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General Practice in a Global Perspective

General Practice in a Global Perspective. Professor Mieke van Driel. Learning objectives. At the conclusion of this session you will be able to understand: the meaning of PHC in a global context the position of PHC in health care systems the role of the general practitioner in PHC

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General Practice in a Global Perspective

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  1. General Practice in a Global Perspective • Professor Mieke van Driel

  2. Learning objectives At the conclusion of this session you will be able to understand: • the meaning of PHC in a global context • the position of PHC in health care systems • the role of the general practitioner in PHC • the specific ecology and epidemiology of PHC • the decision making process in PHC

  3. What is PHC? Some history WHO – Alma Ata 1978 “… health which is a state of complete physical, mental and social wellbeing, …is a fundamental human right and that the attainment …. requires the action of many other social and economic sectors in addition to the health sector.”

  4. “A main social target of governments,… should be the attainment by all peoples of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. Primary health care is the key to attaining this target as part of development in the spirit of social justice.” http://www.paho.org/English/DD/PIN/alma-ata_declaration.htm

  5. What is PHC?

  6. What is PHC? • essential health care based on practical, scientifically sound methods and technology • universally accessible to individuals in the community • at a cost that the community and country can afford • an integral part of the country's health system • first level of contact of individuals with the health system • as closeas possible to where people live and work • first element of a continuing health care process

  7. WONCA World Organisation of Family Doctors • 1972 18 member organisations • 2013 126 member organisations in 102 countries • Mission: “To improve quality of life…” http://www.globalfamilydoctor.com

  8. WONCA EuropeCharacteristics of PHC 11 core characteristics • First contact with health care system; free access • Efficient use of resources by coordination of care • Person-centred approach • Long term relationship • Continuity of care • Specific decision making process • Acute AND chronic care • Management of undifferentiated illness presenting in early stages • Promotes health and wellbeing • Specific responsibility towards community • Multidimensional approach: physical, social and cultural

  9. WONCA Europe:Characteristics of PHC 6 core competencies • Primary care echelon • Person-orientated care • Specific problem solving skills • Comprehensive and integrated approach • Focus on the community • Holistic approach

  10. RACGP http://www.racgp.org.au

  11. PHC as a specialtyScientific basis of PHC • Ecology of PHC • Epidemiology - Episode-oriented care • Medical decision making • Role of PHC in the health care system

  12. Ecology of primary care Ecology of care model Green LA, et al. The Ecology of Medical Care Revisited. N Engl J Med 2001;344:2021-5

  13. Epidemiology of primary care “Episode oriented care” • Reason For Encounter (RFE) • International Classification of Primary Care - ICPC-2/ Snowmed • Bettering the Evaluation And Care of Health BEACH http://www.aihw.gov.au

  14. BEACH 2011-2012 www.aihw.gov.au

  15. BEACH 2011-2012 www.aihw.gov.au

  16. BEACH 2011-2012 www.aihw.gov.au

  17. BEACH 2011-2012

  18. Medical decision making • Presentations in PHC • Wide range of problems • Unselected population • Psychosocial problems • Self-limiting nature of diseases • Mostly non-serious disease • Disease pattern not much developed • Diagnosis often symptom-based (vs disease-based)

  19. Medical decision making • Consequences for the approach in PHC • Often “wait and see” • Deal with uncertainty • Need for all round knowledge • Limited use of technology • Pre-existing knowledge of patient and his environment – extra clues • Better prognosis

  20. Probability of disease in PHC differs from secondary care An example A patient presents with chest pain • Chances that this patient has angina (pretest probability = prevalence) • PHC 4% • ED 24%

  21. The GP as a “filter” • Filter patients who need further investigation, treatment or referral • 85-90% of all episodes encountered by a GP are managed in PHC

  22. The GP as a filterA.Knottnerus Example

  23. Probability of a disease that needs to be treated by an organ specialist 100/1000 = 10% • Sensitivity of the referral (test) by GP

