Do list size and remuneration affect GPs' decisions about how they provide consultations?

Background: Doctors' professional behaviour is influenced by the way they are paid. When GPs are paid per item, i.e., on a fee-for-service basis (FFS), there is a clear relationship between workload and income: more work means more money. In the case of capitation based payment, workload is not directly linked to income since the fees per patient are fixed. In this study list size was considered as an indicator for workload and we investigated how list size and remuneration affect GP decisions about how they provide consultations. The main objectives of this study were to investigate a) how list size is related to consultation length, waiting time to get an appointment, and the likelihood that GPs conduct home visits and b) to what extent the relationships between list size and these three variables are affected by remuneration. Methods: List size was used because this is an important determinant of objective workload. List size was corrected for number of older patients and patients who lived in deprived areas. We focussed on three dependent variables that we expected to be related to remuneration and list size: consultation length; waiting time to get an appointment; and home visits. Data were derived from the second Dutch National Survey of General Practice (DNSGP-2), carried out between 2000 and 2002. The data were collected using electronic medical records, videotaped consultations and postal surveys. Multilevel regression analyses were performed to assess the hypothesized relationships. Results: Our results indicate that list size is negatively related to consultation length, especially among GPs with relatively large lists. A correlation between list size and waiting time to get an appointment, and a correlation between list size and the likelihood of a home visit were only found for GPs with small practices. These correlations are modified by the proportion of patients for whom GPs receive capitation fees. Waiting times to get an appointment tend to become shorter with increasing patient lists when there is a larger capitation percentage. The likelihood that GPs will conduct home visit rises with increasing patient lists when the capitation percentage is small. Conclusion: Remuneration appears to affect GPs' decisions about how they provide consultations, especially among GPs with relatively small patient lists. This role is, however, small compared to other factors such as patient characteristics.

Measures of quality, costs and equity in primary health care instruments developed to analyse and compare primary care in 35 countries

ABSTRACT Background The Quality and Costs of Primary Care in Europe (QUALICOPC) study aims to analyse and compare how primary health care systems in 35 countries perform in terms of quality, costs and equity. This article answers the question ‘how can the organisation and delivery of primary health care and its outcomes be measured through surveys of general practitioners (GPs) and patients?’ It will also deal with the process of pooling questions and the subsequent development and application of exclusion criteria to arrive a set of appropriate questions for a broad international comparative study. Methods The development of the questionnaires consisted of four phases: a search for existing validated questionnaires, the classification and selection of relevant questions, shortening of the questionnaires in three consensus rounds and the pilot survey. Consensus was reached on the basis of exclusion criteria (e.g. the applicability for international comparison). based on the pilot survey comprehensibility increased and the number of questions was further restricted, as the questionnaires were too long. Results Four questionnaires were developed: one for GPs, one for patients about their experiences with their GP, another for patients about what they consider important and a practice questionnaire. The GP questionnaire mainly focused on the structural aspects, e.g. economic conditions, and care processes, e.g. comprehensiveness of services of primary care. The Patient Experiences questionnaire focused on the care processes and outcomes, e.g. how do patients experience access to care? The questionnaire about what patients consider important was complementary to the experiences questionnaire, as it enabled weighing the answers from the latter. Finally, the practice questionnaire included questions on practice characteristics. Discussion The QUALICOPC researchers have developed four questionnaires to characterise the organisation and delivery of primary health care and to compare and analyse the outcomes. Data collected with these instruments will not only allow us to show in detail the variation in process and outcomes of primary health care, but also to explain the differences from features of the (primary) health care system

Under the spell: The motivations of adult Australians to learn Italian in continuing education settings

This study examines the motivations of adult Australians of non-Italian origin to learn Italian in continuing educational contexts in Sydney. Despite the fact that Italian is one of the most taught languages in Australia, very little research has been conducted in this area. The theoretical framework of this investigation combines second language (L2) learning motivation paradigms with poststructuralist perspectives, applying concepts such as integrativeness, ideal L2 self, language investment, and identity negotiation. The research was conducted on a group of adult Australians enrolled in courses of Italian at beginner, intermediate and advanced levels, using a mixed methods approach. Through the triangulation of the quantitative and qualitative data sets, the motivational factors which shape the interest of the study’s participants to learn Italian are explored in depth. The findings show that the main reasons to learn Italian are cultural, and are linked to various aspects of the reality of Italy, such as its historical heritage, artistic production, gastronomic tradition and lifestyle opportunities. The presence of a large and well-established Italian migrant community in Sydney plays a pivotal role in attracting learners to Italian culture. Encounters with Italians and Italian culture both in Italy and Australia ignite participants’ willingness to become closer to an Italian community and, to some extent, to identify with it, triggering dynamics of identity (re)construction. These findings confirm the socially and culturally situated nature of second language learning, relating learners’ motivations to sentiments of attachment and belonging and to processes of identity development