Time is money: general practitioners' reflections on the fee-for-service system

BACKGROUND

Fee-for-service is a common payment model for remunerating general practitioners (GPs) in OECD countries. In Norway, GPs earn two-thirds of their income through fee-for-service, which is determined by the number of consultations and procedures they register as fees. In general, fee-for-service incentivises many and short consultations and is associated with high service provision. GPs act as gatekeepers for various treatments and interventions, such as addictive drugs, antibiotics, referrals, and sickness certification. This study aims to explore GPs' reflections on and perceptions of the fee-for-service system, with a specific focus on its potential impact on gatekeeping decisions.

METHODS

We conducted six focus group interviews with 33 GPs in 2022 in Norway. We analysed the data using thematic analysis.

RESULTS

We identified three main themes related to GPs' reflections and perceptions of the fee-for-service system. First, the participants were aware of the profitability of different fees and described potential strategies to increase their income, such as having shorter consultations or performing routine procedures on all patients. Second, the participants acknowledged that the fees might influence GP behaviour. Two perspectives on the fees were present in the discussions: fees as incentives and fees as compensation. The participants reported that financial incentives were not directly decisive in gatekeeping decisions, but that rejecting requests required substantially more time compared to granting them. Consequently, time constraints may contribute to GPs' decisions to grant patient requests even when the requests are deemed unreasonable. Last, the participants reported challenges with remembering and interpreting fees, especially complex fees.

CONCLUSIONS

GPs are aware of the profitability within the fee-for-service system, believe that fee-for-service may influence their decision-making, and face challenges with remembering and interpreting certain fees. Furthermore, the fee-for-service system can potentially affect GPs' gatekeeping decisions by incentivising shorter consultations, which may result in increased consultations with inadequate time to reject unnecessary treatments.

The cost of saying no: general practitioners' gatekeeping role in sickness absence certification

BACKGROUND

General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification.

METHODS

Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke's thematic analysis approach.

RESULTS

Our results indicate that GPs' sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs' opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs' available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence.

CONCLUSION

Our study suggests that GPs' decisions about sickness certification is largely driven by patient preferences. The GPs' gatekeeping function is limited to negotiations about grade and duration of absence spells.

Requisitos uniformes para originais submetidos a Revistas Biomédicas

Um pequeno grupo de editores de revistas da área médica reuniu-se informalmente em Vancouver, Colúmbia Britânica, em 1978, para estabelecer diretrizes para o formato dos originais submetidos a suas revistas. Esse grupo ficou conhecido como o Grupo de Vancouver. Seus requisitos para apresentação de originais, que incluíam os formatos de referências bibliográficas desenvolvidos pela Biblioteca Nacional de Medicina (National Library of Medicine - NLM), foram publicados pela primeira vez em 1979. O Grupo de Vancouver se expandiu e evoluiu para o Comitê Internacional de Editores de Revistas Médicas (International Committee of Medical Journal Editors - ICMJE), que se reúne anualmente. Gradualmente, este comitê vem ampliando seus alvos de atenção. O comitê produziu quatro edições prévias dos requisitos uniformes. Ao longo dos anos, surgiram questões que vão além da preparação dos originais. Algumas delas são tratadas agora nos requisitos uniformes; outras são contempladas em pareceres separados. Cada parecer foi publicado em uma revista científica; todos estão reproduzidos no final deste artigo.

Changes in life expectancy and disease burden in Norway, 1990–2019: an analysis of the Global Burden of Disease Study 2019

Background

Methods

Findings

Interpretation

Funding

Training physicians in providing complex information to patients with multiple sclerosis: a randomised controlled trial

OBJECTIVE

To evaluate the effect of a specific communication training for neurologists on how to provide complex information about treatment options to patients with multiple sclerosis (MS).

DESIGN

Single-centre, single-blind, randomised controlled trial.

SETTING

One university hospital in Norway.

PARTICIPANTS

Thirty-four patients with early-stage MS.

INTERVENTION

A 3-hour training for neurologists on how to provide complex information about MS escalation therapy.

MAIN OUTCOME MEASURES

Patient recall rate, measured with a reliable counting system of provided and recalled information about drugs.

SECONDARY OUTCOME MEASURES

Number of information units provided by the physicians. Effects on patient involvement through questionnaires.

METHODS

Patients with MS were instructed to imagine a disease development and were randomised and blinded to meet a physician to receive information on escalation therapy, before or after the physician had participated in a 3-hour training on how to provide complex information. Consultations and immediate patient recall interviews were video-recorded and transcribed verbatim.

