Download Primary Care Convention The

Cancer survival and
the gatekeeper principle
- have we missed some side effects of gatekeeper systems?
Peter Vedsted, Prof., PhD
Frede Olesen, Prof., DrMedSci
The Research Unit for General Practice
Research Centre for Cancer Diagnosis in Primary Care – CaP
Aarhus University
Denmark
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
UNIVERSITY OF AARHUS
DENMARK
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
Frede Olesen, Res. Unit for GP, Univ. of Aarhus, Denmark
The Research Unit for General Practice
Aarhus University, Denmark
Frede Olesen
Research director
Professor, dr.med.sci,
[email protected]
Funded by: Danish Cancer Society
Peter Vedsted
Head of the CaP
centre, vice director
Ph.d., professor
[email protected]
|
The Novo Nordisk Foundation
Outline
 The ‘primary care convention’
 Cancer survival caused surprise
 The ecologic study
 The perspectives
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
Primary Care Convention
 The ’General Practitioner’ doing ’Family Medicine’
 a person-centred approach,
 a unique consultation process, a relationship over time,
 provide longitudinal continuity of care
 Position in the healthcare system
 first point of contact, open and unlimited access,
 makes efficient use of healthcare resources…, managing the
interface with other specialities ...
The European Definitions of General Practice /Family Medicine, WONCA EUROPE, 2002
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
’The gatekeeper invention’
 Precise point of entry and first contact
 Right to refer to specialist treatment
 Guidance, continuity and communication
 Rationing and efficiency
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
A total health care system- integration:
- the GP should be perfect in the inverted T
- quality: balance in the inverted T
 Vertical – towards the hospital
 Horisontal – PHC team
Hospital
Familie etc.
general practice
Funded by: Danish Cancer Society
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The Novo Nordisk Foundation
Social care etc.
The question
- do we fail in the vertical part?
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
About cancer and primary care
 Lifetime cancer risk is 35%1
 At least >80% are seen in primary care2,3
 90% present symptoms
 25% of total mortality1
Sources:
1. Albreht et al. European Journal of Cancer. 2008;1451–1456
2: Allgar et al. British Journal of Cancer 2005;92:1959–70
3: Hansen. Delay in the diagnosis of cancer [Thesis]. University of Aarhus, 2008
Funded by: Danish Cancer Society
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The Novo Nordisk Foundation
We were surprised… again…
Møller H et al. British Journal of Cancer. 2009;101, S110–4
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
Have we ignored something?
 The principle of a strong primary care sector, i.e. with general
practice as gatekeeper, as first point of contact and with a list
system, has documented advantages
 However, are there adverse consequences?
 Is the GP a ‘hostage’ in rationing care and in keeping waiting lists
short?
 Is it so difficult to refer that the threshold gets too high?
 What is the consequence of the relation and repeated contact?
Selected sources:
Starfield B et al. Contribution of primary care to health systems and health. Milbank Q 2005;83:457-502.
Walley J et al. Primary health care: making Alma-Ata a reality. Lancet 2008;372:1001-1007.
Starfield B. Is primary care essential? Lancet 1994;344:1129-1133.
Halm EA et al. Is gatekeeping better than traditional care? A survey of physicians' attitudes. JAMA 1997;278:1677-1681.
Freeman GK et al. Continuity of care: an essential element of modern general practice? Fam Pract 2003;20:623-627.
Goodwin N. Diagnostic delays and referral management schemes: how "integrated" primary care might damage your health. Int J of Integrated Care 2008; 8
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
The ecologic study
 Is there an association between the organisation of general practice
and the relative one-year cancer survival?
 Data included:
 The relative one-year survival for 42 cancers in 19 countries1
 The organisation of general practice (gatekeeper, list system, first
point of contact)2,3
 Analysis:
 Median survival, composite survival index
1: Møller H et al. A visual summary of the EUROCARE-4 results: a UK perspective. Br J Cancer 2009;101(Suppl 2):S110-4.
2: Boerma WG et al. Service profiles of general practitioners in Europe. European GP Task Profile Study. Br J Gen Pract 1997;47:481-6.
3: Saltman RB et al. Primary care in the driver's seat? 1 ed. Maidenhead: Open University Press; 2006.
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
Adverse effect of the gatekeeper system?
Relative one-year survival (%)
Gatekeeper
List system
No
Countries
Median (%)
7
73.4
p-value
0.004
Yes
12
67.8
No
9
73.4
0.004
Yes
10
66.3
First point of
Always
10
66.3
contact
Depends
7
73.4
No
2
73.4
0.001
Vedsted P et al. Are the serious problems in cancer survival partly rooted in gatekeeper principles? Submitted
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
Conclusion
 Cancer is common, and most patients present with symptoms
 Primary care is essential in early cancer diagnosis
 Does the organisation with general practice as gatekeeper, as first
point of contact and with a list system result in:
 5-7% lower one-year survival in cancer?
 2,000 lost person-years in Denmark each year?
 We need to know! And if so – WHY?
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation
Conclusion II: Have we ignored something?
 Are there adverse consequences of gatekeeping?
 Is the GP a ‘hostage’ in rationing care and in keeping waiting lists
short?
 Is it so difficult to refer that the threshold gets too high?
 What is the consequence of the relation and repeated contact?
 Even if a strong front line gives the best system
 We must investigate side effects
 Is gatekeeping the problem – not the strong front line?
Funded by: Danish Cancer Society
|
The Novo Nordisk Foundation