general practice and none on its effect on inequality of care for children. Method: Questionnaire administered to parents of the ACT Kindergarten Health Screen asking the name of their child’s usual GP and practice address between 2001 and 2008. Results: Parents of 30,789 children named 433 GPs and 141 practices. In each year, an average of 77% of parents could name both the GP and the practice, an average of 11% of parents could name only the practice, and an average of 12% of parents could name neither. In each year, 25% of parents could not name a usual GP for children of Aboriginal or Torres Straight Islander descent, or children born outside of Australia, compared to 10% of all other children (p = < 0.0001). The frequency of GPs displaying continuity of care varied over time with 19% of GPs being present in the ACT in only one year and 39% of GPs being present in every year over the eight years of study. GPs displayed two different forms of transience either by working in more than one practice in each year (5% of GPs), or by not being present in the ACT region from one year to the next (15% of GPs). Fewer parents nominated transient GPs as their child’s GP compared to choosing GPs who displayed continuity (p < 0.001). Conclusions: Many GPs (39%) were reported to provide continuity of care for in the ACT region and some GPs (20%) displayed transient care. Indigenous children or children born outside of Australia had less equity of access to a nominated GP than all other children. Such inequity might disappear if voluntary registration of children was adopted in Australian general practice. Background In Australia, there is no formal process where patients The story of the GP who remained in one location mana- voluntarily register with individual GPs or their practices ging the many health problems people present over time and thereby create administrative registries. There are a is a story unique to general practice. The theme of conti- number of indirect methods of counting GPs used by nuity of care was first described in Holland [1] and more DOHA from an analysis of Medicare data producing recently weaves through stories of Australian general paradoxical results [5,6]. For example, the full-time practices published on the RACGP website [2]. A recent equivalent method of counting individual GPs produces a systematic review defined continuity of care as a three decrease in numbers of GPs between 2004 and 2008 in dimensional description of health care which included the ACT, but the headcount method produces a small informational, longitudinal, and personal continuity of increase. None of these methods result in a published care [3]. Each of these dimensions have been adopted in account of individual GPs or individual general practices the 2010 RACGP standards for general practice as an over time. Our study aims to address this gap by analys- achievable standard in Australia [4], but do not comment ing systematically gathered names of GPs and their prac- on how provider continuity might be achieved by GPs. tice addresses. Our first null hypothesis was that similar proportions of GPs display continuity and transient care over time. * Correspondence: marjan.kljakovic@anu.edu.au A principle policy goal of Medicare is to provide equal Academic Unit of General Practice and Community Health in the School of General Practice, Rural and Indigenous Health, at the Australian National care for equal need to all Australian people, for all ages. University Medical School, PO Box 11 Woden, ACT 2606, Australia Nevertheless, previous research has shown that Medicare Full list of author information is available at the end of the article © 2011 Kljakovic et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kljakovic et al. BMC Family Practice 2011, 12:106 Page 2 of 8 http://www.biomedcentral.com/1471-2296/12/106 does not guarantee equity of health care for health same when the first name was missing. The matching was related outcomes [7]. Our second study aim was to also visually assessed to correct any mismatching GPs. describe the equity of access to GP care for children in The accuracy of the matching was critical to the results. the ACT. Our second null hypothesis was there are no The matching of practices was reliable due to the use of disparities in equity of access to GPs for Indigenous chil- the phone number for matching. The GP matching was dren (who are of Aboriginal or Torres Strait Islander des- dependent on text fields and therefore the level of confi- cent), or overseas born, compared to all other