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3PECULIARITIES OF WORK IN GENERAL PRACTITIONER'S OFFICE AS SEEN BY PHYSICIANS
(RESULTS OF QUESTIONNAIRES)
Abstract
Questionnaires filled in by general practitioners (GP) working at the General Practitioners' Office (GPO) concerning the results of their work from 2008 to 2010 have been reviewed by 419 indices, which allowed assessing the effectiveness of their work in the republic as a whole. The main direction in the GPO work is therapeutic. It should be noted that day hospital beds are poorly occupied, with low level of hospitalization and disease registration (or visits for medical advice) and increased mortality rate per 100 cases of disease, which necessitates deep analysis in every region followed by organizational and legislative decision making. Home mortality from the main causes is tending to decrease; during 2008-2010, it changed from 81% to 66%. Certain conclusions regarding the tendencies in the practical activity of GPOs have been made for health care managers.
Keywords
general practitioner's office, general practitioner, morbidity, mortality, level of hospitalization, day hospital
AUTHORS
Tatiana Matveichik
PhD, Associate Professor Department of Public Health and Healthcare Belarusian Medical Academy of Post-Graduate Education
Minsk, Belorussia matveichik51 @rambler.ru
Inna Savina
Senior Research Fellow Republican Scientific and Practical Center
for Medical Technologies, Informatics, Management and Economics of Healthcare Minsk, Belorussia
Svetlana Antipova
PhD, Associate Professor, Republican Scientific and Practical Center
for Medical Technologies, Informatics, Management and Economics of Healthcare Minsk, Belorussia
Irina Bryleva
Senior Teacher Department of Public Health and Healthcare Belarusian Medical Academy of Post-Graduate Education Minsk, Belorussia
The work of the General Practitioner's Office (GPO) attracts increased attention of health care managers and population, because it combines the main requirements concerning accessibility, continuity and quality of medical care. In order to obtain information about the GPs work in GPO, including the data not envisaged by the official statistics, a questionnaire was developed and sent to GPOs of some regions. The authors deliberately preserve anonymity of these regions so that to exclude unnecessary questions that may arise from regional health authorities. The GPs answers were systematized, tabulated and analyzed.
Materials and methods
Ten filled in questionnaires were summarized by 127 items; among them, 76 for the period of 2008-2010 with several parameters for each year. In general, 419 indices were analyzed in each questionnaire.
Every GPO served from 775 to 4329 people within a radius of 5 -30 km. The attached feldsher - obstetric stations (FOS) had 7 GPOs; out of them, one GPO had 3 FOSs and a
nursing hospital; 2 GPOs had 2 FOSs and 4 GPOs had 1 FOS each. The distance between FOS and GPO ranged from 3,5 to 17 km, and that between GPO and central district medical establishment was 12 - 55 km. Medical coverage of every FOS ranged from 189 to 1233 people.
In the structure of medical coverage, children of 0-17 years old made 2-21,7%; working age persons - 44,2-62,6%, and people older those who are able to work - 20,653,5%. Inverse correlation between the number of children and that of retired people was found. At the territory of medical coverage of three GPOs, there are industrial enterprises with the number of workers exceeding 200. At the territory of nine GPOs, there are agricultural enterprises with the number of workers ranging from 53 to 765. All GPOs have schools and preschool institutions with various numbers of pupils and preschool children at the territory of their service.
General practitioner's offices were staffed with physicians, on average, by 76,2%, with nurses by 82,7%; incomplete staffing was noted (more than two available posts of physicians). Feldsher-obstetric stations had a full staff of physicians. All GPOs were provided with vehicles (one car per each GPO).
Results and discussion
According to the performed analysis, the number of referrals for medical advice (per one citizen) to the GPO and FOS varies as seen by the number of calls to the ambulance and emergency medical service. These calls are served by the district ambulance service as well as by the GPO personnel. The relationship between the number of referrals to the GPO or FOS and the radius of the served area was not possible to find. The frequency of visits of GPO physicians to every FOS varied from 2 to 4 visits a month.
