Bergen Open Research Archive >   Faculty of Medicine >   Department of Public Health and Primary Health Care >   Section for General Practice >

Please use this identifier to cite or link to this item: http://hdl.handle.net/1956/1557

Title:	The changing role of gatekeepers: rationing and shared decision-making in primary care
Authors:	Carlsen, Benedicte
Issue Date:	21-Jun-2006
Publisher:	The University of Bergen
Abstract:	The Norwegian health care system is increasingly dependent on the general practitioner’s (GP’s) gatekeeper function for cost containment and for fair and effective resource allocation. GPs enjoy extensive professional freedom and there is considerable room for discretionary choices. At the same time, during recent decades, the patient’s power and rights have been strengthened. This situation calls for a better understanding of GPs’ allocative decision making and the patient’s role in it. Hitherto the literature on resource allocation tends to overlook the patient’s role in GP decision-making while the literature about GP–patient interaction tends to omit questions of resource allocation. This thesis takes an interdisciplinary approach to GPs’ rationing decisions and the ideals of patient involvement. It is based on two separate studies. The first study explores how GPs experience the gatekeeper role under the influence of patients and other factors such as medical responsibility, economic incentives, competition and the desire to preserve professional autonomy. The second study analyses how attitudes towards patient involvement influence patient satisfaction and referral rates. Study 1 (Paper I and II) is based on focus group interviews with a strategic sample of 81 GPs from the municipalities of Bergen and Oslo combined with a short questionnaire survey among the same participants. The interviews took place in 2002. Interviews were coded by hand and analysed qualitatively through framework analysis. The survey data were analysed descriptively. Study 2 is a questionnaire study among GPs and their patients carried out during 2004 in Bergen. The data are based on questionnaires handed out by 56 GPs and the responses from 1268 of their patients. Descriptive statistics, linear and logistic regressions were the main forms of analysis. The key finding of the first study was that Norwegian GPs’ commitment to the gatekeeper role seems to be declining, and that they generally make rationing decisions only when they are able to come to an agreement with patients and avoid conflict. The findings also suggest that many Norwegian GPs do not fully understand the need for rationing while others regard rationing as conflicting with other concerns. In study 2 (Paper III and IV) the results indicate that Norwegian patients have a strong preference for patient involvement while GPs are relatively less positive to involving patients in medical decision-making. GPs with positive attitudes to patient involvement referred less and were more likely to have satisfied patients. Agreement of attitudes towards patient involvement between patients and GP had a strong and significant negative effect on referral rate but no significant effect on patient satisfaction. The suggested interpretation of the results is that the participating GPs have turned their attention towards patients’ preferences and away from unpleasant rationing decisions. GPs and patients’ attitudes towards patient involvement affect resource allocation, but this association is poorly understood. Hence there is a need for further interdisciplinary studies to explore how GP–patient interaction affects resource allocation. Open debate about the role and limitations of patient involvement and how increased patient power affects resource allocation should be encouraged. Fastlegenes portvaktrolle: Prioritering og brukermedvirkning i primærhelsetjenesten. Det norske helsevesenet er avhengig av fastlegenes portvaktrolle for å sikre kostnadskontroll samt en rettferdig og effektiv fordeling av ressursene. Primærlegene har tradisjonelt hatt en høy grad av profesjonell frihet og stort rom for skjønnsmessige avgjørelser, samtidig som pasientenes innflytelse og rettigheter gradvis er blitt styrket i løpet av de siste 30 årene. På bakgrunn av dette er det ønskelig med en bedre forståelse av hvordan fastlegene tar beslutninger som får betydning for ressursfordelingen og hvilken rolle pasienten spiller i beslutningsprosessen. Hittil har studier av ressursallokering stort sett utelatt pasientens rolle for legenes beslutninger samtidig som studier av lege-pasientforhold i liten grad har befattet seg med ressursbruk. Denne studien har en tverrfaglig tilnærming til primærlegers prioriteringsbeslutninger og idealer om brukermedvirkning. Studien består av to deler. Første del er basert på gruppeintervjuer og utforsker hvilke hensyn legene tar i vanskelige avgjørelser som portvakter. Andre del av studien er basert på en spørreundersøkelse blant fastleger og deres pasienter der vi undersøker hvordan legen og pasientens holdninger til brukermedvirkning påvirker pasienttilfredshet og henvisningsrate. Den første delstudien er basert på fokusgruppeintervjuer med 81 fastleger fra Bergen og Oslo kombinert med et kort spørreskjema blant gruppedeltakerne. Intervjuene ble gjennomført i 2002. Den andre delstudien ble gjennomført i 2004 og er en spørreundersøkelse blant 56 fastleger i Bergen og 1268 av deres pasienter. Hovedresultatet i den første delstudien var at mange primærleger i vår studie opplever at de i mindre grad fungerer som portvakter og i liten grad identifiserer seg med den rollen. Det ser ut til at fastlegene hovedsaklig sier nei til lavt prioriterte tjenester når de oppnår enighet med pasienten og dermed unngår konflikt. Fastlegene ser ut til å ha liten forståelse for behovet for å prioritere helsetjenester i en situasjon med god ressurstilgang. En del rapporterer også at de i liten grad følger nasjonale retningslinjer. I tillegg kommer portvaktrollen og ansvaret for å forvalte fellesskapets ressurser ofte i konflikt med hensynet til den enkelte pasient og dennes rett til å delta i medisinske beslutninger. Også økonomiske insentiver i fastlegeordningen, økt medisinsk ansvar og tydeligere konkurranse om pasienter oppleves som faktorer som gjør det vanskeligere for fastlegene å prioritere helsetjenester. Resultatene i den andre delstudien indikerer at norske pasienter har en sterk preferanse for brukermedvirkning, mens fastlegene foretrekker en litt svakere grad av brukermedvirkning. Fastleger som er positive til brukermedvirkning hadde mer tilfredse pasienter og henviste mindre enn de som var mer negative til brukermedvirkning. Samsvar i holdninger til brukermedvirkning mellom lege og pasient påvirket ikke pasienttilfredshet, men hadde derimot en negativ effekt på antall henvisninger. Konklusjonen av studien er at mange fastleger i vårt materiale retter oppmerksomheten mot pasientenes ønsker og behov og bort fra det de opplever som ubehagelige prioriteringsoppgaver. Fastleger og pasienters holdninger til brukermedvirkning påvirker ressursbruken i helsevesenet, men vi vet foreløpig lite om disse sammenhengene. Følgelig er det behov for videre tverrfaglige studier som kan utforske hvordan lege-pasientinteraksjon påvirker ressursbruk og -fordeling i helsesektoren.
Description:	This doctoral thesis is based on the following articles: I: Carlsen, Benedicte and Norheim, Ole F. Introduction of the patient-list system in general practice: Changes in Norwegian physicians’ perception of their gatekeeper role. Scandinavian Journal of Primary Health Care 2003, 21(4): 209-13. II: Carlsen, Benedicte and Norheim, Ole F. “Saying no is no easy matter”. A qualitative study of competing concerns in rationing decisions in general practice. BMC Health Services Research 2005, 5:70 III: Carlsen, Benedicte and Aakvik, Arild. Patient involvement in clinical decision-making: The effect of GP attitude on patient satisfaction. Health Expectations 2006, 9: 148-157. IV: Carlsen, Benedicte, Aakvik, Arild and Norheim, Ole F. Congruence in attitudes between doctors and patients results in lower referral rates. A questionnaire survey among Norwegian general practitioners and their patients. Manuscript submitted January 2006.
URI:	http://hdl.handle.net/1956/1557
ISBN:	82-308-0146-0
Appears in Collections:	Section for General Practice Department of Economics Stein Rokkan Centre for Social Studies

