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Patrizio Armeni , Amelia Compagni , Stefano Tasselli and Francesco Longo.

The impact of interaction and interdependence within a multi-professional primary care group practice on general practitioners’ clinical behavior and on quality of care. Patrizio Armeni , Amelia Compagni , Stefano Tasselli and Francesco Longo. CERGAS, Università Bocconi , Milano.

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Patrizio Armeni , Amelia Compagni , Stefano Tasselli and Francesco Longo.

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  1. The impact of interaction and interdependence within a multi-professional primary care group practice on general practitioners’ clinical behavior and on quality of care PatrizioArmeni, Amelia Compagni, Stefano Tasselli and Francesco Longo. CERGAS, UniversitàBocconi, Milano

  2. Joint Medical Practices in Primary Care in Italy Solo practice • Joint medicalpracticeswith spontaneousmembership • Associations • Networks • Group Primary care center E.g. Spain, Finland… ONE REGION HAS INTRODUCED A MANDATED FORM OF JOINT MEDICAL PRACTICE COMPRISING 15-30 GPs and OTHER PROFESSIONS: Primary Care Unit Strong reductionofendogeneity

  3. PCUs as Opportunity • PCUsfavorinteraction and collaborationbetweenGPs and betweenGPs and otherprofessionals • BUT each PCU can decide howmuch to “activate” theseopportunities • GPs can “activate” their PCU overseveraldimensions (CFA) • Interaction • Peer-interaction = PCU meetings and degreeofpartecipation (GPs) • Inter-professionalinteraction = participationofnurses, specialists, others • Interdependence • Peer-interdependence = GPsassistingotherGPs’ patients • Inter-professionalinterdependence = care processesmanagedtogetherwithspecialists and nurses • Extra services • Extra-clinicalservices = therapeuticeducation, technology etc. • Extensionto LHA services = blooddrawings, reservationofconsultations, drugdistribution • Out-of-office = PCU office openedduringholydays and nights

  4. Researchquestions • RESEARCH QUESTIONS • the impact of interaction and interdependence on: Variability of behaviors(prescription of diagnosticexams and referral for specialistcontultations)  Reductionofvariability due togradualcreationofsharedknowledgethroughinteraction and toenhanced social controlthroughinterdependence  Increaseofvariability due toenhancedabilityto discriminate differentpatients’ needs (effectfueledbyheterogeneity in patients) H1: Interaction and interdependence show ambiguousimpacts on the variabilityofbehaviors Qualityof care (adherencetoguidelinesfordiabetes)  Interaction “per se” maynotbesufficientto motivate GPstochange and enhancetheirapproachtochronicdiseases management Interdependencewithoutsteering and monitoringmay generate confusion and dispersionof information (e.g. peerinterdependence  dispersionof information; IP-ID  under-organizeddivisionoflabor) Interaction and interdependence, ifdevelopedtogether, can promote information sharing (appliedto a shared pool ofpatients), organizedmultidisciplinar management ofdiseases H2.a: Interaction and interdependence “per se” shouldnot show signifincant impact (negative, ifany) on management ofdiabetes H2.b: Positive complementaritiesshould emerge betweeninteraction and interdependence Perceptionofresponsiveness(patients’ inappropriate accessesto ED) • Patientsevaluateresponsiveness on the basisofvisibleprocesses and on the lackofconfusion H3: Peer-interdependenceisperceivedasbetterresponsiveness; Inter-professionalinterdependenceiscoupledwith a perceptionofbetterresponsivenessonlyif the processisorganized and monitored

  5. DATA AND METHODSTHE HEALTHCARE SYSTEM IN EMILIA ROMAGNA: KEY FIGURES • Data from the Emilia-Romagna RegionObservatory on Primary Care • 4.3 millionsinhabitants • 7.9 billion € for healthcarespending in 2008: • 4.5% prevention • 41.8% hospital services • 53.7% district & primary care • 17 Public Local HealthAuthorities: • 11 LocalHealthAuthorities (L.H.A.) • 4 TeachingHospitals (T.H.) • 1 Hospital Trust • 1 IRCCS • 61,000 employees (14.1 per 1,000 inhabitants) • 3,100 GPs(+ 600 pediatricians) • 2.0 MD per 1,000 inhabitants • 6.1 Nurses per 1,000 inhabitants • 19,800 private and public hospital beds (4.5 per 1,000 inhabitants)

  6. DATA AND METHODS:the models H1: fixedeffects 2-levels regression H2 and H3: Impact analysisbased on a mixed-effectmultilevel (3) regression Fixedeffects Randomeffects