TABLE 1. SOME CHARACTERISTICS OF GPOS WORK DURING 2008-2010
Items GPO №
№ 1 № 2 № 3 № 4 № 5 № 6 № 7 № 8 № 9 № 10
Aver./year number of referrals - 1,2 6,6 4,3 10,4 5,5 6,9 6,7 - -
to FOS per 1citizen
Aver./year number of referrals 5,4 3,8 3,9 5,1 5,1 4,1 6,1 6,0 3,9 8,2
to GPO per 1citizen
Aver./year calls to ambulance and
emerg. 1270 2795 1181 1502 2109 1121 560 3674 559 1735
med.service in GPO
area
Number of GPO
nurses' visits 7403 3129 1918 9036 2191 4324 1245 6542 2277 1436
per year
Among them: children % 26,4 16,5 19,2 15,8 19,4 31,3 5,0 43,1 51,5 0,0
Home visits % 11,6 37,4 51,3 21,4 51,0 13,6 66,6 45,5 70,6 41,9
Among them: children % 31,9 72,4 54,8 31,4 26,0 50,8 18,6 94,6 54,5 0,0
Based on the results of questionnaires, high percentage of pregnant women and children are covered by home nursing. Immunoprophylaxis and fluorographic examinations were timely performed.
The number of beds in day hospitals (DH) in GPOs depends on the number of population living in the area of medical coverage and makes from 2 to 8 beds. Average stay in DH did not exceed 8 days. In 50% of cases, the beds were occupied fairly well; in
the other 50% of cases, this index was smaller than 300 days. The main diseases of patients treated in DHs were indicated in the questionnaire. These were ischemic heart disease, atherosclerotic cardiosclerosis, arterial hypertension, chronic obstructive pulmonary disease, acute impairment of cerebral circulation, acute bronchitis, lumbago, neurologic manifestations of spinal osteochondrosis, vertebrogenic lumbalgia, chronic gastritis, dorsalgia, tracheobronchitis, obliterating atherosclerosis, bronchial asthma, polyneuropathy, placenta previa and others.
Home care is practiced by 8 out of 10 GPOs, its average duration being about 8, 6 days. In this case, the main diseases included chronic obstructive pulmonary disease, acute impairment of cerebral circulation, ischemic heart disease, arterial hypertension, discirculatory encephalopathy, lumbalgia, thoracolumbalgia, acute bronchitis, atherosclerotic cardiosclerosis, neurologic manifestations of spinal osteochondrosis, oncologic diseases and others.
All surgeries performed in GPOs are given in 4 questionnaires, their volume is minimal.
Among the population within the medical coverage of GPOs, there are cases of tuberculosis (annually detected including).
As seen from Table 1, nurses receive a considerable volume of GPO patients, children including. The main functions and forms of activity of medical nurses working at GPOs were listed in 6 out of 10 GPOs. This work includes immunization, home nursing, prophylactic examination of schoolchildren. Besides, the nurses keep medical records, store the remedies, write out prescriptions; visit children, disabled people, war veterans and lonely people older 80 years at home. They also help GPs to receive patients, make numerous injections, blood tests for cholesterol, etc.
During 2008-2010, patients were mostly received by therapists (50,5-90,7%). On the average, therapeutic profile amounted to 71,2; neurologic - 7,1; laryngological - 3,6; surgical - 3,3 and ophthalmologic - 2,7% of cases. Visits to an obstetrician or a gynecologist were recorded by 6 GPO physicians out of 10. In the GPO structure, they ranged from 0,2 to 3,1% per year and depended on the age of the population in the given area.
The attitude of patients to healthy life-style was assessed arbitrary (smoking, alcohol consumption, healthy nutrition, etc) and presented in a laconic form in 4 questionnaires, which allowed concluding that healthy way of life is not popular among the adult population. These findings were also confirmed by other studies (Matveichik, 2011).
A considerable work on promoting healthy life-style conducted by GPO medical workers was noted in questionnaires. It included lectures, discussions, medical bulletins, etc. Technical means for transmitting information are not available in GPOs.
Health status of the population covered by GPOs was assessed for 3 districts of the republic according to proportion of groups of dispensary observation in 2010 (Table 2). Spread in data concerning the groups of dispensary observation among the rural population may be accounted not only for the differences in health status but mostly for some peculiarities in the assessment and registration of these data.
