May, 2012 - SUPPORT Summary of a systematic review | print this article |

Is general practice effective?

General practice (primary care) provides entry for the majority of patients in many healthcare systems, and includes care for a wide range of common, often poorly-defined health problems. Primary care can be offered in health centres, hospitals or by independent physicians, and sometimes fulfills a gatekeeping function for access to specialist services. Reimbursements are usually made on a fee-for-service or capitation basis unless general practitioners are salaried employees. It has been argued that while the care offered by general practitioners is cheaper than specialist care it is also of lower quality.

 

Key messages

  • Increased availability of primary care may lead to lower mortality and morbidity and increased life expectancy
  • Primary care may reduce healthcare costs compared to specialist care. The use of medical specialists instead of general practitioners in primary care may lead to higher costs
  • Capitation is more likely to lead to the achievement of primary care goals as well as cost reduction
  • A gatekeeping system probably leads to little or no change in costs
  • Personal continuity probably increases patient satisfaction and health outcomes, and leads to lower costs
  • Primary care may reduce costs without effects on outcomes for cer-tain diagnoses compared to specialist care

Background

The WHO Alma Ata declaration of 1978 stipulates that primary care should be the first level of contact within national healthcare systems by bringing healthcare to the places where people live and work. Ideally, primary care should be client-focused and care provided by the same primary provider over long periods. This enables general practitioners to know the background and life history of their clients. Rooted in this holistic knowledge, greater trust and understanding should result in well-adapted, acceptable and comprehensive treatment and patient management. By advising and deciding on referrals to specialists, general practitioners assume an important role in controlling healthcare spending given that services at lower levels of the healthcare system are usually cheaper than those at higher levels. General practitioners encounter a wide range of diseases and syndromes and concern has been raised as to whether general practitioners are able to identify conditions requiring specialist attention promptly, and provide services of a quality equal to their specialist peers.


About the systematic review underlying this summary

Review Objectives: To find evidence of the cost-effectiveness and quality of the work done by physicians in primary care.
/What the review authors searched forWhat the review authors found 
Interventions Studies in which costs, quality and/or results in specialist care versus primary care were compared

6 studies of primary care and its impact on health indicators

7 studies on primary care and costs in health care systems

6 studies on reimbursement systems

4 studies on the effects of gatekeeper systems

6 studies on the effects of continuity of care

6 studies on the effects of medical specialities in primary care

10 studies comparing quality of care in primary and specialist care

Participants

Individuals and populations.

No limits with regard to study design (cohort, cross-sectional, case-control, RCT, reviews, database studies)

31 studies focusing on individuals or events

4 studies comparing outcomes across populations (same country)

3 studies comparing outcomes across countries

7 literature reviews

Settings No restrictions
OECD, majority from the United States of America (USA) and Western Europe
Outcomes Public health outcomes and proportion of health care resources allocated to primary care

6 studies on public health outcomes and proportion of health care resources allocated to primary care

7 studies on total health care system expenditure and proportion of health care resources allocated to primary care

22 studies on performance/effects of primary care and ways of organising primary care

10 studies on differences in quality of and cost for care between primary and specialist care

Date of most recent search: Not specified.

Limitations: This review has important limitations with regard to the methods used to identify studies. Only studies published in English were included and reference lists were not checked. It is also not clear if multiple reviewers screened texts and extracted data or not. The date of the most recent search is not provided, and the review might be out-of-date given that it was published in 2001.

The review is narrative and no weighing or quantification of the findings beyond that provided in the underlying publications is attempted.

Engström S, Foldevi M, Borgquist L. Is general practice effective? A systematic literature review. Scand J Prim Healthcare 2001; 19:131-144.

Summary of findings

A total of 45 publications, including literature reviews, studies comparing outcomes across countries or across populations, and studies focusing on individuals or events, were included. All studies were conducted in Organization for Economic Co-operation and Development (OECD) countries, mainly in the United States of America (USA) and Western Europe. The identified studies investigated the impact of primary care on health indicators and costs, compared reimbursement systems, evaluated the effects of gatekeeper systems, the continuity of care and medical specialities in primary care, and compared the quality of care provided by general practitioners and specialists.

