A Systems Approach to Continuity of Care Patient Attitude

1. A Systems Approach to Continuity of CarePatient Attitude A/Prof JP Sturmberg University of NSW A/Prof F Carinci Monash Institute of Health Services Research RACGP-conference, Perth 2002

2. Health Care System Doctor Patient Consultation (Process) Consultation (Outcomes) Systems-based Concept of Continuity of Care

3. ACCESS to care Health financing Doctor-Patient Stability MORBIDITY Psycho-social + + - Patient Satisfaction The Need For a Systems Approach

4. Method

5. Health Care System

6. Doctor

7. Patient

8. Consultation - Process

9. Consultation - Outcome

10. Results of Multivariate Logistic Regression Outcome = Low Patients’ Attitude towards medical care Events = 259/1069 Variable Category* OR 95% CI Effect in aged < 40 2.05 1.09-3.87 Males (RC:females) Effect in aged ³ 40, < 65 1.65 0.93-2.92 Effect in aged ³ 65 0.98 0.59-1.64 Effect in aged <40 1.01 0.98-1.04 Age Effect in aged ³ 40, < 65 0.96 0.94-0.99 Effect in aged ³ 65 1.03 1.01-1.06 Patient Unemployment (RC:no) Yes 1.77 1.06-2.95 Self-reported morbidity (RC:physical only or complex) Social only 1.69 1.03-2.77 Administrative/None 2.00 1.21-3.32 Psychological symptoms (RC:no) Yes 0.66 0.47-0.93 Yes 2.31 1.37-3.88 Social symptoms (RC:no) Missing 3.37 1.71-6.64 Low 1.52 1.03-2.23 Patient knowledge of doctor (RC:high) Always enough time by GP (RC:yes) No 1.80 1.26-2.58 Financing for health (RC:public) Private or mix 0.69 0.50-0.95 Health System Charging system (RC:known) Unknown 0.48 0.31-0.75 Effect in aged < 40 0.66 0.35-1.25 Practice Seize (RC: 1-3 GPs) Effect in aged ³ 40, < 65 1.27 0.70-2.29 Effect in aged ³ 65 1.02 0.58-1.79 Effect in aged < 40 0.89 0.79-0.99 Effect in aged ³ 40, < 65 1.15 1.04-1.27 Doctor-patient stability Effect in aged ³ 65 1.01 0.91-1.13 Unknown in aged < 40 0.18 0.05-0.59 0.92 0.86-0.98 Doctor-patient communication Consultation (Process) Effect in aged < 40 0.98 0.93-1.03 Length of consultation Effect in aged ³ 40, < 65 1.03 1.00-1.07 Effect in aged ³ 65 0.96 0.92-0.99 Effect in aged < 40 1.75 0.69-4.44 Referral to secondary care (RC:yes) Effect in aged ³ 40, < 65 2.19 0.96-5.00 Effect in aged ³ 65 0.46 0.23-0.90 Effect in aged < 40 1.09 1.01-1.17 Effect in aged ³ 40, < 65 0.99 0.92-1.06 Patient enablement Consultation (Outcome) Effect in aged ³ 65 1.02 0.97-1.08 Prescription (RC: other) Old and new medicine 2.26 1.55-3.28 Patient satisfaction (RC:high) Low 1.71 1.14-2.56 0.25 0.50 1.00 2.00 5.00 Decreased Risk Increased Risk ODDS RATIO * red: significant increased risk;green: significant decreased risk. When reference category is not indicated, effect is unit increase

11. INCREASED RISK DECREASED RISK • Psychological Symptoms • Mixed Funding of Health • Care • Better Communication • 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 Global correlates of low attitude

12. Age-specific correlates of low attitude

13. Conclusions (1) Age is an important effect modifier • 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

14. Bad experiences with family doctors institutions Stigma, Guilt, Shame Somatisation Lack of Coping Lack of Social Support Low self-esteem Dissatisfaction 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

15. Missing psychosocial dimensions High prescribing rates More investigations Dissatisfaction Lack of tacit knowledge 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

16. ? • Patient too demanding • Complex Morbidity Doctor too busy Conclusions (4) Systems Effects Doctor does not have enough time for patient Mixed funding for health care

17. Do they seek anonymity? Do they more easily find the doctor that suits their needs? Conclusions (5) Practice Size TREND (NS): Young patients with a holistic attitude seem to prefer large practices

18. Middle-aged patients avoiding a stable doctor-patient relationship Young patients seeking stable doctor-patient relationship Old patients who are NOT referred have high holistic attitude Middle-aged patients who are NOT referred have low holistic attitude Conclusions (6) Paradoxes

19. 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