1. A Systems Approach to Continuity of Care Patient Attitude A/Prof JP Sturmberg University of NSW A/Prof F Carinci Monash Institute of Health Services Research RACGP-conference, Perth 2002

2. Health Care System Consultation (Outcomes) Doctor Patient Consultation (Process) Systems-based Concept of Continuity of Care

3. Doctor-Patient Stability Patient Satisfaction + ACCESS to care Health financing + The Need For a Systems Approach MORBIDITY Psycho-social -

4. Method

5. Health Care System Low Attitude Univariate OR (95%CI) Time dedicated by GP – not always enough1.77 (1.29-1.86) Funding for health care – mix of private/public0.69 (0.52-0.93) Delay to get an appointmentns Practice sizens Billing by this doctorns

6. Doctor Low Attitude Univariate OR (95%CI) Knowledge about the patientns Consultation difficultyns Doctor’s holistic attitudens

7. Patient Low Attitude Univariate OR (95%CI) Gender – male1.38 (1.03-2.41) Age  65 2.40 (1.67-3.45) Employment Status (RC=employed) - Unemployed - Social support pension - Retired 1.75 (1.08-2.84) 1.79 (1.17-2.75) 2.28 (1.60-3.25) Social problem – present1.71 (1.26-2.32) Health Status – poor health1.46 (1.07-2.00) Psychological problemns Patient’s knowledge about the doctorns Expecting a scriptns

8. Consultation - Process Low Attitude Univariate OR (95%CI) Communication – poor1.45 (1.07-1.98) Patient sent for investigations – no0.71 (0.51-0.99) Doctor requested this visit – nons Doctor-patient stability - lowns Consultation length – 11-15 min Consultation length – 11-10 min ns Patient sent for secondary care – nons

9. Consultation - Outcome Low Attitude Univariate OR (95%CI) Patient Satisfaction – low1.66 (1.17-2.36) Enablement - moderatens Would you see this doctor again - nons Received a script for old and new medication - yes1.87 (1.28-2.73)

10. Results of Multivariate Logistic Regression

11. Global correlates of low attitude INCREASED RISK Social Problem Administrative Problem Social Symptom Not Knowing the Doctor Not Having Enough Time with the Doctor Receiving a Script for an Old and New Problem Dissatisfaction DECREASED RISK Psychological Symptoms Mixed Funding of Health Care Better Communication

12. Age-specific correlates of low attitude < 40  40, <65  65 Gender – Male  Increasing Age  Increasing Patient Enablement  Increasing Doctor-Patient Stability  Increasing Consultation Length  Referral – Not referred 

13. Conclusions (1) Being young, middle-aged or old modifies the sense and strength of the association between gender, age, doctor-patient stability, length of consultation, patient enablement The effect of age itself changes: “getting older” in middle aged is associated to better attitudes, in old patients to lower attitude Age is an important effect modifier

14. Conclusions (2) Vulnerable Groups Patients presenting with issues of a social nature – frank social problems or indirect social problems, eg. Related to DSS, Workers Compensation Patients who have not omitted to social problems Stigma, Guilt, Shame Somatisation Lack of Coping Lack of Social Support Low self-esteem Bad experiences with family doctors institutions Dissatisfaction

15. Conclusions (3) Not Knowing the Doctor Experiential Reasons for not seeing the same doctor Wanting to maintain anonymity Difficulties accessing the same doctor Communication Difficulties Missing psychosocial dimensions High prescribing rates More investigations Dissatisfaction Lack of tacit knowledge

16. Conclusions (4) Systems Effects Doctor does not have enough time for patient Mixed funding for health care Doctor too busy Patient too demanding Complex Morbidity ?

17. Conclusions (5) Practice Size TREND (NS): Young patients with a holistic attitude seem to prefer large practices Do they seek anonymity? Do they more easily find the doctor that suits their needs?

18. Conclusions (6) Paradoxes Middle-aged patients who are NOT referred have low holistic attitude Old patients who are NOT referred have high holistic attitude Young patients seeking stable doctor- patient relationship Middle-aged patients avoiding a stable doctor- patient relationship

19. Summary Multivariate logistic regression identifies factors associated to a target outcome Sophisticated strategy is needed to increase precision of the final model Sense and strength of association between different characteristics and holistic attitudes changes across different age groups A systems approach is needed to explain the complex relationships between different dimensions and component variables