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The Use of Quality Information by General Practitioners

´╗┐The Use of Quality Information by General Practitioners

Discussion


In many countries policy reforms are implemented that rely on GPs to guide patients to the 'best' hospitals using publicly available quality information. If a success, these reforms enhance the medical quality and patient centeredness of these health care systems, especially in areas where multiple providers operate. In this study we show the effect of report card use by GPs in referring their patients to the hospital under optimal conditions. In contrast to prior studies we do not use surveys of patients or GPs, but use actual referral data. Given the training and experience of GPs, GPs should be well equipped to understand, interpret and use the quality information wisely. In addition, patients rely on their GP for their hospital choice. Given these circumstances we expect that if the current quality information would have the potential to alter choices of patients for hospitals, our study should bring this to light.

Our analyses show mixed results regarding the impact of report cards. The overall analyses did not show significant alteration in referral patterns of GPs in the intervention group compared to the control group within and outside the study in line with previous studies. It should be noted, that given the rather small number of referrals in the intervention group, minor changes in referral patterns that were actually there, may have not been revealed in our analyses due to power issues. Nonetheless, for breast cancer this study shows that a one point higher score on indicators for medical effectiveness results in a 1.0% (p=0.01) increase in the likeliness of referring a patient to that hospital. Given the differences of a maximum of nine percentages between the best and worst performing hospital on breast cancer (see Additional file 1: Table S1), the total effect may sum up to a total of 9%. This finding is in line with the qualitative statements of the GPs, where they mentioned that the breast cancer indicators for medical effectiveness appeared to be the most valid, reliable and differentiating indicators and therefore the most convincing indicators to alter their referral patterns.

The finding that GPs rely for their referrals on other aspects than quality information is in line with previous survey studies, that show that GPs usually refer patients to hospitals based on their (informed) opinion about a particular hospital rather than quality information. To improve our health care system, meaningful outcome measures should be developed and published in a comprehensible way for GPs and patients. For many conditions, at least in the Dutch context, outcome indicators are available via administrative data, clinical registries or Patient Reported Outcomes and should become public.

While our experimental design is robust due to the randomization and the use of an internal and external control group and also comparing the intervention group with the referral patterns in the previous year, our study may have suffered from possible limitations. First, the number of GPs included in our study is limited, therefore minor changes in referral patterns might not result in statistically significant changes, although we do include a substantial number of referrals in our study. Second, the period of our study is only one year. Therefore results in this study should be interpreted as short term results.

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