reports

Quality, costs and the role of primary health care

Linkoping, Sweden: Linkoping University.

Linkoping University, Linkoping, Sweden

The general aim of this thesis is to describe and analyse the role of primary  care in health care systems in terms of health, health care utilisation and costs,  and to study the feasibility of retrieval of data from computerised medical  records to monitor medical quality.

The thesis includes five studies, a systematic literature review, a register  study of utilisation of hospital and primary care, a study based on data from  computerised medical records of individual patients cost for primary care, and  two studies of management of respiratory infections in primary care based on  data from computerised medical records of twelve health centres.

The general findings of the literature review were that an expansion of  the primary care component of the health care system would most likely result  in better health, lower hospital care consumption and lower expenses for care.  The personal physician and continuity of care were core elements to achieve  this, and the significance of the way primary care is organised and funded was  evident.

In the register study fifty health centres were compared. Age and rates of  outpatient hospital visits were the most important factors explaining the  variation of rates of hospitalisations between the health centres’ areas.  Hospital district also influenced hospitalisation rates in the different health  centres’ areas, indicating that the health care structure in the district per se was  an important factor. The rates of visits to general practitioners correlated  negatively with rates of hospitalisations.

The study of costs in primary care showed that the variation in the costs  of the individual patients was substantial, also within age groups and within  the diagnosis-related Adjusted Clinical Groups (ACG). Age and gender  explained a smaller part of the variation in costs per patient in primary care.  Adding the ACG weight had a major influence on improving the ability to  explain the variation in costs at patient level. The ACG system might be of  value in the calculation of weighted capitation in Swedish primary care, but  appears to be sensitive to the thoroughness with which physicians registerdiagnoses.

The retrieval of data from computerised medical records comprised a  total number of 19 965 encounters for respiratory tract infections i.e. 199 per1000 inhabitants during the year 2001. Most frequent diagnoses were common  cold, acute tonsillitis, and acute bronchitis. The number of antibiotic prescriptions was 7 961, accounting for 47% of the episodes. The most  commonly prescribed antibiotics were phenoxymethylpenicillin (61%),  tetracyclines (18%) and macrolides (8%).

A rapid test was performed in 43% of the encounters: for C-reactive  protein (CRP) in 31%; for Group A beta-haemolytic streptococci (StrepA) in  22%; and both tests were performed in 10% of the encounters. The findings in  the study indicate that StrepA and CRP tests were used too frequently and  often with minor contributions to patient management. The frequencies of  tests and of antibiotic prescriptions varied greatly between health centres in a  way that hardly could be explained by differences in morbidity.

Computerised medical records provided a source of clinical information,  which might be a feasible and pragmatic method for studying daily practice,  and for follow-up of adherence to guidelines in general practice.