children. dence for accurate matching was reduced. In 2008, six general practices (named Index General Practices) from the ACT region agreed to measure the Methods Each year, all 4 to 6 year old primary school-entry children concordance between parents naming a GP and practice take part in the ACT Kindergarten Health Screen for a in the Kindergarten screen and whether the child’s name population-based school health assessment, which had been recorded in the named practice records. includes a survey completed by parents (delivery and We undertook descriptive statistics of continuity for the structure described elsewhere [8]). Since 1998, this survey named GPs and their practices between 2001 and 2008. has comprised a general health questionnaire that includes Statistical comparisons were made using chi-squared tests questions asking the name of the child’sGPand the and T-tests for categorical and continuous outcomes address of the general practice. Response rates of 85% to respectively. All analysis was undertaken using SAS 89% to the questionnaire are achieved each year. The dis- version 9.1.3. tribution of all the 105 private and government funded Ethical approval was obtained from the Australian kindergartens match the spread of general practices across Nation University Human Ethics Committee and the the ACT region increasing the likelihood that most GPs ACT Health Human Research Ethics Committee. and general practices are named each year. Results Defining the naming of GPs Parents of 30,789 children responded to the questionnaire 1. ‘Naming a GP ’ was defined when parents between 2001 and 2008. The mean age of the children was responded yes to the question “Does your child have 5.7 years, 50.5% were male, 1.8% were Indigenous children, a usual medical practitioner?” and provided the name and 6.3% were children were born outside of Australia. of the GP and a practice address. There was an average of 31.3 (95% CI 29.0 to 33.7) chil- 2. Parents who could not name a GP were defined as dren in each general practice named by parents, with a ‘Not Naming a GP’. range of 1 to 283 children per practice. 3. A ‘New GP’ was defined as a GP who was not Significantly more parents of children born outside of named in any of the previous years. Australia could not name a usual GP for their child 4. A ‘GP left the area’ was defined as a GP who was compared to parents of all other Canberra children not named in a current year and never again. (27% versus 10% Chi squared = 514.9, df = 1, p = < 5. A ‘GP displayed transient care’ was defined as a 0.001). Table 1 shows that this result was consistent in GP who was not named in a current year but was each year over the eight years of study. The proportions named in subsequent years. varied from one year to the next for parents of Indigen- ous children. However overall, significantly more parents Data were collected from parents in each year from 2001 of Indigenous children could not name a usual GP for until 2008 inclusive. The data entered into the screening their child compared to all other children in Canberra database are cleaned and checked. Each year, a list of when the results of eight years of study were combined. names of new GPs and any new practice address (includ- (17% versus 11%, Chi squared = 19.7, df = 1, p = < ing phone number) is produced by the local General Prac- 0.001). When the parents of Indigenous children and tice Liaison Unit in the Canberra Hospital. This list is the parents of children born outside of Australia were checked against ACT’s telephone book for accuracy. Prac- combined, significantly more parents of the combined tices were deemed to match against the list if the phone groups could not name a usual GP for their child com- number was the same or the name and address was the pared to all other Canberra children (25% versus 10%, same each year. The matching was also visually assessed Chi squared = 498.9, df = 1, p = < 0.001). to correct any mismatching practices. GPs were deemed Parents named 433 individual GPs and 141 practice to match if the full name was the same or last name and addresses between 2001 and 2008. An average of 77% first initial were the same. Or the first three characters of (95% CI 76.5-77.5) of parents could name both the GP thelastnameand firstnamewerethesame.Orthefirst and the practice, an average of 11% (95% CI 10.6-11.3) of three characters of the last name and practice were the parents could name only the practice address, and an Kljakovic et al. BMC Family Practice 2011, 12:106 Page 3 of 8 