Who Wants To Improve Collaboration in Services for Individuals with Chronic Conditions? Specialists and Rural General Practitioners Taking Action in a Fragmented Health Care System

doi:10.21203/rs.3.rs-778270/v1

Introduction

Strategies to improve fragmented care for individuals with chronic conditions can be futile if those health care professionals who would have benefited are not engaged. We aimed to explore motivation and previous collaboration quality of general practitioners (GPs) and specialists who participate in an intervention study to improve their collaboration, and GPs who do not participate.

Methods

Explorative survey among rural GPs and specialists for spinal cord injury (SCI) participating in an intervention to improve collaboration, and non-participating GPs, from August to October 2020, in Switzerland.

Results

Eight GPs and 13 specialists of the intervention study and 23 non-participating GPs took part. Specialists were from various medical disciplines. Participating GPs were located farther away from a hospital and consulted a higher number of patients. Overall, the collaboration quality at the primary-secondary care interface was good. Whereas specialists and participating GPs were mostly satisfied with their collaboration, non-participating GPs’ reported a lower quality regarding some aspects of collaboration. Furthermore, differences in collaboration quality between general chronic care and SCI specific care could be observed.

Conclusion

The collaboration quality was rather high in participating physicians. The benefit of the intervention would have been higher in non-participating than participating GPs. When participation is optional, interventions to improve collaboration likely do not achieve the effect that would actually be possible.

General Practice

General practitioners

Specialists

Collaboration

Switzerland

Spinal cord injury.

Similar to many other countries, the increasing number of persons with chronic conditions and multimorbidity in Switzerland complicate care provision (1). To manage these conditions, the importance of coordination and continuity between primary and secondary care has been highlighted in quantitative and qualitative studies (2–6), specifically by implementing integrated care approaches (7). Eliminating competition and enhancing the collaboration between care providers will likely sustain high-quality care, tackle unequal access to services and improve productivity (8). Most integrated care approaches create a gatekeeping role, a single contact point for patients, and support the patients in navigating and choosing appropriate professionals (9). These findings have not been systematically implemented in Swiss healthcare, instead highly fragmented healthcare can be observed (10, 11). Most patients with chronic conditions are able to choose healthcare providers freely, and duplication of services occurs frequently (12).

Researchers developed typologies and theoretical frameworks to provide guidance for improving fragmented interfaces of primary and secondary care, (13, 14), as well as described providers’ competencies and preferences for collaboration (15–18). It is suggested, that approaches to implement or improve integrated care cannot be planned without close involvement of health care providers (9), since there seems to be as mismatch about interventions and outcomes that are considered relevant by researchers, on the one hand, and clinicians and patients, on the other hand (19). The own motivation to participate in integrated care is especially relevant for providers, as they are able “to help address health inequalities, improve outcomes, and deliver joined-up, efficient services” (8). In light of this, a quality improvement study showed that participating primary care physicians differed in characteristics and performance levels at baseline, compared to non-participating physicians (20). Furthermore, the authors made evident that participation bias caused by the voluntary nature of research participation led to an intervention, in which the ones who would have benefited the most, did not engage. In summary, researchers should pay close attention to their interventions’ relevance and engagement strategies, as it remained vague how to identify care providers and how to engage them properly.

Spinal cord injury (SCI) is an exemplification of a chronic condition that requires lifelong care for secondary health conditions. These patients’ needs blur boundaries and responsibilities of care providers at the interface of primary and secondary care (21, 22). In Switzerland, individuals with SCI who live close to one of four specialised SCI centres seem to benefit from a good interface, as patient-reported primary care services were rated of high quality (23). In contrast, patient-reported quality of SCI-related care and primary care services were rated unfavourably in rural areas with insufficient transportation possibilities. These findings led to the assumption that collaboration with medical specialists and transfer of knowledge might be better in primary care around specialised centres and of benefit for the patients (24, 25). Even though the specific relation of communication to patient outcomes has not been studied before, its importance is evident (26). With this in mind, the Spinal Cord Injury – Collaboration (SCI-Co) intervention study was started to develop, implement and evaluate a new care model for persons with SCI in rural Switzerland (27). Rural general practitioners (GPs) in the intervention group will receive medical education and practice visits by specialists. Among other objectives, this study will test if collaboration between rural GPs and specialists can be improved. The participants’ characteristics and motivation at baseline of the intervention remained unexplored by now, similar to the gap in the literature.

