Remuneration and organization in general practice: Three essays on doctors' preferences

The need for recruiting and retaining general practitioners (GPs) is expected to increase substantially in the next years, both because of an ageing population and a reform suggesting to shift more resources to primary care. This will not only reinforce the current challenge of recruitment and retention in rural areas, but it may also make it more difficult to recruit and retain GPs in urban areas. The evidence for the effectiveness of various incentives schemes, which can be specifically implemented to boost recruitment to general practice, is generally considered to be poor. The overarching objective of this thesis is to improve the current understanding of what policy makers could do to boost recruitment and retention of GPs. More specifically, this thesis aims to identify doctors’ preferences for various pecuniary and non-pecuniary job characteristics. Structured questionnaires, including discrete choice experiments (DCEs), were used to collect data from young doctors (i.e. medical students and interns in 2010) and GPs (those registered in the HELFO database in 2012). The results suggest that joint policy programs containing several non-pecuniary incentives (e.g. improved opportunity for professional development and control over working hours), could contribute to solve the current issue of getting doctors to rural areas. Increased income, from the current levels in Norway, appears to have limited effects. This is because doctors’ value income increases beyond a reference level, which has already been achieved, to a limited extent. Furthermore, the results suggest that an increasing proportion of doctors would prefer salaried contracts rather than private practice (i.e. the current default contract for GPs). This applies particularly among younger female doctors

Decision Making for Childhood Vaccinations : an Economic Approach to Explaining Demand for Vaccinations in Mphuka and Bwumve Traditional Authorites, Malawi

Background: There are large variations in vaccination coverage, not only between high and low-income countries but also across low income countries and within low income countries. The reasons behind these variations are only sketchily understood. In particular, the current understanding of demand for childhood vaccinations is limited. Due to inadequate vaccination coverage more than one million children die annually from vaccine preventable diseases. Objective: The study set out to examine demand for childhood vaccinations from an economic perspective: to identify caretakers` perceptions of potential costs and benefits of vaccinating a child, and to examine the association between these perceptions and caretakers` decision making for childhood vaccination. Furthermore the study seeks to identify variables associated with caretakers` perception of benefits of vaccinating a child. Methods: The study was cross sectional, used structured questionnaires and employed a two stage cluster sampling technique. Respondents were caretakers of children at the age 18 - 59 months, in total 635 respondents were included in the study. The study was conducted in two traditional authorities in Thyolo district, Malawi. Descriptive statistics were used to describe the variables of study. Logistic regression analyses (univariate and multivariate) were conducted to measure the association between predicted explanatory variables from economic theory and decision making for childhood vaccination, and to examine the relationship between predicted explanatory variables and perceived benefits. Results: 96.1 percent of the respondents reported to fully have vaccinated their youngest child in the age 18 – 59 months for all routine EPI vaccinations. The large majority of caretakers scored the measured benefits of vaccinating a child to be high, while they to a large extent were divided in their perceptions of costs. A large share of caretakers had to travel substantial distances to vaccinate their children. Incorrect knowledge of vaccination schedule (OR = 2.95 (CI 0.97 – 8.99) P= 0, 06), fear for severity of side effects (OR= 3.8 (CI 0.89-16.17) P= 0.07), distrust in information on vaccination (OR=27.55 (CI 5- 149) P=0, 00) and giving birth at home (OR=2.52 (CI = 1.18-5.39) P=0.02) were found to be determinants for vaccination default (not having fully vaccinated youngest eligible child for all EPI routine vaccinations) in the univariate analysis. Not any of these determinants remained significant in the multivariate regression analysis (p-value < 0.05). Distrust in received information (OR= 27.52 CI (6 – 131) P=0.00) and being aware of less than two side effects (OR= 2.32 (CI 1.15- 4.68) P=0.019) were found to be determinants for limited perceived benefits (scoring the preventive effect of vaccination as limited) in the multivariate analysis. Discussion and conclusion: The study documents and points to the possibility and necessity of achieving high vaccination coverage in areas where many caretakers need to travel long distances to reach vaccinations, and where a large number of caretakers perceive the traveling and waiting time as long. The study suggests that high level of trust in information and in vaccinators may be an essential explanatory factor; in the way that trust facilitates positive perceived benefits which again make caretakers seek childhood vaccinations even though there are considerable costs involved. The study, however, does not provide the final explanation for why caretakers in the study area vaccinate their children, and nevertheless for why caretakers vaccinate or do not vaccinate their children in other areas. More emphasis should be devoted to demand for childhood vaccinations, both in research and in policy making

General practitioners’ altered preferences for private practice vs. salaried positions: a consequence of proposed policy regulations?

