Weak association between socioeconomic Care Need Index and primary care visits per registered patient in three Swedish regions

Abstract

Objective

The objective was to examine the association between primary care consultations and a Care Need Index (CNI) used to compensate Swedish primary care practices for the extra workload associated with patients with low socioeconomic status.

Design

Observational study combining graphical analysis with linear regressions of cross-sectional administrative practice-level data.

Setting

Three Swedish regions, Västra Götaland, Skåne and Östergötland (3.5 million residents). Outcomes were measured in February 2018 and the CNI was computed based on data for 31 December 2017.

Subjects

The unit of analysis was the primary care practice (n = 390).

Main outcome measures

i) Number of GP visits per registered patient; ii) Number of nurse visits per registered patient; iii) Number of morbidity-weighted GP visits per registered patient; iv) Number of morbidity-weighted nurse visits per registered patient.

Results

The linear associations between the CNI and GP visits per patient were positive and statistically significant (p<0.01) for both the unweighted and weighted measure in two regions, but the associations were mainly due to 10 practices with very high CNI values. The results for nurse visits varied across regions.

Conclusions

For most levels of the CNI, there was no association with the number of consultations provided. This result may indicate insufficient compensation, weak incentives to spend the money, decisions to spend the money on other things than consultations, or stronger competition for patients among low-CNI practices. The result of this observational study should not be taken as evidence against the possibility that the CNI adjustment of capitation may have affected the socioeconomic equity in GP and nurse visits.

Key Points

• Swedish primary care practices receive extra compensation for socioeconomically deprived patients but it is unknown how this affects service provision.

• Practice-level data from three regions years 2017-2018 indicate weak or no relation between the socioeconomic burden and the number of physical consultations per patient.

• Results are similar when adjusting for patients' morbidity levels, suggesting that the weak gradient was not explained by longer consultations.

• The exception is that a small number of practices with very high burdens provide more consultations per patient.

• The results may reflect insufficient compensation, lack of incentives, or funds being spent on other things than consultations.

Keywords:

• Family practice
• health economy
• health services research
• quality development
• statistics
• Care Need Index
• risk-adjusted payment

Disclosurestatement

No potential conflict of interest was reported by the author(s).

Notes

1 Two PCCs lacked data from January.

2 In Västra Götaland, the ACG was calculated using only diagnoses set in primary care; in the other regions, we also included diagnoses registered in secondary care. The ACGs based on primary care cost weights from 2013 mapped to primary care diagnoses (Västra Götaland) or all diagnoses (other regions).

3 We preferred the model for February because the CNI was calculated based on background characteristics as of 31 Dec 2017 and thus describes the patient population better in early 2018. (January would be even better, but the data was incomplete for two PCCs, see endnote 1.)

Additional information

Funding

Funding from the Swedish Research Council of Health, Working Life and Welfare (FORTE) is gratefully acknowledged.