Therefore, the aims of this study were to 1) explore the motivation of GPs and specialists who participate in an intervention study to improve collaboration, and compare this to GPs who do not participate, and 2) compare the self-reported collaboration quality pre-intervention between participating GPs and specialists, and non-participating GPs.

Sampling

Sampling was based on the physicians’ own motivation to participate (27). Inclusion criteria for GPs comprised: 1) GPs’ practice is located more than 60 minutes car driving distance to the nearest specialised SCI centre, 2) GP group practice, 3) GPs’ practice offers comprehensive services such as ultrasound, physio-, and occupational therapy, and 4) GPs’ practice is accessible for wheelchair users. Those successfully recruited for SCI-Co were referred to as “participating” GPs. Those who were eligible for participation but unwilling to commit were referred to as “non-participating” GPs.

Specialists for SCI from the four specialised centres in Switzerland were asked to participate (28). Specialised physicians were included if they had contact with GPs on a regular basis. The definition of “regular contact” was not further specified, as the centres differ in size and modes of collaboration.

Survey instrument

A questionnaire survey in physicians was conducted to evaluate collaboration. The survey took approximately 15 minutes to complete and had five parts: personal characteristics, employment, characteristics of the place of work, the “Doctor´s Opinion on Collaboration” (DOC) questionnaire, and an estimate of the satisfaction with collaboration. We chose the DOC questionnaire because it is the only tool we know of that can specifically be used with both GPs and medical specialists. The DOC was developed and validated in 2010 by Berendsen et al. in English (29). To survey the DOC in German-speaking physicians, two researchers (AG, RT) independently translated the statements into German. A preliminary German version was agreed on and was translated back to English. Any differences from the original version were discussed and a final German version was developed and tested by a third researcher (SE).

The DOC comprises 20 items to measure five dimensions with positive or negative statements: organisation, communication, professional expertise, perception (originally called “image”), and knowing each other. Physicians rated their agreement on a five-point Likert scale (1 = completely disagree to 5 = completely agree). We added a question regarding the overall satisfaction after the DOC. GPs were asked to fill out the DOC for their collaboration with specialists in general, and for collaborating with specialists for SCI. Likewise, they rated their satisfaction with collaboration for both scenarios. Specialists for SCI were asked to fill out the questionnaire for working with GPs.

Survey administration

Both, GPs and specialists were offered to fill out the survey on a paper-based version or web-based version on SoSci survey. We sent a mail version of the survey to eligible GPs that contained a cover letter explaining the aims of the survey and a stamped return envelope in September 2020. Additionally, the cover letter included the web link to the online version of the survey. Two weeks after receiving the letter, we sent an e-mail reminder to all GPs to invite them again to participate in the survey via mail or SoSci. Research assistants employed at the four specialised SCI centres received the paper-based version of the survey, which included the link to the SoSci version, and handed them to eligible specialists from August to October 2020. Data generated by the paper versions of the survey were entered into the online survey tool by one researcher (RT).

Statistical analysis

Statistical analyses and data preparation were performed using Stata version 15.1 for Windows (College Station, TX). Descriptive statistics in the tables are reported with raw numbers and percentages and continuous variables are reported with mean and standard deviation or median and minimum/maximum if applicable. DOC was visualised for a transparent overview of all five levels of the Likert scale. For the description in the body text, the Likert scales are simplified (answer categories 4 and 5 = agree; answer category 3 = neutral; answer categories 2 and 1 = disagree). We excluded responses with no data for DOC from the analysis.