  24. Probability of a disease that needs to be treated by an organ specialist 100/1000 = 10% • Sensitivity of the referral by GP = 90/100 = 90% • Specificity of the referral by GP

  25. Probability of a disease that needs to be treated by an organ specialist 100/1000 = 10% • Sensitivity of the referral by GP = 90/100 = 90% • Specificity of the referral by GP = 810/900 = 90% • Predictive value of a referral

  26. Probability of a disease that needs to be treated by an organ specialist 100/1000 = 10% • Sensitivity of the referral by GP = 90/100 = 90% • Specificity of the referral by GP = 810/900 = 90% • Predictive value of a referral = 90/180 = 50%

  27. After training by specialist…. Situation

  28. Probability of a disease that needs to be treated by an organ specialist 100/1000 = 10% • Sensitivity of the referral by GP

  29. Probability of a disease that needs to be treated by an organ specialist 100/1000 = 10% • Sensitivity of the referral by GP = 95/100 = 95% • Specificity of the referral by GP

  30. Probability of a disease that needs to be treated by an organ specialist 100/1000 = 10% • Sensitivity of the referral by GP = 95/100 = 95% • Specificity of the referral by GP = 405/900 = 45% • Predictive value of a referral

  31. Probability of a disease that needs to be treated by an organ specialist 100/1000 = 10% • Sensitivity of the referral by GP = 95/100 = 95% • Specificity of the referral by GP = 405/900 = 45% • Predictive value of a referral = 95/590 = 16%

  32. Role of PHC in the health care system • Better health outcomes • Lower costs • Greater equity in health Starfield et al. Policy relevant determinants of health. Health Policy 2002;60:201-18. http://www.bibalex.org/Supercourse/SupercoursePPT/17011-18001/17361.ppt#263,7,Evidence of the Benefits of a Primary Care-Oriented Health System

  33. 14 industrialised countries • Health system characteristics • Distribution of resources regulated, Financing of PHC • Number and wages of GPs versus specialists • Patient lists, Cost sharing by patients • 24h access • Strength of academic departments,…. • Practice characteristics • First-contact care • Comprehensiveness, Coordination • Family-centredness, Community orientation • Major health indicators • Low birth weight, neo/postnatal mortality, infant mortality • Life expectancy • Smoking,… • Income inequality

  34. Evidence of the Benefits of a Primary Care-Oriented Health System

  35. Primary Care Score vs. Health Care Expenditures, 1997 UK DK NTH FIN SP CAN AUS SWE JAP GER US BEL FR Based on data in Starfield & Shi, Health Policy 2002; 60:201-18.

  36. Primary Care Scores, 1980s and 1990s *Scores available only for the 1990s

  37. Primary Care Score and Premature Mortality in 18 OECD Countries 10000 PYLL Low PC Countries* 5000 All Countries* High PC Countries* 0 1970 1980 1990 2000 Year *Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77. Macinko J et al. Health Serv Res 2003; 38(3):831-865.

  38. Overall, countries that achieve better health levels… • Are primary care-oriented • Have more equitable resource distributions • Have government-provided health services or health insurance • Have little or no private health insurance • Have no or low co-payments for health services

  39. References • Starfield B, Shi L. Policy relevant determinants of health: an international perspective. Health Policy 2002;60:201-18. • Green LA, Fryer GE Jr, Yawn BP, Lanier D, Dovey SM. The Ecology of Medical Care Revisited. N Engl J Med 2001;344:2021-5. • Del Mar CB, Freeman GK, van Weel C. “only a GP?”: is the solution to the general practice crisis intellectual? MJA 2003;179:26-9. • Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health Serv Res 2003; 38(3):831-865. • www.globalfamilydoctor.com/ • www.racgp.org.au • www.aihw.gov.au/ • www.who.org • http://www.paho.org/English/DD/PIN/alma-ata_declaration.htm

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