RESULTS

Patient recall rate was 0.37 (SD=0.10) pre-intervention and 0.39 (SD=0.10) post-intervention. The effect of the intervention on recall rate predicted with a general linear model covariate was not significant (coefficient parameter 0.07 (SE 0.04, 95% CI (-0.01 to 0.15)), p=0.099).The physicians tended to provide significantly fewer information units after the training, with an average of 91.0 (SD=30.3) pre-intervention and 76.5 (SD=17.4) post-intervention; coefficient parameter -0.09 (SE 0.02, 95% CI (-0.13 to -0.05)), p<0.001. There was a significant negative association between the amount of provided information and the recall rate (coefficient parameter -0.29 (SE 0.05, 95% CI (-0.39 to -0.18)), p<0.001). We found no significant effects on patient involvement using the Control Preference Scale, Collaborate or Four Habits Patient Questionnaire.

CONCLUSION

A brief course for physicians on providing complex information reduced the amount of information provided, but did not improve patient recall rate.

TRIAL REGISTRATION NUMBER

ISRCTN42739508.

How well do doctors understand a scientific article in English when it is not their first language? A randomised controlled trial

INTRODUCTION

English is the lingua franca of science. How well doctors understand English is therefore crucial for their understanding of scientific articles. However, only 5% of the world's population have English as their first language.

METHODS

Objectives: To compare doctors' comprehension of a scientific article when read in their first language (Norwegian) versus their second language (English). Our hypothesis was that doctors reading the article in Norwegian would comprehend the content better than those reading it in English.

DESIGN

Parallel group randomised controlled trial. We randomised doctors to read the same clinical review article in either Norwegian or English, before completing a questionnaire about the content of the article.

SETTING

Conference in primary care medicine in Norway, 2018.

PARTICIPANTS

130 native Norwegian-speaking doctors, 71 women and 59 men. One participant withdrew before responding to the questionnaire and was excluded from the analyses.

INTERVENTIONS

Participants were randomly assigned to read a review article in either Norwegian (n=64) or English (n=66). Reading time was limited to 7 min followed by 7 min to answer a questionnaire.

MAIN OUTCOME MEASURES

Total score on questions related to the article content (potential range -9 to 20).

RESULTS

Doctors who read the article in Norwegian had a mean total score of 10.40 (SD 3.96) compared with 9.08 (SD 3.47) among doctors who read the article in English, giving a mean difference of 1.32 (95% CI 0.03 to 2.62; p=0.046). Age was independently associated with total score, with decreased comprehension with increasing age.

CONCLUSION

The difference in comprehension between the group who read in Norwegian and the group who read in English was statistically significant but modest, suggesting that the language gap in academia is possible to overcome.

Nurses' perceptions of patient participation in the myocardial infarction pathway

Aim

To explore nurses' perceptions of patient participation in different phases of the myocardial infarction pathway.

Design

Qualitative design with a hermeneutical approach.

Methods

Five focus groups were conducted at two hospitals, one with and one without percutaneous coronary intervention facilities, between February-November 2018. Participants were recruited through purposive sampling. Twenty-two nurses experienced in cardiac care participated. The analysis had a hermeneutical approach.

Results

The findings revealed nurses' perceptions of patient participation in different phases of the myocardial infarction pathway. Four themes were identified: (a) variation between paternalism and autonomy in the acute phase; (b) individualization of dialogue and patient participation during treatment; (c) lack of coherence in the pathway hinders patient participation at discharge; and (d) cardiac rehabilitation promotes patients' autonomous decisions in lifestyle changes.

Changes in job satisfaction among doctors in Norway from 2010 to 2017: a study based on repeated surveys

OBJECTIVE

To assess job satisfaction for different categories of Norwegian doctors from 2010 to 2016-2017.

DESIGN

Cross-sectional surveys in 2010, 2012, 2014 and 2016-2017 of partly overlapping samples.

SETTING

Norway from 2010 to 2016-2017.

PARTICIPANTS

Doctors working in different job positions (hospital doctors, general practitioners (GPs), private practice specialists, doctors in academia). Response rates were 67% (1014/1520) in 2010, 71% (1279/1792) in 2012, 75% (1158/1545) in 2014 and 73% (1604/2195) in 2016-2017. The same 548 doctors responded at all four points in time.

MAIN OUTCOME MEASURE

Job Satisfaction Scale (JSS), a 10-item widely used instrument, with scores ranging from 1 (low satisfaction) to 7 (high satisfaction) for each item, and an unweighted mean total sum score.