A considerable variability of both primary and accumulated morbidity has been found. In 2010, average morbidity for all GPOs was lower than similar average republican data. To a certain degree, it may be due to low referral of several categories of citizens to GPOs possibly because of territorial and transport problems and a large distance from the GPO (from 5 to 30 km) in rural areas.
TABLE 2. HEALTH ESTIMATES OF THE POPULATION BY THE PROPORTION OF GROUPS OF DISPENSARY OBSERVATION AMONG EXAMINED ADULT GPO PATIENTS FROM DISTRICTS A, B, AND C AS COMPARED WITH REGIONS OF THESE DISTRICTS AND THE REPUBLIC OF BELARUS AS A WHOLE DURING 2010 ACCORDING TO STATISTICAL REPORTS (%)
Region D 1 D 2 D 3
Retired Work ing age Among them Retired Work ing age Among them Retired Work ing age Among them
M F M F M F
GPO of district A. 1,0 19,4 17,9 20,9 38,6 55,6 58,8 52,4 60,3 25 23,3 26,7
Region of district A. 5,2 23,4 22,2 24,7 25,5 38,5 40,2 36,7 69,6 38,1 37,6 38,6
GPO of district B. 4,2 23,4 24,2 22,8 24,2 38,9 36,2 41 71,6 37,7 39,6 36
GPO of district C. 0 44,3 41,6 47,3 0,7 30,2 31,6 29 99,3 25,5 26,8 24
Region of districts B. and C. 2,3 19,3 18,4 20,3 4,4 38,1 38,4 38 93,3 42,6 43,2 42
Republic of Belarus 4,5 22,1 21,4 22,7 19,0 39,2 39,9 38,4 76,5 38,7 38,7 38,9
Variability in the morbidity and mortality rates for the population covered by GPOs is given in Table 3. The comparison between the accumulated morbidity and mortality of the population provided by GPO physicians in their questionnaires shows a number of morbidity cases per one case of death, which is presented in Table 3 as the morbidity / mortality ratios. The greater is this ratio, the better is this index. The inverse index, the mortality / morbidity ratio, presents the number of deaths per 100 cases of morbidity. This index estimated for each disease characterizes the lethality. The given data show the need for more accurate registration when assessing the situation in every medical district.
TABLE 3. ACCUMULATED MORBIDITY AND MORTALITY OF THE ADULT GPO POPULATION (ALL CLASSES OF DISEASES, MEAN VALUES DURING 2008-2010)
Indices GPO №
№ 1 № 2 № 3 № 4 № 5 №6 №7 №8 № 9 № 10 Mean
Adult morbidity per 1000 1085,0 1029,4 1539,0 725,2 498,3 625,5 648,2 700,9 628,4 1034,1 851,4
Adult mortality per 1000 20,4 14,4 11,1 20,7 24,9 19,1 22,4 26,6 23,3 28,3 20,5
Adults in general morb./mort. 54 72 141 36 20 33 29 26 27 38 42
Adult mortality per 100 cases of morb. (%) 1,87 1,40 0,72 2,86 5,07 3,06 3,48 3,84 3,70 2,83 2,42
Work. age population morb./mort 15 H/fl 438 53 100 300 142 95 194 228 90
Work. age population mortality per 100 cases of morbidity (%) 7,19 0,00 0,26 2,08 1,37 0,41 0,76 1,06 0,58 0,47 1,12
Retired morb./mort. 3 0 25 30 14 30 15 13 16 25 17
Retired mortality per 100 cases of morbidity (%) 33,27 0,00 3,95 3,50 7,47 3,34 16,13 7,67 6,51 4,11 6,10
The comparison between general morbidity for all classes of diseases and the mortality from all the causes can serve to a certain degree as an estimate for the quality of medical care provided to the population and for the possibility of its receiving. In this case, it should be taken into account that mortality covers the people who died and the morbidity shows the recorded cases of diseases. Therefore, the general morbidity / mortality ratio shows the number of cases of diseases per 1 case of death. The number of deaths per 100 of recorded diseases can also give an estimate for many aspects of organizing and receiving medical care. Assessment of these indices for various medical establishments and regions in dynamics may be helpful when planning medical and social events.
