Individual and area factors associated with general practitioner integration in Australia: A multilevel analysis

Abstract

The further integration of primary care within the wider health system is an imperative for reform in all countries. The aim of this paper is to determine the factors associated with general practitioner (GP) integration using the GP Integration Index which has been recently developed and is demonstrating good reliability. The analysis is based on a database derived from an Australia-wide mail questionnaire survey of 1874 GPs drawn from a 20% stratified random sample of 123 Divisions of General Practice (47.8% adjusted response rate). The GP Integration Index measures the level of GPs’ integration with the health care system based upon a description of their own behaviour. It consists of nine GP integration factors, and their two associated higher-order factors—Primary Care Management (PCM) and Community Health Role (CHR)—as well as five GP integration enabling factors. A multivariate multilevel analysis was undertaken. An explanatory model for both PCM and CHR was tested based on the GP integration factors as well as general practice, GP and regional characteristics.

CHR and PCM were most strongly associated with GP integration enabling factors (mainly at the individual-level) and, for CHR only, with urban–rural location (mainly at the area-level). The most important single explanatory variable for both PCM and CHR was the GP integration enabling factor, “Knowledge of local resources.” The important explanatory variables were those reflecting the way GPs work, rather than their broad ‘classification’ within individual or GP-setting groupings. Based on these results, some revision to the proposed model was necessary.

We conclude that processes of care factors (as compared to structure of care factors) are more important in relation to GP integration than previously recognised. Future policy initiatives to promote GP integration should focus on programs to improve GP's knowledge of local resources.

Introduction

Integration of primary care within the wider health system has been identified as an imperative for reform in health care systems throughout the world. (McCormick & Boyd, 1994). This reflects the increasing number of services that individuals with illnesses, particularly chronic illnesses requiring ongoing care, must receive (and in the correct sequence) for care to be optimal. General practice has been a central focus of many of these reforms, many of which have involved the integration of general practitioners (GPs) with the health care system. Australian initiatives include Coordinated Care Trials, Shared Care programs, GP–Hospital liaison schemes, Hospital in the Home and IT strategies linking GPs to other health care providers (Powell-Davies et al., undated). Whether these various integration initiatives really promote better use of resources and lead to better long-term patient health outcomes is still unclear (Department of Human Services, Victoria, 2000). More generally, the concept of GP integration has been little explored. What is the meaning of the concept and how should it be defined? What are the content and boundaries of this term? What are the constituent dimensions in what is clearly a multidimensional concept? Also what are the factors—whether organisational or behavioural—that promote GP integration with the health care system?

A constraint to evaluation and a better understanding of the concept and its associated factors is that, until recently, the concept has not been intensively studied with the purpose of producing a valid and reliable scale to measure GP integration. The GP Integration Index was developed specifically to overcome this limitation (e.g. Southern, Batterham et al., 2002). It provides a measure of the level of GPs’ integration with the health care system based upon a description of their own behaviour.

The aim of this paper is to determine the factors associated with GP integration using this Index. The purpose for doing so is that, if these factors can be identified, some may be amenable to change through the policy-making process, leading to greater GP and health service integration. A dataset of a national, stratified-random sample of Australian GPs who had completed the GP Integration Index was subjected to a multilevel analysis to this end. This form of analysis was chosen because the conceptual model developed in Batterham et al. (2002) made clear that these factors may be area-based particularly those relating to the characteristics of the health care system. They may also be related more directly to characteristics of the individual GP, only some of which reflect the characteristics of the system. With individual GPs practising within nominated geographical areas, the data have a natural hierarchical structure.