Ethical approval and informed consent

The ethical approval was sought and awarded by the Ethics Committee of Northwest and Central Switzerland (EKNZ; # 2019-01527-2). The approval confirms that the study fulfils the general ethical and scientific standards for research with humans. The project is carried out in accordance with relevant guidelines and regulations. Participating healthcare professionals provided informed consent for study participation. They confirmed that participation was voluntary, could be redrawn at any time and that non-participation does not result in any negative consequences.

Participant characteristics

Eight GPs and 13 specialists of the intervention study and 23 non-participating GPs took part. None of the participating GPs, 7 specialists and 17 non-participating GPs returned paper questionnaires, all others filled out the online survey. Descriptive statistics of their characteristics are presented in Table 1.

Table 1

– Characteristics of study population
Personal characteristics	Participating GPs (N = 8)	Non-participating GPs (N = 23)	Specialists (N = 13)
Online questionnaire – n (%)	8 (100)	6 (26)	6 (46)
Age in years – mean (SD)	51.5 (7.9)	50.5 (10.2)	44.8 (9.9)
Female – n (%)	3 (38)	7 (30)	5 (39)
Issuing country of academic title, Switzerland – n (%)	5 (63)	18 (78)	1 (8)
Years since receiving academic title – mean (SD)	22.3 (11.8)	20.1 (12.4)	15.3 (12.0)
Years since becoming a GP – mean (SD)	16.2 (10.6)	15 (9.5)	-
Title – n (%)
M.D. and university lecturer	0 (0)	0 (0)	2 (15)
M.D.	8 (100)	19 (83)	10 (77)
Practicing physician	0 (0)	4 (17)	0 (0)
Medical focus – n (%)
General internal medicine	7 (88)	23 (100)	5 (39)
Physical medicine and rehabilitation	0 (0)	1 (4)	5 (39)
Neurology	0 (0)	0 (0)	5 (39)
Tropical medicine	2 (25)	0 (0)	0 (0)
Manual medicine	0 (0)	2 (9)	1 (8)
Urology	0 (0)	0 (0)	2 (15)
Paediatrics	1 (13)	0 (0)	0 (0)
Intensive care	1 (13)	0 (0)	0 (0)
Geriatrics	0 (0)	1 (4)	1 (8)
Emergency medicine	0 (0)	0 (0)	1 (8)
Psychosomatic and psychosocial medicine	0 (0)	0 (0)	1 (8)
Sports medicine	0 (0)	1 (4)	0 (0)
Participation in CME as – n (%)
Participant	8 (100)	22 (96)	13 (100)
Speaker	4 (50)	1 (4)	4 (31)
Yearly activity in CME – n (%)
> 50 hours	4 (50)	10 (44)	4 (31)
45–50 hours	1 (13)	3 (13)	2 (15)
30–44 hours	3 (38)	4 (17)	3 (23)
15–29 hours	0 (0)	5 (22)	2 (15)
5–14 hours	0 (0)	1 (4)	2 (15)
< 5 hours	0 (0)	0 (0)	0 (0)
Employment
Years employed at current place of work – mean (SD)	7.0 (9.0)	13.3 (9.8)	7.5 (7.9)
Self-employed – n (%)	4 (50)	15 (65)	-
Percentage of employment – mean (SD)	74.3 (34.1)	84.3 (16.6)	90.8 (17.1)
Working hours per week – mean (SD)	49.0 (22.5)	44.7 (9.6)	52.8 (10.7)
Patients caring for in one month – mean (SD)	426.0 (199.2)	356.0 (199.9)	59.5 (57.6)
Average patient age – mean (SD)	43.8 (16.9)	53.4 (7.5)	-
Providing care for patients with SCI personally – n (%)	6 (75)	18 (78)	-
Times of weekly contact with specialists/GPs – mean (SD)	9.1 (7.0)	7.9 (6.9)	4.5 (7.7)
Communication channel with specialists/GPs – n (%)
Phone	5 (63)	19 (83)	12 (92)
E-Mail	7 (88)	21 (91)	9 (69)
Telefax	0 (0)	2 (9)	0 (0)
Personal	1 (13)	4 (17)	0 (0)
Abbreviations: CME: Continuous medical education; GPs: general practitioners; HCPs: healthcare professionals; SCI: spinal cord injury; SD: standard deviation. The total for each column differs due to missings.