http://www.biomedcentral.com/1471-2296/12/106 Table 1 The percent of parents of Indigenous children, parents of children born outside Australia, and parents of both groups compared to the percent of parents of all other children in the ACT who did not name a usual GP for their child between 2001 and 2008 Year Parents of Indigenous children Parents of children born outside Australia Both groups of parents of Indigenous children or children born outside Australia Yes No# p-value* Yes No# p-value* Yes No# p-value* 2001 19% 12% 0.0983 28% 10% < .0001 26% 10% < .0001 2002 20% 10% 0.0116 27% 9% < .0001 26% 9% < .0001 2003 13% 11% 0.6895 28% 10% < .0001 24% 10% < .0001 2004 13% 10% 0.2693 23% 9% < .0001 21% 9% < .0001 2005 19% 10% 0.0051 25% 9% < .0001 24% 9% < .0001 2006 16% 10% 0.1536 29% 9% < .0001 27% 9% < .0001 2007 17% 11% 0.1064 25% 10% < .0001 24% 9% < .0001 2008 20% 14% 0.1882 29% 13% < .0001 27% 13% < .0001 Total 17% 11% < .0001 27% 10% < .0001 25% 10% < .0001 *Chi squared test. # Parents of all other children in the ACT Kljakovic et al. BMC Family Practice 2011, 12:106 Page 4 of 8 http://www.biomedcentral.com/1471-2296/12/106 average of 12% (95% CI 11.8-12.5) of parents could not Discussion name either the child’s GP, nor the child’s general practice The provision of continuity of care is considered an address. achievable standard in Australian general practice by the Parents named an average of 2.68 (95% CI 2.55 to 2.81) RACGP [4]. To the best of our knowledge, this is the first GPs per practice per year. There was a 15% decline in the study to describe how general practitioners achieved this number of practices named by parents from 118 in 2001 standard by providing continuity of provider care over to 100 in 2008. There was a 13% point decline in solo time. We rejected our first hypothesis to find a greater practitioners named by parents from 42% (n = 49) in proportion of GPs displayed continuity of provider care, 2001 to 29% (n = 29) in 2008. There was a 4% point rise rather than transient care, but that only 39% of GPs in large general practices (defined as six or more GPs per appeared to have been present in the ACT for the full practice) named by parents from 9% (n = 11) in 2001 to eight years of the study. 13% (n = 13) in 2008. Our study also described for the first time how GPs DOHA, AIHW, and Medicare use different methods to displayed two different forms of transience -either by measure the number of GPs in the ACT region as listed working in more than one practice in each year or by in Table 2. Our method of counting GPs found 130 fewer not being present in the ACT region from one year to GPs each year if compared with DOHA’sheadcount the next. From the parents’ perspective such GPs ran method described in Table 2 [a] and we found 100 more the risk of impairing longitudinal and personal continu- GPs each year if compared with DOHA’s FTE method ity of care for children. described in Table 2 [c]. The long-term lack of GPs within the ACT region has In the 2008, 171 parents nominated one of the six Index been documented [9]. Our study indicated that GP attri- general practices as their child’s practice: two practices tion was an unlikely cause of transient because in each had 100% concordance with 22 and 16 parents, one prac- year we found slightly more GPs arrived in the ACT (22), tice had 99% concordance with 75 parents, one practice compared to leaving (21). Furthermore, the different had 88% concordance with 26 parents, one practice had methods of counting GPs within the ACT (Table 2) all 77% concordance with 26 parents, and one practice had agreed that the number of GPs remained constant over 67% concordance with 6 parents respectively. The overall time. However, the small level of GP turnover would give mean concordance found matching a child listed in the the appearance of transience. Those parents who were practice records and the parent having named the practice used to seeing only one GP for their care, would perceive was 89%, (Chi squared = 24.041, df = 5, p < 0.001). transience as a threat to longitudinal continuity of care Figure 1 shows the frequency of GPs displaying continu- when forced to see a range of GPs over time. Further- ityof carevaried overtimewith 19% ofGPs named in more, the 15% attrition in the numbers of general prac- only one year and 39% of GPs were named in each of the tices was due to the loss in the number of solo or small eight years studied. An average of 324 GPs (92%) were GP practices in the ACT. Our study found small prac- reported by parents to be working in