The Role of Family Practice in Different Health Care Systems

The content of family practice was established by:

1. utilization indicators per patient/visit, per patient year, per encounter, per episode of care and per patient per year;
2. the distribution of reasons for encounter/visit by ICPC-chapter; most frequent (groups of) reasons for encounter expressed as a symptom/complaint; most frequent (groups of) diagnoses in new episodes of care; most frequent (groups of) diagnoses in encounters per episode. While the incidence of chronic health problems is considerably smaller than their prevalence it is more representative considerably smaller than their prevalence, it is more representative for the content of family practice. Therefore, for selected major chronic diseases cumulative prevalences for the complete observation period were calculated;
3. prescriptions per 1000 direct encounters and per 1000 patients per year.

To improve comparability, all Transhis data were directly standardized for the sex/age distribution of the 1996 US population, in effect using the NAMCS data (that we could not recalculate) as the standard. Utilization indicators and epidemiological rates were calculated using definitions from WONCA’s International Glossary of Primary Care.⁴²

Results

Utilization

Substantial differences and similarities in utilization existed Table 2 often comparable NAMCS data were unavailable to us. Differences in the numbers of episodes of care and of encounters per patient per year were smaller than those in utilization per episode. In Japan, utilization per episode was relatively high, as was the use of physiotherapy and additional testing; in Poland, counseling, electrocardiograms and laboratory tests were rather prominent. Home visits appeared to be common only in the Netherlands; however, the proportion of out-of-hours encounters was quite similar in the 3 Transhis databases. In the Netherlands and Poland, family physicians were actively involved in referring to specialists, as opposed to the situation in Japan.

Reasons for Encounter

The distribution of reasons for encounter by ICPC-chapter illustrates the wide scope of family practice, as well as differences resulting from national health care systems Table 3. Digestive, circulatory, musculoskeletal, respiratory, and skin problems were frequent in all databases. Psychological problems were frequent in Dutch and US primary care, while digestive problems were very prominent in Japan. However, general problems, including prevention, were less frequent. The very limited contribution of Japanese family physicians to gynecologic/obstetric care and psychological and social problems is clear.

The top 30 reasons for an encounter expressed as a symptom/complaint are presented in Table 4. The rank order is derived from the highest frequency per 1000 listed patients (NAMCS: per 1000 US-population). In the US (last column), the relative contribution of family practice to care for common symptoms/complaints appears to be generally high but unevenly distributed; the overall US distribution was rather similar to the Dutch data. Only 35 groups of symptoms/complaints covered the top-thirties in all databases, at the same time including 45% to 60% of all symptom/complaint reasons for encounter.

Diagnoses

Table 5 and Table 6 present the diagnoses in the same format as Table 4; NAMCS-data on new episodes of care per 1000 patients per year were unavailable. The distribution of the incidences of common conditions in Table 5 reflects disease presented to a family physician: respiratory infections, prevention, trauma, gastrointestinal, musculoskeletal and skin problems were frequent in the 3 databases. Approximately 50 diagnoses covered 45% to 60% of all new episodes of care. Large differences, again, existed in the contribution of family practice to gynecology/obstetrics and to psychosocial problems.

Upper respiratory tract infections were far more often diagnosed in Japan and Poland than in the Netherlands, and Polish family physicians diagnosed more tonsillitis and strep throat. In Japan, the family physician’s contribution to prevention was very low, and very high to care for intestinal problems.

Table 6 shows the most frequent face-to-face encounters per episode of care per 1000 patients per year for all four databases, together with the family physician’s contribution to the NAMCS data. Again, data from the Netherlands and NAMCS were relatively similar, and family physicians in the US had a relatively important contribution to care for most common episodes of care. The very high overall number of face-to-face encounters per 1000 patients per year in Japan was rather evenly distributed over the most common episodes of care. The proportion of all encounters per 1000 patients per year covered by the top thirty for each country was 70% to 75%.

Prescribing

Only information on prescriptions by a family physician per 1000 encounters was available for the US. The same rate was calculated for the other 3 database, also, in addition to the number of prescriptions per 1000 patients per year Table 7. Data on prescriptions per 1000 direct encounters in the four countries indicated both similarities and differences. For example, family physicians in the US prescribed more antimicrobial agents than the Dutch, while the choice of antibiotics strongly differed. Dutch physicians prescribed many laxatives, while Polish physicians prescribed many antidiarrheals Cardiovascular treatment in the Netherlands and the US was rather similar, although the choice of drugs differed. Data per 1000 patients per year provided a rather different perspective on prescribing; especially in Japan, and to a lesser extent, in Poland, the large number of encounters per episode resulted in large differences between data per year versus per encounter.