The majority of respondents were male and GPs were on average slightly older than specialists. One specialist received the academic title in Switzerland in comparison to 23 GPs. GPs seemed to have moderately more experience in clinical practice than specialists. Overall, 43 of 44 physicians attended continuous medical education. A small number of specialists and participating GPs indicated that they are involved in educational events as speakers. Participating GPs’ yearly activity in education was slightly higher than non-participating physicians’ activity.

Even though participating GPs indicated a smaller percentage of employment, the number of working hours per week was slightly higher compared to non-participating GPs. Specialists reported the highest percentage of employment and working hours per week.

Answers regarding the weekly contact differed between professional groups. Participating GPs answered to have on average nine weekly contacts with specialists, non-participating GPs eight times, and specialists five times. All physicians answered to use the phone and e-mail as major communication channels with each other.

Table 2

– Characteristics of work place
Characteristics of place of work	Participating GPs (N = 8)	Non-participating GPs (N = 23)	Specialists (N = 13)
Type of provider – n (%)
Cantonal hospital/ university hospital	-	-	3 (23)
Specialised centre	-	-	10 (77)
Regional or peripheral hospital	-	-	0 (0)
Current position in hospital – n (%)
Chief physician	-	-	1 (8)
Senior physician	-	-	6 (4)
Leading physician	-	-	4 (31)
Hospital physician	-	-	1 (8)
Assistant physician	-	-	1 (8)
Amount beds for acute care in hospital – mean (SD)	-	-	69.8 (62.7)
Group practice (> 1 physician) – n (%)	8 (100)	14 (61)	-
Number of HCPs in practice – median (min-max)
Physicians	2.5 (1–8)	1 (0–7)	-
Medical practice assistants	5 (4–14)	7 (0–13)	-
Medical practice coordinators	1 (0–1)	0 (0)	-
Nurse	0 (0–10)	0 (0–2)	-
Physiotherapist	0 (0–3)	0 (0–10)	-
Occupational therapist	0 (0–4)	0 (0)	-
Speech therapist	0 (0–1)	0 (0)	-
Dietician	0 (0–1)	0 (0–1)	-
Psychologist	0 (0–3)	0 (0)	-
Psychotherapist	0 (0)	0 (0–2)
Using electronic medical records – n (%)	8 (100)	20 (87)	13 (100)
Distance practice to next hospital in km – mean (SD)	15.8 (11.1)	8.9 (6.2)	-
Amount patients consulting practice in one month – mean (SD)	851.7 (388.9)	812.5 (818.1)	-
Colleague cares for patients with SCI – n (%)	2 (25)	5 (22)	-
Abbreviations: GPs: general practitioners; HCPs: healthcare professionals; km: kilometres; SCI: spinal cord injury. The total for each column differs due to missings.

Specialists were from various medical disciplines and mostly employed in specialised centres. The distance to the next hospital was on average a bit higher for participating than for non-participating GPs. All participating GPs and specialists and most non-participating GPs answered that they work with electronic medical records.

DOC questionnaire and satisfaction with collaboration

Answers to the DOC questionnaire are presented in Fig. 1 for collaboration in general care and for SCI care in Fig. 2.

Participating and non-participating GPs for general care

Eight participating and 22 non-participating GPs answered the DOC questionnaire for collaboration in general care. Most GPs (96%) felt that they work well with specialists. Some GPs agreed that the time span between referral and first consult with the specialist (delay) and was too long. However, most GPs agree that they can avoid this delay by having agreements with specialists. The time span between the first consult with the specialist and follow-up (waiting list) does not seem to be too long for the GPs. In contrast to 27% of non-participating GPs, 71% participating GPs did not agree that discharge is well organised by the specialist. Whereas the majority of non-participating GPs wanted to improve the quality of their referrals, participating GPs do not agree. Furthermore, the participating GPs rather tended to want the specialists to improve their referral back to primary care, than the non-participating GPs.