Background: General practitioners (GPs) in most high-income countries have a history of being independent private providers with much autonomy. While GPs remain private providers, their autonomous position appears to be challenged by increased policy regulations. This paper examines the extent to which GPs’ preferences for private practice vs. salaried contracts changed in a period where a new health care reform, involving proposed increased regulations of the GPs, was introduced. Methods: We use data collected from Norwegian GPs through structured online questionnaires in December 2009 and May 2012. Results: We find that the proportion of GPs who prefer private practice (i.e. the default contract for GPs in Norway) decreases from 52% to 36% in the period from 2009 to 2012. While 67% of the GPs who worked in private practice preferred this type of contract in 2009, the proportion had dropped by 20 percentage points in 2012. Salaried contracts are preferred by GPs who are young, work in a small municipality, have more patients listed than they prefer, work more hours per week than they prefer, have relatively low income or few patients listed. Conclusion: We find that GPs’ preferences for private practice vs. salaried positions have changed substantially in the last few years, with a significant shift towards salaried contracts. With the proportions of GPs remaining fairly similar across private practice and salaried positions, there is an increasing discrepancy between GPs’ current contract and their preferred one

Innovations in use of registry data (INOREG)

Abstract: In recent years there have been several political initiatives in Norway, requiring more research into how multimorbidity and health care pathways in the municipality affect outcomes such as work participation, hospital admissions, disability and quality of life for patients with chronic diseases. Most of the care is provided outside hospitals and has been difficult to capture in large, registry-based studies. Focusing on two important groups, patients with chronic obstructive pulmonary disease (COPD) and musculoskeletal disorders (MSD), the INOREG project aims to reduce these knowledge gaps. In the paper we present 1) the data that are used in the project, 2) the construction of samples, variables and possible methods for analysis and 3) an example on how the data and methods will be applied.  The project database is constructed from a novel linkage of national health and welfare registries.  The data cover social, primary and specialized care for all COPD and MSD patients in Norway, long-term care data from Oslo and Trondheim municipalities and functioning and quality of life for ca. 2,700 patients treated at physiotherapy clinics in the FYSIOPRIM project. This enables construction of care pathways and outcomes at the individual level from 2008 through 2019. The project will fill knowledge gaps regarding the patterns of care at different levels in the health care system, and the association to outcomes for chronic patient groups. If the project is successful, it will provide improved insight on how to further develop provision and coordination of services to the decision makers, and ideally reduce inequalities in health

Combination of health care service use and the relation to demographic and socioeconomic factors for patients with musculoskeletal disorders: a descriptive cohort study

Abstract Background Patients with musculoskeletal disorders (MSDs) access health care in different ways. Despite the high prevalence and significant costs, we know little about the different ways patients use health care. We aim to fill this gap by identifying which combinations of health care services patients use for new MSDs, and its relation to clinical characteristics, demographic and socioeconomic factors, long-term use and costs, and discuss what the implications of this variation are. Methods The study combines Norwegian registers on health care use, diagnoses, comorbidities, demographic and socioeconomic factors. Patients (≥ 18 years) are included by their first health consultation for MSD in 2013–2015. Latent class analysis (LCA) with count data of first year consultations for General Practitioners (GPs), hospital consultants, physiotherapists and chiropractors are used to identify combinations of health care use. Long-term high-cost patients are defined as total cost year 1–5 above 95th percentile (≥ 3 744€). Results We identified seven latent classes: 1: GP, low use; 2: GP, high use; 3: GP and hospital; 4: GP and physiotherapy, low use; 5: GP, hospital and physiotherapy, high use; 6: Chiropractor, low use; 7: GP and chiropractor, high use. Median first year health care contacts varied between classes from 1–30 and costs from 20€-838€. Eighty-seven percent belonged to class 1, 4 or 6, characterised by few consultations and treatment in primary care. Classes with high first year use were characterised by higher age, lower education and more comorbidities and were overrepresented among the long-term high-cost users. Conclusion There was a large variation in first year health care service use, and we identified seven latent classes based on frequency of consultations. A small proportion of patients accounted for a high proportion of total resource use. This can indicate the potential for more efficient resource use. However, the effect of demographic and socioeconomic variables for determining combinations of service use can be interpreted as the health care system transforming unobserved patient needs into variations in use. These findings contribute to the understanding of clinical pathways and can help in the planning of future care, reduction in disparities and improvement in health outcomes for patients with MSDs