 

1) Public health outcomes and proportion of healthcare resources allocated to primary care

  • Increased availability of primary care may lead to lower mortality and morbidity and increased life expectancy
  • Increased availability of primary care may lead to an improved satisfaction/cost ratio.
Outcomes Impact No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Public health outcomes and proportion of healthcare resources allocated to primary care

- Increased availability of primary care is associated with lower mortality rates, increased life expectancy, lower (post) neonatal mortality rates, and a lower rate of low birth weight

- Close association between ranking of primary care and 12 public health indicators and satisfaction/cost ratio

- Lack of primary care doctor: OR 4.4 for severe uncontrolled hypertension

(6 studies)


Comparisons across States in the USA

Comparisons across 10 countries

Case-control study

GRADE: GRADE Working Group grades of evidence (see above and last page)

 

2) Total healthcare system expenditure and proportion of healthcare resources allocated to primary care

  • Compared to specialist care, primary care may reduce healthcare costs but may not lead to any differences in health outcomes

Outcomes Impact No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Total healthcare system expenditure and proportion of healthcare resources allocated to primary care

- Increased availability of primary care physicians reduces healthcare costs (in-hospital and out-of-hospital). Health outcomes are similar.

- Primary care physician rather than specialist as personal physician results in 33% lower annual healthcare expenditure.

- Primary care physician rather than hospital as primary source of care results in 35% less inpatient care and 50% fewer emergency room visits.

- Ambulatory care episodes: 53% cheaper if started with personal primary care physician.

- Low back pain: similar outcomes but 50% less cost if treated by primary care physician rather than specialist.

(7 studies)


Database studies of insurance claims, cohort and cross-sectional studies of individuals, literature review including 23 studies.
GRADE: GRADE Working Group grades of evidence (see above and last page)

 

  3) Performance/effects of primary care and ways of organising primary care

  • Capitation probably leads to fewer single-doctor practices, and better achievement of primary care goals and reduced costs
  • A gatekeeper system probably leads to little or no difference in costs
  • Group practices probably lead to better quality standards
  • Personal continuity probably increases patient satisfaction and health outcomes, and leads to lower costs
  • The use of medical specialists in primary care probably leads to higher costs
Outcomes Impact No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Performance/effects of primary care and ways of organising primary care

Re-imbursement systems:
- Capitation is associated with fewer single-doctor practices and the better achievement of primary care goals.
- Fee-for-service increases flexibility and activity of physicians, 41% more hospitalisations and 12% more drugs prescribed

Gatekeeper system:
- Tends to reduce costs and hospital outpatient consultations (mostly not significant).

Single or group practices:
- Group practices have better quality standards and lower hospitalisation rates than HMO/group practices.
- Community health centres have the best outcome scores.

Continuity of care:
- Greater positive effects of primary care if doctor choice is free, resulting in long-term patient-doctor relationships.
- Personal continuity increases patient satisfaction and compli-ance with therapeutic regimens, reduces hospital admissions, and saves time and laboratory tests.
- Previous knowledge of the patient increases the odds of the doctor recognising psychosocial problems influencing the patient’s health.

Medical specialities in primary care:
- Increasing availability of family/general practitioners is associated with a lower rate of avoidable hospitalisations.
- Hospitalisations are 100% higher for cardiologists and 50% higher for endocrinologists compared with family practitioners.
- Patients attending primary care in family practices have 40% lower hospitalisation costs than those attending primary care in internal medicine.
- Generalists are more accessible than specialists.