Communication with specialists was mostly agreed to be of good quality and positive. Also, the majority of GPs feels appreciated and confident in their working relationship with specialists. Furthermore, all GPs seem to agree that there are certain benefits to knowing specialists personally. Most participating GPs (71%) are satisfied with their collaboration with specialists for general care. An even larger majority of non-participating GPs (91%) are as well.

Participating, non-participating GPs and specialists for SCI care

Four participating, 14 non-participating GPs and 13 specialists answered the DOC questionnaire for SCI specific collaboration. Most participating (75%) and half of the non-participating GPs agreed that they work well with specialists for SCI. Most specialists (69%) agreed that they work well with GPs and specialists in their hospital. All physicians gave rather mixed answers regarding delay and waiting lists to being too long. Unsurprisingly the majority of specialists (83%) agreed that discharge is well organised by themselves. Most non-participating GPs agreed as well, but participating GPs were rather neutral regarding this statement.

There are more notable differences in SCI specific collaboration quality, between groups of GPs. While none of the participating GPs agreed, some non-participating GPs agreed that their referrals should be improved. Specialists gave mixed answers, but rather agreed than GPs, that their referral to primary care should be improved. Compared to the majority of participating GPs (75%), few of non-participating GPs (42%) appreciated feedback from the specialists for SCI. Moreover, some non-participating GPs (43%) did not feel confident in their working relationship with specialists. Conversely, all specialists and all participating GPs felt confident.

The majority of participating GPs (75%) and specialists (69%) reported to be satisfied with the SCI specific collaboration. In comparison, most, but fewer non-participating GPs (57%) reported to be satisfied.

Main findings

Overall, the collaboration quality at the primary-secondary care interface seemed to be good, as all physicians agreed that they work well together. Especially, communication and the perception seemed to work well. Whereas specialists were mostly satisfied with their collaboration with GPs, there were notable differences between participating and non-participating GPs’ reported quality.

Furthermore, we observed differences between general chronic care and SCI-specific care. In general, non-participating GPs reported a lower collaboration quality with specialists than participating GPs. They reported to be slightly less confident in working with specialists in SCI care. All GPs seemed to have better experiences with discharges by the specialists in general chronic care than in SCI-specific care. Furthermore, participating GPs wanted SCI specialists to learn about how they work and most specialists seemed to agree that they should.

Comparison with existing literature and improvement possibilities

Our study confirmed the fragmentation of the Swiss healthcare system and showed improvement possibilities in referral and discharge processes. In other studies, a lack of discharge communication between primary and secondary care resulted in delayed follow-up treatment, disrupting continuity of care (6, 30). Furthermore, communication lapses were associated with a significantly higher risk of readmission (6). Thus, the improvement or re-organisation of discharge and referral processes back to primary care was focused on in many intervention studies (3, 31, 32). Similar to the findings of Tzartzas et al., the GPs in our study indicated decision-related distress regarding their referral to specialists (33). Most GPs wanted to improve the quality of their referral, but most specialists seemed to be content with it. Furthermore, the quality of the patients’ discharge differed between professions in our study. GPs seemed to be discontent about how the discharge was organised by specialists for both, SCI specific and general care. Tandjung et al. detailed that Swiss GPs reported to lack information about treatments and further requirements within a reasonable time (11).

Our study shows that advancements for collaborative practice were present albeit the fragmented health system in Switzerland. Consistent with previous research, the physicians in our study were aware that knowing each other is beneficial for the working relationship (17, 18). There were no indications that highly-influencing factors for good collaboration such as communication and appreciation of each other (2, 16, 17) were currently lacking. Furthermore, almost all physicians worked with electronic medical records, which were associated with improvements in coordination and communication (5). Contradictory to other results (18, 29), the participating GPs in our study were more interested to educate specialists on their work and competencies, than to only learn from specialists’ expertise. As SCI specialists indicated that they are willing to do so, future collaborative education should incorporate both, general and specialised topics, to stimulate exchange between physicians.

