Abstract
Objective. This study examined whether age, gender, and comorbidity were of importance for an individual's choice of listing with either a public or a private primary health care (PHC) practice. Design and setting. The study was a register-based closed cohort study in one private and one public PHC practice in Blekinge County in southern Sweden. Subjects. A cohort (12 696 individuals) was studied comprising all those listed with the public or private PHC practice on 1 October 2005 who were also listed with the public PHC practice on 1 October 2004. Main outcome measures. The listing/re-listing behaviour of the population in this cohort was studied at two points in time, 1 October 2005 and 1 October 2006, with respect to age, gender, and comorbidity level as measured by the ACG Case-Mix system. Results. Individuals listed with the public practice both on 1 October 2005 and one year later were significantly older, were more often females, and had a higher comorbidity level than individuals listed with the private practice. Individuals with a higher comorbidity level were more likely to re-list or to stay listed with the public practice. Conclusions. This study shows that the probability of choosing a public instead of private PHC provider increased with higher age and comorbidity level of the individuals. It is suggested that using a measure of comorbidity can help us understand more about the chronically ill individual's choice of health care provider. This would be of importance when health care policy-makers decide on reimbursement system or organization of PHC.
In a market-oriented primary health care (PHC) system, such as is under development in Sweden, it is important to be able to understand and to monitor factors of importance for the individual's choice of PHC provider.
It was found that age, gender, and comorbidity were important factors for the choice of PHC provider.
The probability to choose a public rather than private PHC provider increased with higher age, female gender, and higher comorbidity level of the individuals.
The number of primary health care (PHC) patients with more than one chronic disease is increasing and they account for a large part of all resources in the health care system [Citation1]. These patients’ perceptions and trust in their PHC provider is important for the whole health care system. Comorbidity increases in an ageing population [Citation2] and a previous study from Sweden has shown that prevalence of patients with more than one chronic disease can be as high as 55% in patients over 77 years old [Citation3], but can range between 10% for patients under 20 years old to more than 70% for patients over 80 years old [Citation4].
PHC in Sweden is not financed, provided, and organized by the state. It is financed by the county councils and provided by either the county councils or by other health care providers. In the 1990s criticism of public health care for its bureaucracy, low efficiency, and long waiting times [Citation5,Citation6] was a reason to start privatization of the health care system. So far it has had the result that about 13% of general practitioners work as private doctors, but only a few private hospitals exist [Citation7].
However, recently there has been an increase in the private health care sector due to a change in regulations in Swedish health care. Individuals in many Swedish counties can now freely choose whether they want to be listed with a public or a private PHC practice. It has given rise to a debate regarding the access of care for individuals in socioeconomically challenged areas and elderly individuals with comorbidities [Citation8,Citation9]. Access to a private PHC can be different from a public one because in order to increase profits the private PHC tends to decrease costs [Citation10] as it is solely reimbursed by the county council. Public PHC in Sweden is non-profit. In a study from Finland, suffering from chronic disease was associated with worse accessibility to private PHC, although generally accessibility and continuity of care in private PHC were better than in public PHC [Citation11]. Patients’ choice of health care provider, especially with regard to patients with comorbidities, has become a hot topic and a cause of much debate during the current privatization of PHC in Sweden.
The aim of this study was to investigate whether comorbidity was of importance for the individual's choice of listing with either public or private PHC in a municipality in Blekinge, Sweden.
Material and methods
Study design and study population
The study population comprised all those listed (16 882) with two PHC practices (one private and one public) serving the municipality of Ronneby in Blekinge County in southern Sweden, with urban and rural areas, during the period from 1 October 2005 to 1 October 2006. Data on age, gender, and date of listing/re-listing were obtained from the Blekinge County Council's listing database (LisBet™).
From the study population, a sub-population was identified as a closed cohort comprising all those 12 696 individuals listed with the public practice on 1 October 2004, who were listed with either the public or the private practice on 1 October 2005 ( and ). The sub-population was identified as the comorbidity calculation using the ACG Case-Mix system needed data on collected diagnoses one year prior to the start of the study, which was obtainable only from individuals listed with the public practice in 2004.