ANALYSIS

General Linear Modelling, controlling for gender and age, and paired t-tests.

RESULTS

For all doctors, the mean scores of JSS decreased significantly from 5.52 (95% CI 5.42 to 5.61) in 2010 to 5.30 (5.22 to 5.38) in 2016-2017. The decrease was significant for GPs (5.54, 5.43 to 5.65 vs 5.17, 5.07 to 5.28) and hospital doctors (5.14, 5.07 to 5.21 vs 5.00, 4.94 to 5.06). Private practice specialists were most satisfied, followed by GPs and hospital doctors. The difference between the GPs and the private practice specialists increased over time.

CONCLUSIONS

From 2010 to 2016-2017 job satisfaction for Norwegian doctors decreased, but it was still at a relatively high level. Several healthcare reforms and regulations over the last decade and changes in the professional culture may explain some of the reduced satisfaction.

Development of a measurement system for complex oral information transfer in medical consultations

Background

Information exchange between physician and patient is crucial to achieve patient involvement, shared decision making and treatment adherence. No reliable method exists for measuring how much information physicians provide in a complex, unscripted medical conversation, nor how much of this information patients recall. This study aims to fill this gap by developing a measurement system designed to compare complex orally provided information to patient recall.

Methods

The development of the complex information transfer measurement system required nine methodological steps. Core activities were data collection, definition of information units and the first draft of a codebook, refinement through independent coding and consensus, and reliability testing. Videotapes of physician-patient consultations based on a standardized scenario and post-consultation interviews with patients constituted the data. The codebook was developed from verbatim transcriptions of the videotapes. Inter-rater reliability was calculated using a random selection of 10% of the statements in the transcriptions.

Results

Thirtyfour transcriptions of visits and interviews were collected. We developed a set of rules for defining a single unit of information, defined detailed criteria for exclusion and inclusion of relevant units of information, and outlined systematic counting procedures. In the refinement phase, we established a system for comparing the information provided by the physician with what the patient recalled. While linguistic and conceptual issues arose during the process, coders still achieved good inter-rater reliability, with intra-class correlation for patient recall: 0.723, and for doctors: 0.761. A full codebook is available as an appendix.

Conclusions

A measurement system specifically aimed at quantifying complex unscripted information exchange may be a useful addition to the tools for evaluating the results of health communication training and randomized controlled trials.

Electronic supplementary material

The online version of this article (10.1186/s12874-019-0788-7) contains supplementary material, which is available to authorized users.

Patients' narratives of their patient participation in the myocardial infarction pathway

AIM

To explore how patients in areas without local percutaneous coronary intervention (PCI) facilities experience patient participation in different phases of the myocardial infarction pathway.

BACKGROUND

Acute treatment of myocardial infarction often involves PCI. In Norway, this treatment is centralized at certain hospitals; thus, patients often require long-distance transportation and experience frequent hospital transfers. Short hospital stays, transfers between hospitals and the patient's emotional state pose challenges to promoting patient participation.

DESIGN

A qualitative design with a narrative approach.

METHODS

Participants were recruited through purposive sampling. Eight men and two women were interviewed in 2016.

FINDINGS

Four themes related to the patients' experiences at the beginning, middle and end of the pathway were identified: (a) Lack of verbal communication in the acute phase; (b) trust in healthcare professionals and treatment; (c) lack of participation and coordination at discharge; and (d) shared decision-making in rehabilitation. The findings showed how the patients moved from a low level of patient participation in the acute phase to a high level of patient participation in the rehabilitation phase.

CONCLUSION

This is the first study to explore patient participation in different phases of the myocardial infarction pathway. We argue that individual plans for information and patient participation are important to improve patient involvement in an earlier stage of the pathway. Further research from a healthcare professional perspective can be valuable to understand this topic.

IMPACT

This study gives new insight that can be valuable for healthcare professionals in implementing patient participation throughout the pathway.

Rapid methods including network meta-analysis to produce evidence in clinical decision support: a decision analysis

BACKGROUND

Conducting systematic reviews is time-consuming but crucial to construct evidence-based patient decision aids, clinical practice guidelines and decision analyses. New methods might enable developers to produce a knowledge base more rapidly. However, trading off scientific rigour for speed when creating a knowledge base is controversial, and the consequences are insufficiently known. We developed and applied faster methods including systematic reviews and network meta-analyses, assessed their feasibility and compared them to a gold standard approach. We also assessed the feasibility of using decision analysis to perform this comparison.

