The impact of practice size and ownership on general practice care in Australia

Moel-Mandel, Caroline de; Sundararajan, Vijaya

doi:10.5694/mja2.51038

Cited by 11 publications

(8 citation statements)

References 15 publications

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“…Should such initiatives reach a similar threshold as found in major cities, alternative models of care or funding arrangements may be required for additional equity gains. Moreover, unintended negative consequences should be monitored, such as excessive workforce turnover and reliance on fly‐in/locum GPs which can compromise continuity of care, 52 especially for disadvantaged individuals.…”

Section: Discussionmentioning

confidence: 99%

Association of individual‐socioeconomic variation in quality‐of‐primary care with area‐level service organisation: A multilevel analysis using linked data

Butler

Larkins

Korda

2023

Evaluation Clinical Practice

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Rationale, Aims and ObjectivesEnsuring equitable access to primary care (PC) contributes to reducing differences in health related to people's socioeconomic circumstances. However, there is limited data on system‐level factors associated with equitable access to high‐quality PC. We examine whether individual‐level socioeconomic variation in general practitioner (GP) quality‐of‐care varies by area‐level organisation of PC services.MethodsBaseline data (2006–2009) from the Sax Institute's 45 and Up Study, involving 267,153 adults in New South Wales, Australia, were linked to Medicare Benefits Schedule claims and death data (to December 2012). Small area‐level measures of PC service organisation were GPs per capita, bulk‐billing (i.e., no copayment) rates, out‐of‐pocket costs (OPCs), rates of after‐hours and chronic disease care planning/coordination services. Using multilevel logistic regression with cross‐level interaction terms we quantified the relationship between area‐level PC service characteristics and individual‐level socioeconomic variation in need‐adjusted quality‐of‐care (continuity‐of‐care, long‐consultations, and care planning), separately by remoteness.ResultsIn major cities, more bulk‐billing and chronic disease services and fewer OPCs within areas were associated with an increased odds of continuity‐of‐care—more so among people of high‐ than low education (e.g., bulk‐billing interaction with university vs. no school certificate 1.006 [1.000, 1.011]). While more bulk‐billing, after‐hours services and fewer OPCs were associated with long consultations and care planning across all education levels, in regional locations alone, more after‐hours services were associated with larger increases in the odds of long consultations among people with low‐ than high education (0.970 [0.951, 0.989]). Area GP availability was not associated with outcomes.ConclusionsIn major cities, PC initiatives at the local level, such as bulk‐billing and after‐hours access, were not associated with a relative benefit for low‐ compared with high‐education individuals. In regional locations, policies supporting after‐hours access may improve access to long consultations, more so for people with low‐ compared with high‐education.

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Section: Discussionmentioning

confidence: 99%

Association of individual‐socioeconomic variation in quality‐of‐primary care with area‐level service organisation: A multilevel analysis using linked data

Butler

Larkins

Korda

2023

Evaluation Clinical Practice

View full text Add to dashboard Cite

show abstract

“…Should such initiatives reach a similar threshold as found in major cities, alternative models of care or funding arrangements may be required for additional equity gains. Moreover, unintended negative consequences should be monitored, such as excessive workforce turnover and reliance on fly-in/locum GPs which can compromise continuity-of-care [38], especially for disadvantaged individuals.…”

Section: Discussionmentioning

confidence: 99%

Does individual-socioeconomic variation in quality-of-primary care vary according to area-level service organisation? Multilevel analysis using linked data

Butler

Larkins

Jorm

et al. 2022

Preprint

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BackgroundThere is limited data on system-level factors associated with equitable access to high-quality primary care. We examine whether individual-level socioeconomic variation in general practitioner (GP) quality-of-care varies by area-level organisation of primary healthcare (PHC) services.MethodsBaseline data (2006–2009) from the Sax Institute’s 45 and Up Study, involving 267,153 adults in New South Wales, Australia, were linked to Medicare Benefits Schedule and death data (to December 2012). Using multilevel logistic regression with cross-level interaction terms we quantified the relationship between small area-level PHC service characteristics and individual-level socioeconomic variation in need-adjusted quality-of-care (continuity-of-care, long-consultations, and care planning), separately by remoteness.Key findingsIn major cities, more bulk-billing(i.e. no co-payment) and chronic disease services and fewer out-of-pocket costs within areas were associated with an increased odds of continuity-of-care—more so among people of high-than low-education (e.g. bulk-billing interaction with university versus no school certificate 1.006[1.000,1.011]). While more bulk-billing, after-hours services and fewer OPC were associated with long-consultations and care planning across all education levels, in regional locations alone, more after-hours services were associated with larger increases in the odds of long consultations among people with low-than high-education (0.970[0.951,0.989]). Area GP availability was not associated with outcomes.ImplicationsIn major cities, PHC initiatives at the local level, such as bulk-billing and after-hours access, were not associated with a relative benefit for low-compared to high-education individuals. In regional locations, policies supporting after-hour access may improve access to long consultations, more so for people with low-compared to high-education.Key messagesWhat we knowEquitable access to high-quality primary healthcare is expected to reduce socioeconomic inequalities in health.Quality-of-care varies according to both individual socioeconomic position and local primary healthcare service organisation and delivery.However, there is limited data on system-level factors associated with equitable access to high-quality care.What this study addsIn major cities, area-level primary healthcare service characteristics such as bulk-billing (i.e. no co-payment), out-of-pocket costs, chronic disease and after-hours services were not associated with a relative benefit for low-education individuals compared with high-education in quality-of-care.In regional areas, more after-hours services were associated with a higher likelihood of long consultations – more so for people of low-education than high-education.How this study might affect research, practice or policyThe identified area-level service characteristics associated with socioeconomic variation in care indicate avenues for providers and policy makers for improving healthcare equity.Improved data measuring area-level primary healthcare service organisation is needed to better measure the impact of policy initiatives.

