List size and quality of care among GPs within the The Regular General Practitioner Scheme
Systematic review
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Key message
Background
The Regular General Practitioner (RGP) Scheme was introduced in Norway in June 2001. In a revision of the RGP Scheme, it has been proposed to regulate the number of people assigned (list size) to one general practitioner (GP) to a maximum of 2,500 persons. A further suggestion is to let the municipalities decide whether to increase the list up to 1,500 persons in cases where the GP’s list is shorter.
Currently, the relationship between list size and quality of health care services is uncertain.
This overview is intended to be used as part of the documentation concerning decisions about GPs' list size.
Commission
The Norwegian Knowledge Centre for the Health Services was asked by The Norwegian Directorate of Health to review available research which addressed the question: What are the effects of the number of people assigned to GPs on the quality of health care services?
We searched systematically for:
- Systematic reviews, randomized controlled trials, controlled studies and interrupted time series that examine the effect of GPs' list size on quality parameters (primary objective)
- Studies that have assessed GPs' list size in relation to various quality dimensions of services provided by GPs (cross-sectional studies)
Main results
There is an evidence gap regarding the effects of GPs' list size on health care quality parameters. We can not conclude whether short or long lists result in differences in the quality of services provided by primary care physicians.
We have found 91 studies that, although they did not evaluate effect, examined the association between GPs' list size and the quality of the services provided. Among these are sixteen Norwegian registry- and cross-sectional studies. We have presented the studies, including their results, and elucidated that the studies are varied as regards aims, methods used and study settings. It is difficult to use registry- and cross-sectional studies as basis for answering questions on associations. The results of the included studies showed a large variation, thus we are uncertain about a possible association between list size and the quality of primary care physician services. None of the studies examined what the optimal list size would be in relation to quality of primary care physician services.
Summary
Background
The Regular General Practitioner (RGP) Scheme was introduced in Norway in June 2001. Better availability and better quality in primary health care services were among reasons for introducing the RGP scheme.
The Ministry of Health and Care Services concluded in a status report in 2004, Experiences with the first 2 years of the RGP Scheme , that the RGP Scheme works very well but that there also were some weaknesses . In 2006 the Research Council published the report Evaluation of the Regular General Practitioner Scheme 2001-2005 . It is primarily based on results from several research projects focusing on the four main evaluation areas: medical coverage of GPs, accessibility, continuity, and effectiveness. A number of the related publications refer to GPs' list size - including possible links between list size and services provided by GPs.
The Ministry of Health and Care Services addressed a revised RGP Scheme in December 2011. In the new RGP Scheme, it has been proposed to limit a GP’s list size to a maximum of 2,500 people. A further suggestion is to let the municipalities decide whether to increase the list up to 1,500 persons in cases where the GP’s list is shorter. Today, there is an uncertain relationship between list size and quality of health care services. Is there an optimal list size?
The Norwegian Directorate of Health, Division of Primary Health Care Services/ Unit of Community Health Care Services, requested a systematic review that evaluates the effects of patient list size on the quality of the services provided by GPs who have the responsibility for a defined patient population.
Objective
This systematic review aims to identify and evaluate evidence about the effects of GPs' list size. A second aim is to describe results from research that has looked for possible links between list size and quality parameters.
Method
We searched on February 25 th and 26 th 2012in the following databases:
- MEDLINE
- EMBASE
- Cochrane Library
Two people independently read titles and abstracts from the literature search results. Two people also read the full text version of selected articles. We considered the relevance of selected articles based on our inclusion criteria. The inclusion criteria (PICO) for our primary objective were:
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Population |
General practitioners (GPs) linked to a defined population |
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Interventions |
List size/size of patient population |
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Comparison |
Other list size/size of patient population |
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Outcomes |
Quality of the RGP Scheme. Outcomes depend upon what the studies have defined as quality measures. For instance, capacity, continuity, accessibility, consultation length, number of consultations per patient on the list, type of consultation, waiting time/list, the use of emergency medical services, referrals/ referral practices, resources, hospital admissions, avoided hospital admissions, coordination, patients who switch GP contact, patient outcomes, patient satisfaction, user involvement, effective services, adverse events, safety and security services, workload/hours per week, job satisfaction, costs |
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Study design |
Systematic reviews of high quality. We did not find systematic reviews of high quality, so we searched for randomized controlled trials, non-randomized controlled trials, controlled before-and-after studies, interrupted time series |
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Language |
Publications in English and Scandinavian were included |
We considered relevant quality parameters based on the idea that health care services aims to be effective, safe and secure, to involve and empower users, to be coordinated and characterized by continuity, to utilize resources in a proper manner, and to be accessible and fairly distributed.