The data summarized by 10 GPOs demonstrate a higher rate of deaths per 100 cases of morbidity in the adult population in 2008-2010. In 2010, these indices amount to 2,7; 2,2; 2,4, accordingly, with average republican index being 1,8. In working age persons, they were 1,0; 1,3 and 1,1 (average republican index 0,8); in the retired population - 7,0; 5,4 and 5,9. For rural population, the number of deaths per 100 cases of morbidity is inversely proportional. This is the so called index of reversibility of health impairment, which can possibly be a quantitative estimate for the influence of medical care on the mortality rate under the conditions of available economic resources. This index in dynamics can serve as one of the indicators for the quality of the GPO work and of the whole system of primary medical care. In general, the mortality of the rural population covered by GPOs is lower than that in the republic, working age persons and older population including (Table 4). The mortality at the age of 0-17 years is rare. The mortality of people older those who are able to work from "senility" is higher among the population covered by GPOs. Though chronic diseases are widely spread in this group of population (D3 group of dispensary observation), some questions may arise concerning the reliability of data demonstrating the causes of death as indicated in death certificates, especially taking into account that most common, these are deaths occurring at home.
The data from the questionnaires allow obtaining estimates about home mortality, though this information is not envisaged by official statistics. This index is rather high among the population covered by GPOs service but it tends to decrease: during the three years under study, it decreased from 81% in 2008 to 66,1% in 2010. In general, cases of death occurring at home were registered in 79,3% of all cases of death. Among those who died from these diseases, 85,2% died from neoplasms, 73,0% from circulatory diseases, 25% from respiratory diseases, 27,3% from digestive diseases and 81,8 % from "senility" (Table 4).
TABLE 4. MORTALITY AMONG GPO POPULATION (SUMMED UP BY 10 GPOS, AVERAGE DURING 2008-2010)
Causes of death Home mor-tality% Mortality per 1000 Retir./ working ratio In the republic of belarus 2010, rural population
Total 017 Y. Old Retir ed Wor king age Mortality per 1000 Work. Age Reti -red Retired /working ratio
Neoplasms 85,2 2,1 0,05 5,1 0,9 5,7 2,3 1,2 5,5 4,6
Circulat. diseases 73,0 8,4 26,0 1,4 19,0 13,0 2,6 38,0 14,6
Respirat. Diseases 25,0 0,2 0,4 0,2 2,4 0,3 1,7 5,7
Digest. diseases 27,3 0,3 0,05 0,6 0,2 2,4 0,6 0,5 1,2 2,4
"Senility" 81,8 3,9 13,3 12,7
All causes 79,3 17,3 0,8 49,4 4,8 10,2 24,4 9,0 63,7 7,1
In 2010, the mortality rate among rural working age population within the medical coverage of 10 GPOs was lower than average republican indices (5,7 per 1000 vs. 9,0). In the same year, mortality of GPO patients older those who are able to work was 1,3 times lower than average republican data (49,3 vs. 63,7 per 1000). Mortality of children aged 017 years was within the average republican levels (0,7-0,8 per 1000). Mortality rate among the rural population in both working age and retired people was lower than average republican data. These were the deaths from circulatory, respiratory and digestive diseases. Mortality from neoplasms in working age persons was lower as compared with average republican data; while in the retired population, it was higher.
It was not easy to give the estimates of patients' disability, because the presented data were not correct in a number of cases. However, according to the available information from some GPOs, these data do not exceed average republican statistics.
According to the data from GPOs, the level of hospitalization among the served population is low; in some questionnaires, it is noted as very low, which is unlikely to be true. It can result from both incomplete registrations of cases of hospitalization and due to the existing instruction on limitation of hospital admissions aimed optimal use of the expensive hospital beds when day hospital beds are available.
