The Role of Family Practice in Different Health Care Systems

The ample use of endoscopy, x-ray, and ultrasound in Japan and of electrocardiograms in Poland contrasts with a relatively modest use of diagnostics in the Netherlands. The referral rate to specialists in the Netherlands is a reliable indicator of the role of secondary care; the very low referral rate in Japan reflects how in a rural area patients seek care either of their family physician or of specialists in a nearby city, to whom they have direct access. The high referral rate in Poland also probably reflects the attitude of former hospital specialists who were practically overnight transformed into family physicians.

It is difficult to interpret all differences in prescribing, because the US data do not include the quantity of medication; in the Transition Project’s data, “Defined Daily Doses” are used to better understand prescribing patterns. This study’s data reflect substantial differences in prescribing antibiotics, oral contraceptives, and cardiovascular and gastrointestinal therapies.^53-56 Prescribing behavior in the Netherlands and the US is rather similar, while very different patterns are found in Japan and Poland. Antibiotic use in upper respiratory tract infections differs largely: the Dutch prescribe infrequently and almost always use penicillins, the Japanese rarely prescribe penicillins.

Conclusions

The main conclusion of our study is that family practice varies as a customized service, determined by a combination of factors, including the burden of disease; the habits, customs, and training of physicians; the regulations promulgated by government and guilds; the way people understand their symptoms; and the availability of money, services, tools, and goods. Another important conclusion is that, paradoxically, while the need to document reasons for visit was first acknowledged in the US many years ago, US family practice still has not been in the position to document their contribution to national health care in sufficient clinical detail focussing on episodes of care over time.^7,9

The recommendation of the IOM to “foster the development of standards for data collection that will ensure the consistency of data elements and definitions of terms, improve coding, permit analysis of episodes of care, and reflect the content of primary care” has not yet resulted in the availability of such (nationally representative) data to be included in a comparative international study.

The possibilities for international cooperation to further develop episode-oriented epidemiology in family practice have, however, increased considerably over the past decade. Further, the potential for international comparative studies in family practice has increased with the introduction of complete electronic patient records based on a standardized documentation of episodes of care with ICPC together with its mapping to ICD-10 (or, for the time being, ICD-9-CM). Now is the time to make a wide use of the new possibilities in routine documentation of patient-physician encounters in family practice by family physicians, wherever they work.^57-60

Acknowledgments

The first and last author gratefully acknowledge the opportunity to work on this paper during their scholarship, in late 1999, at AHCPR (now the Agency for Healthcare and Research Quality) in Washington, DC. The authors do not report any competing interests