Associations between outpatient care and later hospital admissions for patients with chronic obstructive pulmonary disease - a registry study from Norway

Abstract Background Although chronic obstructive pulmonary disease (COPD) admissions put a substantial burden on hospitals, most of the patients’ contacts with health services are in outpatient care. Traditionally, outpatient care has been difficult to capture in population-based samples. In this study we describe outpatient service use in COPD patients and assess associations between outpatient care (contact frequency and specific factors) and next-year COPD hospital admissions or 90-day readmissions. Methods Patients over 40 years of age residing in Oslo or Trondheim at the time of contact in the period 2009–2018 were identified from the Norwegian Patient Registry (in- and outpatient hospital contacts, rehabilitation) and the KUHR registry (contacts with GPs, contract specialists and physiotherapists). These were linked to the Regular General Practitioner registry (characteristics of the GP practice), long-term care data (home and institutional care, need for assistance), socioeconomic and–demographic data from Statistics Norway and the Cause of Death registry. Negative binomial models were applied to study associations between combinations of outpatient care, specific care factors and next-year COPD hospital admissions and 90-day readmissions. The sample consisted of 24,074 individuals. Results A large variation in the frequency and combination of outpatient service use for respiratory diagnoses (GP, emergency room, physiotherapy, contract specialist and outpatient hospital contacts) was apparent. GP and outpatient hospital contact frequency were strongly associated to an increased number of next-year hospital admissions (1.2–3.2 times higher by increasing GP frequency when no outpatient hospital contacts, 2.4-5 times higher in combination with outpatient hospital contacts). Adjusted for healthcare use, comorbidities and sociodemographics, outpatient care factors associated with lower numbers of next-year hospitalisations were fees indicating interaction between providers (7% reduction), spirometry with GP or specialist (7%), continuity of care with GP (15%), and GP follow-up (8%) or rehabilitation (18%) within 30 days vs. later following any current year hospitalisations. For 90-day readmissions results were less evident, and most variables were non-significant. Conclusion As increased use of outpatient care was strongly associated with future hospitalisations, this further stresses the need for good communication between providers when coordinating care for COPD patients. The results indicated possible benefits of care continuity within and interaction between providers

Evaluering av handlingsplan for allmennlegetjenesten 2020–2024: Evalueringsrapport I

Dette er første evalueringsrapport for følgeevalueringen av Handlingsplan for allmennlegetjenesten 2020-2024. De samlede funnene i evalueringen, basert på analyser av registerdata, spørreskjemaundersøkelser og intervjuundersøkelser, tyder på at det fortsatt er betydelige rekrutteringsutfordringer og behov for å utvikle fastlegeordningen. Tiltakene i handlingsplanen synes å være relevante, og flere av tiltakene er fortsatt under utvikling. I det videre arbeidet med handlingsplanen og en bærekraftig og fremtidsrettet allmennlegetjeneste, er det behov for å tilrettelegge for bedre arbeidsvilkår for eksisterende fastleger, og få flere leger inn i fastlegeordningen

Evaluering av handlingsplan for allmennlegetjenesten 2020–2024: Evalueringsrapport I

Dette er første evalueringsrapport for følgeevalueringen av Handlingsplan for allmennlegetjenesten 2020-2024. De samlede funnene i evalueringen, basert på analyser av registerdata, spørreskjemaundersøkelser og intervjuundersøkelser, tyder på at det fortsatt er betydelige rekrutteringsutfordringer og behov for å utvikle fastlegeordningen. Tiltakene i handlingsplanen synes å være relevante, og flere av tiltakene er fortsatt under utvikling. I det videre arbeidet med handlingsplanen og en bærekraftig og fremtidsrettet allmennlegetjeneste, er det behov for å tilrettelegge for bedre arbeidsvilkår for eksisterende fastleger, og få flere leger inn i fastlegeordningen