Figure 1. Flow of individuals in study cohort between PHC practices.
Notes: A = individuals listed with the public practice on 1 October 2004; A1 = individuals listed with the public practice on 1 October 2005; A2 = individuals listed with the public practice on 1 October 2006; B1 = individuals listed with the private practice on 1 October 2005; B2 = individuals listed with the private practice on 1 October 2006. 891 individuals died or moved during the follow-up.
Figure 2. Flow of individuals in study cohort between PHC practices in respect of gender.
Key: ♀ = female; ♂ = male; A = individuals listed with the public practice on 1 October 2004; A1 = individuals listed with the public practice on 1 October 2005; A2 = individuals listed with the public practice on 1 October 2006; B1 = individuals listed with the private practice on 1 October 2005; B2 = individuals listed with the private practice on 1 October 2006.
Variables
The dependent variable was the listing/re-listing status of the individuals from the cohort with regard to the public or the private PHC practice on 1 October 2005 and 1 October 2006.
The independent variables were model of PHC, comorbidity, age, and gender. Two PHC practices served the municipality of Ronneby. One of these practices was a county council-owned PHC practice (public) established in 1974, which in 2005 had 6.25 positions for family physicians. On 1 October 2005 a private PHC practice with three positions opened under contract with Blekinge County Council to offer services similar to those of the public practice. In Blekinge County individuals can actively choose to list with the family physician they want. Those who do not make a choice are passively listed with the nearest PHC practice and they can re-list with the other practice whenever they wish.
The Johns Hopkins ACG (Adjusted Clinical Groups) Case-Mix System [Citation12] was used as the measure of comorbidity. This system was developed in the 1980s to evaluate the relationship between individual morbidity and utilization of health care services. Each ACG group consists of individuals with the same type and degree of comorbidity [Citation13,Citation14]. In our study all individuals in the study population were assigned to one of six levels of comorbidity, so-called resource utilization bands (RUBs). The population in RUB 0 had no need for health care and those in RUB 5 had a very high degree of need for health care resources.
Statistical analysis
In order to analyse the differences between the number of individuals listed with the public and the private practice and re-listing during the study period, chi-squared tests were used. To analyse the importance of comorbidity level for re-listing, logistic regression was used. We analysed the relation between comorbidity level and re-listing status after adjusting for age and gender in two subsequent models. A result of p < 0.05 was considered statistically significant.
All analyses were performed using the statistical package STATA version 10 (Stata Corporation, Texas, USA).
Results
Listing status at beginning and end of study
The opening of the private PHC practice on 1 October 2005 reduced the number of individuals in the study cohort originally listed with the public PHC practice on 1 October 2004 by 11.6% (). The proportion of males listed with the private practice was significantly higher than in the public practice, both at the beginning and at the end of the study (). The proportion of children (aged 0–19) listed with the private practice was higher compared with the public practice at the end of the study (). Individuals aged over 60 were more often listed with the public practice, whereas young adults (aged 20–39) more often were listed with the private practice, both at the beginning and at the end of the study. On 1 October 2005 the individuals listed with the public practice had significantly higher comorbidity level than those listed with the private practice (). We observed that the number of individuals with higher comorbidity level (RUB 2–5) increased significantly at the public practice during our study ().
Table I. Number of individuals in public and private practice at the beginning and end of the study with regard to gender, age, and level of comorbidity.
Re-listing during the study
The proportion of females who remained listed with the public practice was higher than in the group who re-listed with the private practice (). A higher proportion of children and individuals aged 40–59 was found in the group re-listed with the private practice (). A higher proportion of older individuals (over 60 years) was found in the group that remained listed or re-listed with the public practice compared with the private practice ().
Table II. Number of individuals who stayed listed with the same practice and who re-listed with the other practice during the study with regard to gender, age, and level of comorbidity.