Files in This Item: File Description Size Format Paper4_Carlsen.pdf Restricted access. Congruence in attitudes between doctors and patients results in lower referral rates. A questionnaire survey among Norwegian general practitioners and their patients. Benedicte Carlsen, Arild Aakvik and Ole F. Norheim. Submitted January 2006. 56,45 kB Adobe PDF View/Open Paper3_Carlsen.pdf Patient involvement in clinical decision making: the effect of GP attitude on patient satisfaction. Benedicte Carlsen and Arild Aakvik. Health Expectations 9 pp 148 deposited with permission from Blackwell Publishing. http://dx.doi.org/10.1111/j.1369-7625.2006.00385.x 151,47 kB Adobe PDF View/Open Paper2_Carlsen.pdf “Saying no is no easy matter”. A qualitative study of competing concerns in rationing decisions in general practice, Carlsen, Benedicte and Norheim, Ole F. BMC Health Services Research 5(70), Copyright 2005, BioMed Central. http://dx.doi.org/10.1186/1472-6963-5-70 158,72 kB Adobe PDF View/Open Paper1_Carlsen.pdf Introduction of the patient-list system in general practice: Changes in Norwegian physicians’ perception of their gatekeeper role. Carlsen, Benedicte and Norheim, Ole F. Scandinavian journal of primary health care 21(4). http://dx.doi.org/10.1080/02813430310004155 83,99 kB Adobe PDF View/Open MainThesis_Carlsen.pdf Main Thesis - Carlsen 182,59 kB Adobe PDF View/Open

Items in BORA are protected by copyright, with all rights reserved, unless otherwise indicated.