one general practice tices were less likely to have GPs who displayed transient over the eight years of this study. An average of 26 GPs provider care. Therefore their loss would add to the par- (7%) were reported to be working in two general practices, ental perception of transient GPs working in the ACT. and an average of 3 GPs (< 1%) were reported to be work- Various combinations of GP work patterns will influ- ing in three general practices in the ACT region. ence how Australians conceive continuity of care. More Table 3 shows that in each year, an average of 22 GPs research is needed to determine whether a GP who (8%) were categorised as new GPs, an average of 21 GPs works two sessions a week in one practice, or a GP who (8%) were categorised as GP left area, and an average of works two sessions a week in two different practices, is 13 GPs (5%) were categorised as displaying transient perceivedasproviding thesamekindofcontinuityof care. care as the GP who works full time in one practice. Table 4 shows the number of general practices worked Recent surveys of the Australian GP suggest that the per GP over the eight-year period. A total of 64 GPs future GP is unlikely to want to work in one place, full (15%) displayed transient care and fewer parents nomi- time, for a lifetime [10]. A 100-year history of continuity nated them as their child’sGPcomparedtoGPs who of care in New Zealand found that a minority of GPs pro- displayed continuity (mean 3.5 versus 11.3 children per vided longitudinal continuity of care, as did a minority of GP, t-value = 11.71, df = 2312, p < 0.001). Furthermore, general practices (with only 2.8 percent of practices more GPs displayed transient care if parented nomi- remaining at one address for 30 years or more) [11]. The nated them as working in large practices compared to RACGP standards for general practice unfortunately do small practices (mean 3.3 versus 2.1 GPs per practice, not comment on how provider continuity might be t-value = -3.81, df = 132 p < 0.001). achieved in practice [4]. The lack of comment on Kljakovic et al. BMC Family Practice 2011, 12:106 Page 5 of 8 http://www.biomedcentral.com/1471-2296/12/106 Table 2 Comparing the estimates of the number of general practitioners in the ACT from seven sources with the number of GPs and general practices obtained from the ACT Kindergarten Screen between 2001 and 2008 Year Methods used to count numbers of GPs in the ACT Headcount Headcount Full-Time Full-Time Workload Primary Care FTE GPs and GPs [a] [b] Equivalent [c] Equivalent [d] Practitioner [e] Primary Care Other Medical named in ACT Kindergarten Practitioner Practitioners Health Screen [f] [g] 2001 395 387 201 219 283 2002 382 376 196 212 271 2003 386 383 191 203 269 2004 374 370 187 198 398 350 253 2005 375 373 190 200 255 2006 379 381 194 208 391 274 2007 374 373 205 226 408 281 2008 383 383 208 232 371 317 413 289 [a] Source: DOHA [5]. Number of GPs (major specialty at 30 June) who provided at least one MBS service (Non-referred attendance) during the year at a location within the ACT. [b] Source: DOHA [5]. Number of GPs (major specialty at 30 June) who provided at least one MBS service (Non-referred attendance) during the year with their main practice location within the ACT division of GP. [c] Source: DOHA [5]. Number of FTE GPs calculated as the proportion of MBS billing at a location in the ACT divided by the average MBS billing of full-time doctors, capped at 1. [d] Source: DOHA [5]. Number of FEW GPs calculated as the proportion of MBS billing at a location in the ACT divided by the average MBS billing of full-time doctors, not capped at 1, such that an individual GP who bills above average is counted as > 1. [e] Source AIHW [6]. Number primary care practitioners whose main field of work is clinician (includes those whose main job is not in private rooms, e.g. Acute Care Hospital, Defence, which may not be reflected in Medicare data) Note, these data are based on medical registration rather than MBS claims. AIHW compares these data with column [a] [f] Source AIHW [6]. Number FTE primary care practitioners whose main field of work is clinician (includes those whose main job is not in private rooms). Note, AIHW compares these data with column [d] http:// www.aihw.gov.au/publications/index.cfm/title/10723 [g] Source Medicare Australia [19]. Number of GPs (major specialty at 30 June) providing category 1 services (Professional Attendance) during the 3 months ending 30 June (Q2) who generate > = $1000 in fees for the quarter (Q2) with their main practice