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“…Clinics were randomised using a computer-generated minimisation algorithm to maximise the balance across 2 variables—annual chlamydia testing rate among 16- to 29-year-olds in the clinic for 12 months prior to ACCEPt-able (<19% versus ≥19%, based on median testing rate) and number of 16- to 29-year-olds attending the clinic each year (<1,000 versus ≥1,000, based on the 67th percentile of the number of patients at each clinic, to ensure that groups were evenly distributed among relatively smaller and larger clinics because of the potential association of clinic size with patient quality of care [ 26 ]). The trial statistician was blinded to allocation.…”

Section: Methodsmentioning

confidence: 99%

The impact of removing financial incentives and/or audit and feedback on chlamydia testing in general practice: A cluster randomised controlled trial (ACCEPt-able)

et al. 2022

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Background Financial incentives and audit/feedback are widely used in primary care to influence clinician behaviour and increase quality of care. While observational data suggest a decline in quality when these interventions are stopped, their removal has not been evaluated in a randomised controlled trial (RCT), to our knowledge. This trial aimed to determine whether chlamydia testing in general practice is sustained when financial incentives and/or audit/feedback are removed. Methods and findings We undertook a 2 × 2 factorial cluster RCT in 60 general practices in 4 Australian states targeting 49,525 patients aged 16–29 years for annual chlamydia testing. Clinics were recruited between July 2014 and September 2015 and were followed for up to 2 years or until 31 December 2016. Clinics were eligible if they were in the intervention group of a previous cluster RCT where general practitioners (GPs) received financial incentives (AU$5–AU$8) for each chlamydia test and quarterly audit/feedback reports of their chlamydia testing rates. Clinics were randomised into 1 of 4 groups: incentives removed but audit/feedback retained (group A), audit/feedback removed but incentives retained (group B), both removed (group C), or both retained (group D). The primary outcome was the annual chlamydia testing rate among 16- to 29-year-old patients, where the numerator was the number who had at least 1 chlamydia test within 12 months and the denominator was the number who had at least 1 consultation during the same 12 months. We undertook a factorial analysis in which we investigated the effects of removal versus retention of incentives (groups A + C versus groups B + D) and the effects of removal versus retention of audit/feedback (group B + C versus groups A + D) separately. Of 60 clinics, 59 were randomised and 55 (91.7%) provided data (group A: 15 clinics, 11,196 patients; group B: 14, 11,944; group C: 13, 11,566; group D: 13, 14,819). Annual testing decreased from 20.2% to 11.7% (difference −8.8%; 95% CI −10.5% to −7.0%) in clinics with incentives removed and decreased from 20.6% to 14.3% (difference −7.1%; 95% CI −9.6% to −4.7%) where incentives were retained. The adjusted absolute difference in treatment effect was −0.9% (95% CI −3.5% to 1.7%; p = 0.2267). Annual testing decreased from 21.0% to 11.6% (difference −9.5%; 95% CI −11.7% to −7.4%) in clinics where audit/feedback was removed and decreased from 19.9% to 14.5% (difference −6.4%; 95% CI −8.6% to −4.2%) where audit/feedback was retained. The adjusted absolute difference in treatment effect was −2.6% (95% CI −5.4% to −0.1%; p = 0.0336). Study limitations included an unexpected reduction in testing across all groups impacting statistical power, loss of 4 clinics after randomisation, and inclusion of rural clinics only. Conclusions Audit/feedback is more effective than financial incentives of AU$5–AU$8 per chlamydia test at sustaining GP chlamydia testing practices over time in Australian general practice. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12614000595617

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The impact of practice size and ownership on general practice care in Australia

Cited by 11 publications

References 15 publications

Association of individual‐socioeconomic variation in quality‐of‐primary care with area‐level service organisation: A multilevel analysis using linked data

Association of individual‐socioeconomic variation in quality‐of‐primary care with area‐level service organisation: A multilevel analysis using linked data

Does individual-socioeconomic variation in quality-of-primary care vary according to area-level service organisation? Multilevel analysis using linked data

The impact of removing financial incentives and/or audit and feedback on chlamydia testing in general practice: A cluster randomised controlled trial (ACCEPt-able)

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