Our objective was to evaluate the effect of list size on quality parameters. We expected, however, to find a limited amount of literature that met our inclusion criteria. We therefore posed a second objective, which was to describe research that has looked for evidence for a possible relationship between list size and quality parameters.
The following plan was used to find and describe research that had looked for a possible relationship between list size and quality parameters:
- The same population, intervention, comparison and outcomes as for the primary objective (see above)
- No restrictions on study design, i.e. we searched for cross-sectional studies, registerstudies, cohortstudies, uncontrolled longitudinal studies, patient series, economic evaluations and qualitative studies
- Two of us independently read all titles and abstracts from the literature search. Possibly relevant articles were reviewed in fulltext by at least two people independently
- We did not assess the methodological quality of included studies
- The results are summarized by providing a brief tabular form presentation of relevant studies. We have not interpreted or drawn any conclusions from the studies. One of us extracted data from included studies, and another checked that relevant information has been properly collected and referred.
In case of disagreement on any of the above, we consulted a third person for clarification.
We also searched for "grey literature". Grey literature is usually understood to mean literature that is not formally published in sources such as books or journal articles, and is therefore not indexed in databases.
Results
The literature search resulted in 3765 unique references. In addition another 41 references were collected from “grey literature”. A total of 518 publications were retrieved for a full text evaluation.
For our primary purpose, to evaluate the effect of GPs' list size, we found no studies that met our inclusion criteria.
For our secondary purpose, to describe research that has examined a possible relationship between GPs' list size and quality of health care services, we have included 91 studies. The majority of the studies were Norwegian, Danish, Dutch and British registerstudies and cross-sectional studies. A total of 55 articles studied GPs with personal lists, and 36 articles studied practice list size in relation to quality parameters. The studies are presented in tables in appendices 2 and 3. In the tables, the studies are described and the main results are given. The tables also illustrate that the studies varied concerning aims, outcomes measured, methods used and study settings. Among the quality dimensions that have been studied in relation to GPs list size, were:
- general quality
- practice of referrals, prescriptions and medical reports on sick leave
- patient satisfaction
- consultation length, waiting time, accessibility
- outcomes related to physicians (workload, job satisfaction)
- outcomes related to effectiveness (resources/utilisation, costs)
Because of the time schedule for this systematic review, a total of 22 of the requested full text articles for assessment for possible inclusion in the tables in appendix 2 or 3 had not been received upon completion (April 10th, 2012), those are listed in Appendix 5.
Discussion
There is an evidence gap of research to assess the effects of GPs' list size on the quality of primary care physician services. We conducted a systematic literature search in central databases, and a large number of articles were read in full text. There is possibility that we have failed to identify studies on effect.
We identified 91 studies that had looked for a possible relationship between GPs' list size and the quality of health care services. None of these studies evaluated effect. Among these were sixteen Norwegian registerstudies and cross-sectional studies. We consider the results of these studies to be difficult to interpret and hard to use as basis for conclusions. Nevertheless we think it is useful to present an overview of the studies that were available to us.
It is difficult to use registerstudies and cross-sectional studies as basis for answering questions on associations. The results of the included studies showed a large variation, thus we are uncertain about a possible association between list size and the quality of primary care physician services. None of the studies examined what the optimal list size would be in relation to quality of primary care physician services.
Conclusion
We did not identify any studies assessing the effect of GPs' list size on the quality of health care services. Thus, we cannot draw any conclusions on whether short or long patient lists are effective in terms of the quality of services provided by GPs.
We found 91 studies that, although they did not evaluate effect, examined the association between GPs' list size and the quality of primary care physician services. We think it is useful to have an overview of available studies. We have therefore described the studies and their main results. We have also elucidated that, among the studies, there is a great variation regarding aims, methods used, and study settings. None of the studies examined what the optimal list size would be in relation to quality of the primary care physician services.