Based on the results of summarized questionnaires from 10 GPOs, it is possible to realize the level and the role of GP in solving family problems among the population of medical coverage, such as family planning and preservation of reproductive health. In general, every GPO physician records the number, age and sex distribution of the population and individuals working at various enterprises in the area of his/her medical coverage. Eight out of ten GPs responded to the question concerning the number of patients (men and women) who referred to GPOs for this type of medical care during a year: the number of such consultations varied from 78 to 14-15 and 3 per year. The question about the events on family planning and preservation of reproductive health (among schoolchildren including) was answered by 6 out of 10 GPs. These events included lectures and discussions about the harmful effect of alcohol and smoking, AIDS prophylaxis, methods of contraception, as well as those about family planning and healthy life style. Such events were conducted from 1 to 9 times a month. The information about the use of contraceptives, interrupted pregnancies and pregnancies in females under 18 years old was available from 8 GPOs.
Eight GPs noted that they possess necessary knowledge and practical skills to provide consultations concerning family planning, preservation of reproductive and sexual health. They also noted that they had acquired sufficient knowledge on these issues as a result of improved medical training. One GP did not respond to this question, and 1 GP noted to have insufficient knowledge on these issues.
The level of education among young middle level specialists was assessed as satisfactory by 8 out of 10 GPs, 2 GPs did not respond to this question. Unfortunately, not a single GP pointed out the issues, which could be most important in nurses' training. According to our knowledge, training can be more motivated when the trainees are aware of new forms of learning including both conventional teaching and Internet use. During 2011-2012, the needs of the trainees for new forms, methods and the content of educational process have been studied. One hundred and forty head nurses from all regions of Belarus took part in polling by questionnaires. Among the respondents, people aged 25-45 years formed the largest share (62,2%), those from 46 to 60 years old made 26,7%; other persons (11,1%) were either under 25 or above 60 years old.
Among the issues that the respondents would like to study at the courses of improved training, the questions of psychology, ethics and deontology prevail (54% of respondents) followed by those of management and leadership, pharmacy and team work of medical personnel (26%). The respondents who would like to study the issues of legislation, norm-fixing base, and computerization of work and formation of healthy life style amounted to
15%, and those who want to deal with the questions of teaching the patients and members of their families in care, infectious control and prophylaxis of infectious diseases made 5%.
Six GPs noted sufficient number and good quality of issued and received by GPOs medical informational and educational booklets for certain age groups on family planning and preservation of reproductive and sexual health. Two GPs did not respond to this question, and further 2 GPs consider the number of these materials to be insufficient for the population.
Conclusions
The performed analysis based on the results of questionnaires filled in by GPs from 10 GPOs by 419 items allows assessing the work of GPOs and its effectiveness for the republic as a whole. Full staffing of FOSs testifies to adequate staff policy. This experience could be used for organizing the work of a GP's assistant for outpatient care, a specialist of a new type
The main direction of GPO's work is therapeutic. It is noteworthy that the beds in day hospitals are poorly occupied; the level of hospitalization is not sufficient, with lower level of disease registration (or referrals) due to long distance to the medical establishment and higher rate of deaths per 100 cases of disease. All this demands deep analysis in every region followed by legal and organizational decision making.
Home mortality from the main causes is rather high, but it tends to decrease: during 2008-2010, it decreased from 81 to 66,1%. The comparison of general morbidity for all classes of diseases and mortality from all causes may serve to a certain degree as an estimate for the quality of health care provided to the population and the possibility of its receiving. Assessment of these findings for various medical establishments and regions in dynamics may be helpful when planning medical and social events.
Index of reversibility of health impairment (the number of morbidity cases per every case of death) can possibly be a quantitative estimate for the influence of medical care provided by GPOs on the mortality rate under the conditions of available economic resources. In dynamics, this index can serve as an indicator for the quality of the GPO work and of the system of primary medical care as a whole.
The role of GPO specialists with secondary medical education is increasing under the conditions of deficiency in staffed physicians, which is confirmed by a 2-fold increase in visits of patients. This testifies to the accessibility of health care in the system of primary medical care demonstrated by a considerable volume of the performed work (Table 1).
The data from the questionnaires allow having estimates about the rate of home mortality, though this information is not envisaged in official statistics. This index is rather high among the population within the GPOs medical coverage, but it tends to decrease (from 81% in 2008 to 66,1% in 2010). In general, cases of home mortality were registered in 79,3% of all cases of death. Out of all those who died from these diseases, 85,2 % of patients died from neoplasms; 73,0% died from circulatory disorders, 25% from respiratory diseases, 27,3% from digestive diseases and 81,8% from "senility" (Table 4). In general, it corresponds to the republican and world tendencies.
