1. Medical Practice Variations in Primary Care Professor Azeem Majeed University College London

2. Outline of Talk zStructure of NHS zRole of general practitioners zGatekeeping in the NHS zPrevious research zCurrent research zImplications for policy and clinical practice

3. National Health Service zEstablished in 1948 zProvides health care ‘cradle to grave’ zDivision between primary care (GPs) & secondary care (hospital specialists) zNumerous initiatives in recent years to improve efficiency and quality zMore measurement of performance

4. General Practitioners zProvide primary (first contact) care zAround 75% of all medical contacts zAct as gatekeepers to other NHS services zPrescriptions, investigations, outpatient referrals, hospital admissions zGovernment views gatekeeping as more important than do many GPs or patients

5. Why do variations occur? zRandom variation zPatient zDoctor zGeneral practice zLocal health care system zNational health care system

6. Implications of variation zPatients may be denied access to appropriate care zPatients may be at risk of iatrogenesis zDoctors may not be practising ‘evidence- based’ medicine zMay be a marker of inefficient use of resources

7. Antibiotic prescribing rates in 211 general practices in 1998

8. Previous Research: 1980s zVery limited research before 1980s z1980s research very descriptive in nature z20-fold variation in many areas of practice zLittle attempt to understand reasons for variation

9. Previous Research: 1990s zMore analytical in nature, using techniques such as multiple regression zFirst major attempts to ‘explain’ variation zUse ‘patient’ and ‘general practice’ characteristics as explanatory variables zMixed results but typically only a small percentage of variation explained

10. Limitations of Research zMethods often flawed, e.g. small numbers zNo information on clinical case-mix zOften used ecological measures of socio- economic status & ethnicity zLimited information on clinician & health service characteristics zNo information on psychological factors

11. Other types of variation zVariation between groups of patients zVariation between areas in the same country zVariation between different health care systems

12. Annual outpatient referral rates per 1,000 in males

13. % Patients Referred/Year UK US Health Plans

14. Some Other Points zLarge variations also present among specialists and hospitals zVery little research on variations among other clinical professions, e.g., nurses, midwives, therapists zSimilar principles apply to these other groups

15. Changing Clinical Practice zClinical practice guidelines zEducational interventions zFeedback of comparative data zSystematic reviews suggest these interventions have only limited effects

16. Future issues zNew GP contract zIncreased monitoring of performance zQuality payments to general practices zNew resource allocation formula (Carr-Hill formula) zUnderstanding variations important zMore data available for research

17. Conclusions zPractice variations important to many different groups zPrevious research has many limitations zUnderstanding reasons for variations important if interventions to change clinical practice are to be implemented zPatients and government also want to be reassured about the care given by doctors