(22 studies)

Cohort and cross-sectional studies, medical record review

Cross-country comparisons, RCTs

Cohort study

Literature review, cohort studies, insurance claims review

Database study of medical records, RCTs, cross-sectional and cohort studies

GRADE: GRADE Working Group grades of evidence (see above and last page)

 

4) Differences in quality and cost between primary and specialist care

  • Primary care may not lead to any difference in the quality of care for some diagnoses compared to specialist care
  • Primary care may reduce costs without effects on outcomes
Outcomes Impact No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments
Differences in the quality and cost of care between primary and specialist care

- No difference in the quality of diabetes, hypertension, low back pain and depression management between primary and specialist care.

- Management by GPs reduces costs by 30-40% with no apparent effects on outcomes.

(10 studies)


RCTs, cohort studies, medical record review, literature reviews
GRADE: GRADE Working Group grades of evidence (see above and last page)

Relevance of the review for low-income countries

FindingsInterpretation*
APPLICABILITY
All included studies were conducted in high-income countries.

Primary care is a component of virtually all healthcare systems because care for minor health issues needs to be provided in a decentralised way. Hence, at least some of the findings from this study are likely to be valid in LMICs as well.

Conclusions derived from studies of primary care delivered by physicians in HICs may not be directly applicable to LMICs due to structural differences in healthcare options, education and resources.
EQUITY
The review did not discuss equity-related issues.

Primary care could improve equity by lowering financial and institutional access barriers to healthcare.

The resources saved could be employed to improve equity.
ECONOMIC CONSIDERATIONS
Primary care may reduce healthcare costs compared to the health costs of specialist care.

The cost-savings associated with primary care are arguably more relevant in resource-constrained settings and could result in disproportionally positive public health effects if savings are invested in boosting healthcare.

Boosting primary care usually results in lower overall healthcare resource usage (diagnostic tests, drugs, hospitalisations, specialist appointments etc.).

Establishing a primary care system requires additional resources, specifically for the training of general practitioners, public information and education and, if unavailable, healthcare infrastructure (such as health centres etc.).

MONITORING & EVALUATION
The review found evidence from a substantial array of sources for the financial and public health benefits of primary care in high-income countries.

The absence of evidence on the effectiveness of general care from LMICs calls for comprehensive monitoring and evaluation if primary care is introduced/expanded/emphasised. All areas (financial, public health, health outcomes, patient satisfaction, organisational etc.) need to be monitored and evaluated.

*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low and middle-income countries. For additional details about how these judgements were made see: http://www.support-collaboration.org/summaries/methods.htm


Additional information

Related literature

Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L. Impact of payment method on behaviour of primary care physicians: a systematic review. J Health Serv Res Policy. 2001; 6:44-55.

 

Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, Sergison M, Pedersen L. Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians. Cochrane Database of Systematic Reviews 2000, Issue 3. Art. No.: CD002215. DOI: 10.1002/14651858.CD002215.

 

Lewin S, Munabi-Babigumira S, Glenton C, Daniels K, Bosch-Capblanch X, van Wyk BE, Odgaard-Jensen J, Johansen M, Aja GN, Zwarenstein M, Scheel IB. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database of Systematic Reviews 2010, Issue 3. Art. No.: CD004015. DOI: 10.1002/14651858.CD004015.pub3 

 

Starfield B. Is primary care essential? Lancet 1994;344:1129 – 33.

 

WHO. Alma Ata 1978. Primary Health Care. Report of the International Conference on Primary Health Care. Geneva: WHO; 1978.

 

This summary was prepared by

Peter Steinmann, Swiss Tropical and Public Health Institute, Switzerland.


Conflict of interest

None declared. For details, see: www.support-collaboration.org/summaries/coi.htm

 

Acknowledgements

This summary has been peer reviewed by: Sven Engström, Sweden; Julie Cliff, Mozambique.

 

This summary should be cited as

Steinmann P. Is general practice effective? A SUPPORT Summary of a systematic review. May 2011. www.support-collaboration.org/summaries.htm

 

Keywords

All summaries: evidence-informed health policy, evidence-based, systematic review, health systems research, health care, low- and middle-income countries, developing countries, primary health care, specialist care, general practitioner, cost, health outcomes, capitation, fee-for-service, gatekeeper.



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