location within the ACT division of GP. Kljakovic et al. BMC Family Practice 2011, 12:106 Page 6 of 8 http://www.biomedcentral.com/1471-2296/12/106 Figure 1 Percent of GPs named by parents in each year from 2001 to 2008 in the ACT region n = 433 GPs. provider continuity in the RACGP standards impedes [16]. The observed decline in the number of solo or small academic and policy development on what it means for practices and the concomitant rise in the number of large Australian GPs to provide health care over the long term practices had no effect on the constant proportion of par- and how such care shapes our understanding of general ents reporting disparities over time. This indicates that practice [12-15]. changes on the structure of practices did not affect the We rejected our second hypothesis to find disparities in overall rate of nominating a GP or equity of access to equity of access to GP services by children. There were a general practices in the ACT. However, it might be con- constant 12% of children in each year whose parents jectured that the small, but constant, proportion of provi- reported their child did not have a usual medical practi- dertransiencebyGPs may havehad arippleeffecton tioner. There was a doubling in the proportion of parents access in the ACT. One study in New Zealand has shown (25%)who couldnot nameaGPfor theirchild if they that the size of a general practice was influenced by word were of Aboriginal or Torres Strait Islander descent or of mouth [17,18]. Parents might report on their experi- their child was born overseas. This disparity has been ence of transient GPs to other parents who might then found in linguistic studies of provider care in Australia choose not to nominate that practice for their child. Table 3 Comparing the total number of GPs with the number of new GPs, GPs who left the area, and GPs displaying discontinuity of care between 2001 and 2008 Year Total number of GPs New GP GP left area GP displayed discontinuity of care n% n % n % 2001 283 NA1* NA1 NA1 NA1 NA1 NA1 2002 271 28 10% 25 9% 13 5% 2003 269 16 6% 13 5% 14 5% 2004 253 11 4% 20 8% 13 5% 2005 255 15 6% 14 6% 12 5% 2006 274 41 15% 21 8% 16 6% 2007 281 19 7% 21 8% 9 3% 2008 289 22 8% 30 11% NA2* NA2 NA1* Means not applicable as a GP can only be counted in this category if their status in 2000 is known. NA2* Means not applicable as a GP can only be counted in this category if their status in 2008 is known Kljakovic et al. BMC Family Practice 2011, 12:106 Page 7 of 8 http://www.biomedcentral.com/1471-2296/12/106 Table 4 The number of general practices worked per GP during each year between 2001 and 2008 in the ACT Year Number of Practices per GP Total GP worked in one practice during the GP worked in two practices during the GP worked in three practices during the year year year n% n % n % n 2001 319 94% 19 6% 2 1% 340 2002 315 92% 23 7% 3 1% 341 2003 307 91% 27 8% 4 1% 338 2004 307 91% 27 8% 4 1% 338 2005 317 91% 29 8% 4 1% 350 2006 346 92% 29 8% 2 1% 377 2007 356 92% 30 8% 3 1% 389 2008 378 92% 30 7% 3 1% 411 Equivalent; FTE: Full-Time Equivalent; GP: General Practitioner; MBS: Medical Evidence on such social effects requires qualitative stu- Benefits Scheme; PracNet: a Primary Health Care research network in the dies of why parents choose a new practice or to leave a ACT region; RACGP: Royal Australian College of General Practitioners practice. Acknowledgements The first limitation in this study was the parental bias Acknowledgement is given to ACT Health for supporting the administration in naming GPs and their practices. This limitation was of the ACT Kindergarten Health Screen since 1999. Further offset by our systematic method of checking names, by acknowledgement is given to the six index general practices that work with PracNet for their contribution. the high whole-of-population response rate (89%) achieved each year, and by the distribution of kindergar- Author details tens matching the spread of general practices across the Academic Unit of General Practice and Community Health in the School of General Practice, Rural and Indigenous Health, at the Australian National whole of the ACT region. Secondly, our method was University Medical School, PO Box 11 Woden, ACT 2606, Australia. less likely to identify those GPs who work part-time, or Department of Paediatrics at the Canberra Hospital, Australian National work in more than three general practices, or choose University Medical School, PO Box 11 Woden, ACT 2606, Australia. Biostatistics, Covance Pty Ltd Level 3, 4 Research Park