Collaboration quality and characteristics differed between participating and non-participating GPs, confirming that voluntary participation in our intervention has an effect on baseline values (20). Due to the design of our intervention study SCI-Co, we were more prone to identify GPs that were interested in this highly-specialised topic. It is possible that these GPs already consult SCI patients or their motivation to participate could be explained by rather challenging collaboration experiences. Our data on discharge organisation and having solid agreements with specialists for SCI confirms the latter. SCI with its increased health risks and co-morbidities, imposes a highly complex situation to manage. This complexity requires a collaborative attitude with respect and alignment of goals for patient care (2, 16, 17). The interest in SCI and collaborative attitude might have resulted in effort and self-designed improvement strategies; ultimately resulting in higher satisfaction and collaboration quality. Nonetheless, there are GPs, who are not particularly interested to communicate with SCI specialists (26). As SCI is a particular rare condition, the necessity to improve collaboration with SCI specialists might seem to appear rather low. For these physicians, the low level of interaction between physicians results in low interest in the topic, which then results in a lower collaboration quality. As non-participating GPs would benefit the most from our intervention and patients with SCI wish to have a GP that can be contacted (21, 22, 25), we need to find possibilities to engage some of them after our intervention study in a policy improvement scheme.

Further research should explore how roles and responsibilities are defined and acknowledged in daily practice and if physicians are willing to shift roles to optimise access to care for patients with specific needs or living in rural areas. Later on, tools for enhancing communication and information exchange between physicians of different care levels could be explored. The new knowledge could then inform research plans and designs and ultimately, policy makers, who become interested to improve the current model of care.

Limitations and strengths

We realise that the study’s sample size is quite small and limited by the design of our intervention study. Nevertheless, we were able to find a comparable large number of GPs for the control group. Furthermore, SCI is rather rare, but we believe that clinicians and researchers can learn from the complexity and necessity for interdisciplinary care it imposes. This seems to be the first study to look at the motivation to collaborate and perceived collaboration quality of physicians at the primary and secondary care interface for patients with SCI.

Overall, the collaboration quality was rather high in participating physicians. The potential benefit of the intervention would have been higher in non-participating than participating GPs. When participation is optional, interventions to improve collaboration likely do not achieve the effect that would actually be possible

Ethics approval and consent to participate

The ethical approval was sought and awarded by the Ethics Committee of Northwest and Central Switzerland (EKNZ; # 2019-01527-2). The approval confirms that the study fulfils the general ethical and scientific standards for research with humans. The study was registered in clinicaltrials.gov (# NCT04071938, registered on 26/08/2019).

Consent for publication

Not applicable.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors did not receive specific funding for this study.

Authors' contributions

RT and SE designed the study, developed the questionnaires and wrote the main parts of the manuscript. RT assessed and analysed the data. RT and AG translated the DOC questionnaire. All authors reviewed and approved the final manuscript.

Acknowledgements

We would like to thank all physicians who participated in this study.

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No competing interests reported.

Who Wants To Improve Collaboration in Services for Individuals with Chronic Conditions? Specialists and Rural General Practitioners Taking Action in a Fragmented Health Care System

Status:

Version 1

Abstract

Introduction

Methods

Results

Conclusion

Figures

Introduction

Methods

Sampling

Survey instrument

Survey administration

Statistical analysis

Ethical approval and informed consent

Results

Participant characteristics

DOC questionnaire and satisfaction with collaboration

Participating and non-participating GPs for general care

Participating, non-participating GPs and specialists for SCI care

Discussion

Main findings

Comparison with existing literature and improvement possibilities

Limitations and strengths

Conclusion

Declarations

Ethics approval and consent to participate

Consent for publication

Availability of data and materials

Competing interests

Funding

Authors' contributions

Acknowledgements

References

Additional Declarations

Supplementary Files

Status:

Version 1