  7. RESULTS H1.a

  8. H3 H2.a H2.b H3 ? H2

  9. DISCUSSION (1) • Activatingcollaborationthroughinteraction and interdependencedoesnot reduce the variabilityof GP’s behaviors: • Howeverfurtherresearchshouldexploreifthisis due to social control + betterdiscriminationofpatientneeds  more efficientvariability • Peerinterdependencereduces the variabilityofprescriptionofdiagnosticexams (notsurprisingly) • Interaction and interdependenceshould be developedtogether for a bettermanagment of chronicdiseases (diabetes)

  10. DISCUSSION (2) • Patients’ perception of the responsiveness of their GP is more sensible to peer-interdependence alone and actuallyreduced by the complementarity with peer-interaction. • Thismaydepend from the factthatpeer-interdependenceisvisiblewhilepeer-interaction (i.emeetings and more organizational joint activities) isnotbut the lattermaysubtract time from the GPs’ routine clinicalactivities and thismight be perceived by the patientsthatthereforetend to go more to the emergency room for non-urgentmatters • Inter-professionalinterdependenceenhances the perceivedquality of care onlyifcoupled to a goodlevel of interactionamongGPs • InteractionisnotvisiblebutprobablyallowsGPs to coordinate and organizebetter the work and avoidconfusion “I amtreated by an organizedmultidisciplinar team”

  11. Thank Youpatrizio.armeni@unibocconi.it

  12. Extra slides

  13. Primary Care: The Italian Model • Generalpractitioners are independentcontractorspaid on a capitationbasis; additionalpaymentsforfeefor service and results • 2. GPsasgatekeepers – responsibleforreferringpatientsto hospital and specialist care (alsodiagnostics) and forpharmaceuticalprescriptions • 3. GPs can work in solo practices or in joint medicalpracticeswith the assistanceofsecretariesforadministrativetasks and nursesfortriaging and simpleclinicaltasks Hospital and secondary care Referral and gatekeepig GP and GP practices Nurses, secretary Simple technologies

  14. The Italian system ofPrimary Care • GPs: 46,661 ; Pediatricians: 7,621 Activities Age μ=51.6 μ=55.4 Source: FIMMG • Maximum1,500 patients (rosterlist) • FreedomofchoiceofGPs • Thereis a certaindegree of competitionforpatients • MultilevelnegotiationforGPs’ contracts • Capitation rate coversapprox 52.4% ofGPs’ compensation (47.6: FFS, incentives, reimbursementfornurses, etc.)

  15. Joint Medical Practices in Primary Care in Italy Solo practice • Joint medicalpracticeswith spontaneousmembership • Associations • Networks • Group Primary care center E.g. Spain, Finland… ONE REGION HAS INTRODUCED A MANDATED FORM OF JOINT MEDICAL PRACTICE COMPRISING 10-15 GPs and OTHER PROFESSIONS THE CASE OF EMILIA ROMAGNA

  16. Primary Care Units(PCU – Nuclei di Cure Primarie) Mandated PCU Primary care unit(PCU) Primary care center E.g. Spain, Finland… • Joint medical teams • Associations • Networks • Groups • ~ 20.000 patients AND 10-15 GPs per PCU • CoordinatorappointedbyGPs • Professional integrationbetweenGPs, paediatricians, nurses and specialists: • Management ofminor urgentmedicalproblems • Chronicdiseasemanagement • Clinicalaudit • Integration with HealthCare District and Local Health Authority for planning and service delivery purposes • 216 PCU in Emilia-Romagna

  17. Variables and Dimensions • (validated through CFA)

  18. Researchquestions • RESEARCH QUESTIONS Variability of behaviors(prescription of diagnosticexams and referral for specialistcontultations)  Reductionofvariability due togradualcreationofsharedknowledgethroughinteraction and toenhanced social controlthroughinterdependence  Increaseofvariability due toenhancedabilityto discriminate differentpatients’ needs (effectfueledbyheterogeneity in patients) H1.a: Interaction and interdependence show ambiguousimpacts on the variabilityofbehaviors H1.b: higherpatients’ heterogeneityisreflected in highervariabilityofbehaviors Qualityof care (adherencetoguidelinesfordiabetes and patients’ inappropriate accessesto ED)  Interaction “per se” maynotbesufficientto motivate GPstochange and enhancetheirapproachtochronicdiseases management Interdependencewithoutsteering and monitoringmay generate confusion and dispersionof information (e.g. peerinterdependence  dispersionof information; IP-ID  under-organizeddivisionoflabor) but can bepositivelyperceivedbypatientsas a proxyforcollaborationamongGPs Interaction and interdependence, ifdevelopedtogether, can promote information sharing (appliedto a shared pool ofpatients), organizedmultidisciplinar management ofdiseases and a perceptionofbetterqualityof care. H2.a: Interaction and interdependence “per se” shouldnot show signifincant impact (negative, ifany) on management ofdiabetes and on patients-perceivedquality H2.b: Positive complementaritiesshould emerge betweeninteraction and interdependence

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