METHODS

Long-term treatment in bipolar disorder was our testing field. We developed two new methods: an empirically based, rapid network meta-analysis (NMA) and an expert NMA, and conducted a patient survey. We applied these methods to collect effect estimates for evidence-based treatments on outcomes important to patients. The relative importance of outcomes was obtained from patients using a stated preference method. We used multi-criteria decision analysis to compare a gold standard NMA with the rapid NMA in terms of the ability of the gold standard NMA to change the ranking and expected values of treatments for individual patients.

RESULTS

Using rapid methods, it was feasible to identify evidence addressing outcomes important to patients. We found that replacing effect estimates from our rapid NMA with estimates from the gold standard NMA resulted in relatively small changes in the ranking and expected value of treatments. The rapid method sufficed to estimate the effects of nine out of ten options. To produce a ranking of treatments accurate for more than 95% of patients, it was necessary to supplement systematic with rapid methods and to use relative importance weights in the analysis. Integrating estimates of the outcome "treatment burden" had a larger impact on rankings than replacing rapid with gold standard methods. Using patients' importance weights only modestly affected results.

CONCLUSIONS

The transfer of knowledge to practice could benefit from faster systematic reviewing methods. The results in this preliminary assessment suggest that an improved rapid NMA approach might replace gold standard NMAs. Decision analysis could be used to compare evidence summarisation methods.

The development and feasibility of a personal health-optimization system for people with bipolar disorder

Background

People with bipolar disorder often experience ill health and have considerably reduced life expectancies. Suboptimal treatment is common and includes a lack of effective medicines, overtreatment, and non-adherence to medical interventions and lifestyle measures. E- and m-health applications support patients in optimizing their treatment but often exhibit conceptual and technical shortcomings. The objective of this work was to develop and test the usability of a system targeting suboptimal treatment and compare the service to other genres and strategies.

Methods

Based on the frameworks of shared decision-making, multi-criteria decision analysis, and single-subject research design, we interviewed potential users, reviewed research and current approaches, and created a first version using a rapid prototyping framework. We then iteratively improved and expanded the service based on formative usability testing with patients, healthcare providers, and laypeople from Norway, the UK, and Ukraine. The evidence-based health-optimization system was developed using systematic methods. The System Usability Scale and a questionnaire were administered in formative and summative tests. A comparison of the system to current standards for clinical practice guidelines and patient decision aids was performed.

Results

Seventy-eight potential users identified 82 issues. Driven by user feedback, the limited first version was developed into a more comprehensive system. The current version encompasses 21 integrated core features, supporting 6 health-optimization strategies. One crucial feature enables patients and clinicians to explore the likely value of treatments based on mathematical integration of self-reported and research data and the patient’s preferences. The mean ± SD (median) system usability score of the patient-oriented subsystem was 71 ± 18 (73). The mean ± SD (median) system usability score in the summative usability testing was 78 ± 18 (75), well above the norm score of 68. Feedback from the questionnaire was generally positive. Eighteen out of 23 components in the system are not required in international standards for patient decision aids and clinical practice guidelines.

Conclusion

We have developed the first evidence-based health-optimization system enabling patients, clinicians, and caregivers to collaborate in optimizing the patient’s health on a shared platform. User tests indicate that the feasibility of the system is acceptable.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0481-x) contains supplementary material, which is available to authorized users.

What matters to patients? A systematic review of preferences for medication-associated outcomes in mental disorders

OBJECTIVE

To investigate patients' preferences for outcomes associated with psychoactive medications.

SETTING/DESIGN

Systematic review of stated preference studies. No settings restrictions were applied.

PARTICIPANTS/ELIGIBILITY CRITERIA

We included studies containing quantitative data regarding the relative value adults with mental disorders place on treatment outcomes. Studies with high risk of bias were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

We restricted the scope of our review to preferences for outcomes, including the consequences from, attributes of, and health states associated with particular medications or medication classes, and process outcomes.

RESULTS

After reviewing 11 215 citations, 16 studies were included in the systematic review. These studies reported the stated preferences from patients with schizophrenia (n=9), depression (n=4), bipolar disorder (n=2) and attention deficit hyperactive disorder (n=1). The median sample size was 81. Side effects and symptom outcomes outnumbered functioning and process outcomes. Severe disease and hospitalisation were reported to be least desirable. Patients with schizophrenia tended to value disease states as higher and side effects as lower, compared to other stakeholder groups. In depression, the ability to cope with activities was found to be more important than a depressed mood, per se. Patient preferences could not consistently be predicted from demographic or disease variables. Only a limited number of potentially important outcomes had been investigated. Benefits to patients were not part of the purpose in 9 of the 16 studies, and in 10 studies patients were not involved when the outcomes to present were selected.

