Chronic care services and variation between Danish general practices: a nationwide cohort study

Abstract

Background: Little is known about variations in the provision of chronic care services in primary care. Aim: To describe the frequency of chronic care services provided by GPs and analyse the extent of non-random variation in service provision. Design and setting: Nationwide cohort study in Denmark in 2016. Method: Information on chronic care services was obtained from national health registers, including annual chronic care consultations, chronic care procedures, outreach home visits, and talk therapy. The associations between provided services, patient morbidity, and socioeconomic factors were estimated. Service variations were analysed, and excess variation related to practice-specific factors was estimated while accounting for random variation. Results: Chronic care provision was associated with increasing patient age, increasing number of long-term conditions, and indicators of low socioeconomic status. Variation across practices ranged from 1.4 to 128 times more than expected after adjusting for differences in patient population and random variation. Variation related to practice-specific factors was present for all investigated chronic care services. Older patients with lower socioeconomic status and multimorbidity were clustered in practices with low propensity to provide certain chronic care services. Conclusion: Chronic care was provided to patients typically in need of healthcare, i.e. the old, those with multimorbidity, and those with low socioeconomic status, but service provision varied more than expected across practices. GPs provided slightly fewer chronic care services than expected in practices where many patients with multimorbidity and low socioeconomic status were clustered, suggesting inverse care law mechanisms.

Variation in Psychometric Testing in General Practice – A Nationwide Cohort Study

“…Variation in the services provided by Danish GPs has previously been investigated by examining variations in chronic care consultations, including talk therapy sessions. 12 In our study, we found a clear positive dose-response association between PT rate and talk therapy rate. Specifically, we observed the greatest variation in the propensity for PT use among the smallest practices.…”

“…The finding of increased variation in the provided services has also been reported in other studies, with indications that some variation is non-negligible due to derived outcomes, such as the need for immediate identification and treatment of patients at risk of suicidal behavior after the loss of a loved one. 12 , 28 , 29 …”

“… 10 , 11 A recent Danish study found an excess variation between Danish general practices in terms of the chronic care services provided, eg, talk therapy. 12 However, little is known about the use of PTs in general practice. Therefore, we wanted to explore the rate of PT use in general practice by using methods applied for ranking health service providers in a broad unselected national setting.…”

Clinic for Multimorbidity: An Innovative Approach to Integrate General Practice and Specialized Health Care Services

“…Caring for and coordinating care for patients with complex multimorbidity is a demanding task [12,39,40]. One study found that the GP's time consumption and the burden of contacts tend to rise with the number of chronic conditions [8], another study found that service provision for chronic care vary considerably across general practices [41]. The CM had a low inclusion as only 141 patients underwent the intervention during the time of investigation.…”

Effectiveness of an adaptive, multifaceted intervention to enhance care for patients with complex multimorbidity in general practice: protocol for a pragmatic cluster randomised controlled trial (the MM600 trial)

“…Chronic care in general practice is currently organised around specific conditions 15 16. This model is suitable neither for patients nor general practitioners (GPs) 17. Patient-centred care has been promoted through decades as a way to design healthcare systems to meet the patient’s needs and as a way to approach the patient in individual consultations 18 19.…”