Individuals with the lowest comorbidity level (RUB 0) dominated in the group that re-listed with the private practice (see ). Individuals with higher comorbidity level (RUB 2 and higher) were more likely to remain listed with the public practice (see ). The odds ratio for re-listing with the public practice increased with a higher comorbidity level of individuals who were listed with the private practice at the beginning of our study ().
Table III. Age-adjusted and multivariate odds ratios for re-listing with private and public practice during the study period (1 October 2005–1 October 2006).
Discussion
Main findings
In this study we found that a higher comorbidity level, female gender, and age above 60 years were significantly associated with higher probability of being listed with the public practice. A higher comorbidity level and age were also correlated with higher probability of re-listing with the public practice. Using a measure of comorbidity can help us understand more about the chronically ill individual's choice of health care provider.
Strengths and weaknesses of the study
Our data on age, gender, and diagnosis codes are from electronic patient records, which ensure that all the data were included. The ACG Case-Mix system that we used has been evaluated in many countries as a valid tool to estimate comorbidity level [Citation15,Citation16].
The comorbidity level was based only on diagnoses that individuals received at the public PHC practice during the period up to one year before the beginning of our study. Therefore differences in validity and quality of diagnoses between the private and public PHC practice did not influence the results in our study. In a study in Blekinge, about 75% of the inhabitants had at least one visit to their PHC physician during a three-year period and almost 90% of all visits had a registered diagnosis [Citation17]. The diagnoses were not validated. During the period of this study the ACG Case-Mix system was not used for reimbursement, which makes manipulation such as up-coding unlikely. It is more likely that some diagnoses were not registered for various reasons [Citation18].
Distance has an influence on the individual's choice of PHC physician [Citation19,Citation20]. In our study individuals who were listed with both the practices lived close to their respective PHC practice. The influence of distance to the PHC physician on the individual's choice seems unlikely in our study.
The study explored differences in gender, age, and comorbidity level in individuals listed with only two PHC practices, so it is difficult to extrapolate the findings.
Patients in Sweden pay the same rates for both public and private PHC so the economic side of the choice of PHC practice is not as important as it may be in most other countries.
Previous work
Comorbidity is important to take into account when studying choice in PHC because the variation in comorbidity level increases with age. ACG explained about 50% of the variance in use of outpatient care and age and gender only 6–7% [Citation15,Citation16]. Our results agree with other studies in that younger individuals re-list more often [Citation21]. Younger patients more often want to be actively involved in medical decision-making concerning themselves [Citation22], which may make them more active in their choices of the type of PHC practice. Younger age is generally associated with a higher mobility, but another possible explanation could be that private practices offer better accessibility, which is important for this patient group [Citation11]. A possible explanation of the individual's listing choice could be different needs for contact with the PHC team. A study from Sweden shows that older individuals prefer to have stable contact with one PHC physician, while individuals on the labour market prefer to list with a PHC team comprising both physicians and nurses [Citation23]. Also, a low number of patients with higher comorbidity listed with the private practice may be due to the fact that individuals with higher comorbidity chose the public practice. Individuals with higher comorbidity level, probably having previously established good contact with the public PHC practice, chose it to guarantee stable future contact. Individuals’ preferences can also relate to the doctor–patient relationship [Citation24] and patients may prefer physicians whom they have known longer and whose personal attributes and characteristics suit the patients better [Citation25].
Conclusion
With this study we have shown that the probability of choosing a public instead of a private PHC provider increased with higher age and comorbidity level of the individuals. Using a measure of comorbidity can help us understand more about the chronically ill individual's choice of health care provider.
The importance of comorbidity should be made visible for health care policy makers, so that they can make appropriate choices for improving care of elderly patients with comorbidities, when they decide on reimbursement system or organization of PHC. We suggest that a patient's comorbidity level is an important factor when studying individuals’ choice of PHC provider. Further insight could be gained by further studying the reasons for listing or re-listing in individuals with different comorbidity levels.
Ethics
The study was approved by the Research Ethics Committee at Lund University.
Acknowledgements
This study was supported by Blekinge County Council.
Competing interests
The authors declare that they have no competing interests.
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