CONCLUSIONS

Insufficient evidence exists on the relative value patients with mental disorders place on medication-associated outcomes. To increase patient-centredness in decisions involving psychoactive drugs, further research-with outcomes elicited from patients, and for a larger number of conditions-should be undertaken.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42013005685.

Examining the use of an open digital health library for professionals

Background

The Norwegian Electronic Health Library (The Library) is a website for health personnel. Most of the content is also open to the public. Usage statistics have risen sharply in the years 2010-2013.

Objective

We wanted to find out whether the rise was caused by health personnel, the general public, or other factors.

Methods

Since we lacked direct information, we had to use proxy data to shed light on our questions. We applied mixed methods (database of registered users, user survey, usage statistics, and statistics from suppliers), and triangulated between them.

Results

Health personnel were our largest user group, but The Library was also accessed by students, patients, and other groups. Content in Norwegian was preferred to English language content. Concise, practical information was preferred to more comprehensive information. Patient leaflets were the most popular information type. Mobile phone visits differed from personal computer visits both in terms of time of day and what kind of information was viewed.

Conclusions

The Library was used mostly by health personnel, as intended, but our data are inconclusive regarding a possible change in user groups. There was a large degree of consistency in results when using different investigation methods. The survey points toward health personnel being the largest user group, and the usage statistics show that patient leaflets are the most popular content, being viewed by both health personnel and patients.

Tolker leserne forskningsresultater i tråd med forfatternes intensjoner?

Bakgrunn: Forskningsresultater kan formidles på ulike måter, både gjennom tall, tekst og kombinasjoner av disse. Utover et effektestimat er det i klinisk forskning også ønskelig å si noe om hvor sikker man er på resultatet, for eksempel ved å oppgi konfidensintervall og gjøre en vurdering av kvaliteten på dokumentasjonen. Vår hensikt med denne undersøkelsen var å få en indikasjon på hvordan våre måter å formidle resultater på, blir oppfattet blant våre lesere.Materiale og metoder: Vi hentet 17 resultatformuleringer fra Kunnskapssenterets rapporter og utførte en nettbasert spørreundersøkelse. Leserne skulle svare på hva de trodde forfatterne forsøkte å formidle. Åpen invitasjon til å delta i undersøkelsen ble sendt som del av Kunnskapssenterets nyhetsbrev til over 3 000 epostmottakere.Resultater: Vi mottok 173 utfylte spørreskjemaer. For samtlige formuleringer var det flertall (mer enn 50 %) for den tolkningen som etter vår vurdering var mest i tråd med forfatternes intensjoner, men andelen varierte fra 54,1 % til 93,4 %.Konklusjon: Respondentenes tolkninger av Kunnskapssenterets resultatformuleringer samsvarte i hovedsak med intensjonene. Variasjonen i tolkning viste imidlertid at vi må fortsette arbeidet med å finne lettfattelige, men likevel tilstrekkelig presise formuleringer.Ringerike T, Glenton C, Vist GE, Jamtvedt G, Nylenna M. Do readers interpret research results in line with the authors' intentions? Nor J Epidemiol 2013; 23 (2): 231-236.ENGLISH SUMMARYBackground: Research results can be communicated in various ways, for instance through numbers, words, and combinations of these. Within clinical research, in addition to presenting the estimate of effect, it is also desirable to say something about our confidence in this result, for example by presenting a confidence interval and making an assessment of the quality of the evidence. The purpose of this study was to assess how the ways in which we communicate results are perceived by our readers.Material and methods: We selected 17 results-statements taken from reports published by the Norwegian Knowledge Centre for the Health Services, and conducted an online survey. Participants were asked to respond to what they thought the writers were trying to convey. An open invitation to participate in the survey was sent with the biweekly newsletter for the Norwegian Knowledge Centre for the Health Services, which is delivered to over 3,000 e-mail recipients.Results: We received 173 completed questionnaires. For all statements, the majority (over 50 %) chose the interpretation that in our assessment was most in line with the authors’ intentions, but the proportion varied from 54.1 % to 93.4 %.Conclusion: Respondents’ interpretations of the Knowledge Centre’s statements of results corresponded largely with the authors’ intentions. The variation in interpretations shows that we must continue to work to find formulations that are easy to understand, yet sufficiently precise.