According to the data from GPOs, the level of hospitalization among the served population is low. In some questionnaires, it is noted as very low, which does not seem to be true. It can result from both incomplete registration of cases of hospitalization and due to the existing instruction on limitation of hospital admissions aimed optimal use of the expensive hospital beds when day hospital beds are available.
The established structure of receiving patients by GPOs serves as a basis for planning optimal proportion of disciplines to be studied at the courses of improved medical training. The time allocated for therapy can be equal to 50%, for pediatrics - 15%, neurology - 10%, laryngology, surgery and ophthalmology - 5% each; obstetrics and
gynecology - 10% (taking into account the importance of demographic problems). However, the conducted studies showed that the adult population and older people are not going to change the attitude to their health (Matveichik, 2012). Therefore, following the direction of healthy life style promotion, the greatest attention should be concentrated on the work with children and adolescents using up-to-date technologies for transmission of information and specific forms of its presentation (audio- and video-films, video-lectures of well-known health care specialists). Universal informatization outlined by the Ministry of Health of the Republic of Belarus for the period up to 2015 will allow solving all these problems in the near future (Matveichik, Romanova, Shvab, 2012).
Teaching programs for medical personnel with higher nursing education or secondary medical education should include the preferences of the trainees. Among the issues that the respondents would like to study, the questions of psychology, ethics and deontology prevail (54% of respondents), followed by those of management and leadership, pharmacy and team work of medical personnel (26%). The respondents who would like to study the issues of labor legislation, norm-fixing base, computerization of work and the formation of healthy way of life amounted to 15%, and those who want to deal with the questions of teaching the patients and their families in self-care, infectious control and prophylaxis of infectious diseases made 5%.
Based on the results of the analysis, it is possible to realize the role of GP in solving family problems of the population within the GPO medical coverage concerning family planning and preservation of reproductive and sexual health, which is an important part of the GPO work. In general, GPO physicians were informed about the use of contraceptives, cases of interrupted pregnancy and pregnancy in females under 18 years old. The majority of physicians noted that they had acquired sufficient knowledge on these issues as a result of improved medical training. In 2011, some respondents did not answer the questions concerning the promotion of healthy life style. This situation should encourage GPOs to continue working in this direction. There were isolated critical answers to the proposed questions. Some respondents gave no answer to certain questions, and some were reluctant to give a negative answer. This may result from insufficient level of training the GPO personnel on these issues, as well as the shortage of medical informational and educational materials on family planning and preservation of reproductive and sexual health.
The study revealed some peculiarities of general practitioners' work at GPOs, which may be useful for further planning the activity of specialists in the system of primary medical care and may contribute to the improved quality of medical care for the population (Matveichik, 2012; Matveichik, Romanova, Shvab, 2012). Following the Confucianism, "There exist three ways leading to knowledge: the way of meditation as the most noble, the way of learning as the most difficult and the way of experience as the most bitter". The authors dare to take the most difficult way so that to save the reader from the most bitter one.
REFERENCES
1. Matveichik, T. V. (2011 ) Contributing to healthy life style: teaching and methodical text-book, Minsk, Republican Institute for Professional Education, p.76.
2. Matveichik, T. V. (2012) Principles of nursing pedagogics and improving professional skills: teaching and methodical text-book for medical personnel of health care institutions and for people receiving additional education (med., social and ped. workers), Belarusian Medical Academy of Post-Graduate Education, 2nd ed., remade and supplemented, Minsk, State Establishment "Republican Scientific Medical Library", p.160, available at: http://med.by/content/ellibsci/BELMAPO/matvosp.pdf.
3. Matveichik, T. V., Romanova, A. P. & Shvab, L. V. (2012) Nursing instructor in the system of primary medical care (for trainees studying at the courses of "Health care management" and "Nursing management" at higher medical educational establishments and colleges): monograph, Belarusian Medical Academy of Post-Graduate Education, Minsk, State Establishment "Republican Scientific Medical Library", p.88, available at: http://med.by/content/ellibsci/BELMAPO/matvsest.pdf.