Drive, North Ryde, not to care for children. DOHA’s headcount method NSW 2113, Australia. indicted that we might have underestimated the counts by 130 GPs each year. However, Medicare data may Authors’ contributions GR helped conceive of the study and helped to draft the manuscript. SC lead to overestimates of headcounts because an indivi- contributed to the design of the study and performed the statistical analysis. dual GP can have many provider numbers, one for each CS participated in data collection and helped to draft the manuscript. MK state and one for each practice where they work [19]. conceived of the study, and participated in its design and coordination and helped to draft the manuscript. All authors read and approved the final Finally, this study has not described directly the full manuscript. complexity of equity of access to GP services for chil- dren. However, the data points towards a disparity in Competing interests The authors declare that they have no competing interests. equity of access suggesting further policy research is needed to identify possible causes and consequences of Received: 20 June 2011 Accepted: 30 September 2011 such inequality. Published: 30 September 2011 References Conclusions 1. Huygen FJA: Family Medicine. The medical life history of families New York: The ACT is a wealthy region of Australia and yet it has Brunner/Manzel; 1978. a low number of GPs compared to other States and Ter- 2. RACGP | History. [http://www.racgp.org.au/history]. 3. 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Korda RJ, Butler JR, Clements MS, Kunitz SJ: Differential impacts of health care in Australia: trend analysis of socioeconomic inequalities in avoidable mortality. Int J Epidemiol 2007, 36(1):157-165. Abbreviations 8. Phillips CBYR, Glasgow NJ, Ciszek K, Attewell R: Improving response rates ACT: Australian Capital Territory; AIHW: Australian Institute of Health and to primary and supplementary questionnaires by changing response Welfare; DOHA: Department of Health and Aging; FEW: Full-Time Workload Kljakovic et al. BMC Family Practice 2011, 12:106 Page 8 of 8 http://www.biomedcentral.com/1471-2296/12/106 and instruction burden: cluster randomised trial. Australian and New Zealand Journal of Public Health 2005, 29(5):457-460. 9. ACT GP Taskforce, Kljakovic M: General Practice and Sustainable Primary Health Care - The Way Forward. Canberra: ACT Health; 2009, 41. 10. About one in ten doctors plan to quit over the next 5 years. [https:// mabel.org.au/Media/23042009-results.htm]. 11. Kljakovic M: Continuity of care provided by general practice in Wellington over 100 years. New Zealand Family Physician 2008, 35(1):16-21. 12. Dammery D: Fledgling general practice in Australia. Aust Fam Physician 2001, 30(8):808-809. 13. Gandevia B: A history of general practice in australia. Can Fam Physician 1971, 17(10):51-61. 14. Leavesley J: A history of general practice. Med J Aust 1984, 141(2):107-109. 15. Strasser R: The origins of general practice. Med J Aust 1991, 155(9):609-611. 16. Ou L, Chen J, Hillman K: Health services utilisation disparities between English speaking and non-English speaking background Australian infants. BMC Public Health 2010, 10:182. 17. Pilotto LS, McCallum J, Raymond C, McGilchrist C, Veale BM: Sequential continuity of care by general practitioners: which patients change doctor? Med J Aust 1996, 164(8):463-466. 18. Tracey J, Barham P: Survey of North Shore residents’ views of general practice. New Zealand Family Phisician 2001, 28(1):1-8. 19. Statistics. [http://www.medicareaustralia.gov.au/about/stats/index.jsp]. 20. Australian Government: General Practice in Australia: 2004. First edition. Canberra: GP Communications and Business Improvement Unit. Primary Care Division. Department of Health and Aging; 2005. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2296/12/106/prepub doi:10.1186/1471-2296-12-106 Cite this article as: Kljakovic et al.: Inequality in provider continuity for children by Australian general practitioners. BMC Family Practice 2011 12:106. Submit your next manuscript to BioMed Central and take full advantage of: • Convenient online submission • Thorough peer review • No space constraints or color figure charges • Immediate publication on acceptance • Inclusion in PubMed, CAS, Scopus and Google Scholar • Research which is freely available for redistribution Submit your manuscript at www.biomedcentral.com/submit

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Published: Sep 30, 2011

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