Danish general practitioners as gatekeepers for gynaecological patients in regions with different density of resident specialists in gynaecology: in which situations and to whom do they refer? A cross-sectional study

Figures & data

Table 1. Characteristics of responding general practitioners (N = 347).

	Capital Region N (%)	Region of Zealand N (%)	Southern Region N (%)	Central Region N (%)	Northern Region N (%)	All N (%)
Total	62 (17.9)	76 (21.9)	68 (19.6)	74 (21.3)	67 (19.3)	347 (100)
Sex
Males	28 (45.2)	26 (34.2)	28 (41.2)	28 (37.8)	24 (35.8)	134 (38.6)
Females	34 (54.8)	50 (65.8)	40 (58.8)	46 (62.2)	43 (64.2)	213 (61.4)
Age
≤50 yrs.	29 (47.5)	39 (51.3)	37 (54.4)	36 (48.7)	36 (53.7)	177 (51.2)
51–60 yrs.	17 (27.9)	18 (23.7)	18 (26.5)	20 (27.0)	14 (20.9)	87 (25.1)
≥61 yrs.	15 (24.6)	19 (25.0)	13 (19.1)	18 (24.3)	17 (25.4)	82 (23.7)
Years of experience as a GP
5 yrs. or less	18 (29.0)	15 (19.7)	14 (20.6)	21 (28.4)	14 (20.9)	82 (23.6)
6–10 yrs.	6 (9.7)	12 (15.8)	18 (26.5)	12 (16.2)	13 (19.4)	61 (17.6)
More than 10 yrs.	38 (61.3)	49 (64.5)	36 (52.9)	41 (55.4)	40 (59.7)	204 (58.8)
Number of doctors in the practice
One	23 (37.7)	24 (31.6)	21 (30.9)	21 (28.8)	22 (32.8)	111 (32.2)
2–3	28 (45.9)	39 (51.3)	30 (44.1)	30 (41.1)	29 (43.3)	156 (45.2)
4 or more	10 (16.4)	13 (17.1)	17 (25.0)	22 (30.1)	16 (23.9)	78 (22.6)
Distribution by sex
All doctors are women	18 (29.5)	24 (31.6)	13 (19.1)	18 (24.3)	16 (23.8)	89 (25.7)
All doctors are men	16 (26.2)	15 (19.7)	15 (22.1)	16 (21.6)	14 (20.9)	76 (22.0)
Both female and male doctors	27 (44.3)	37 (48.7)	40 (58.8)	40 (54.1)	37 (55.2)	181 (52.3)
All doctors see gynaecological patients
Yes	59 (96.7)	72 (94.7)	64 (95.5)	73 (98.7)	67 (100)	335 (97.1)

There were no statistically significant differences in any GP characteristics between regions (p > 0.05 for Pearson’s Chi-Squared test).

Capital Region: 20.000, Region of Zealand: 46.000, Southern Region: 52.000, Central Region: 71.000 and Northern Region: 145.000 women per Resident Specialist in Gynaecology.

Table 2. Numbers and proportions of General Practitioners (GPs) referring to Resident Specialist in Gynaecology (RSG), Hospital/Outpatient Clinic (HOC) and both equally in specific situation according to a survey of Danish GPs.

	Total
	RSG	HOC	Both
	N (%)	N (%)	N (%)
Where do you most often refer to?	217 (62.9)	33 (9.6)	95 (27.5)
When do you choose one treatment site over another?
Waiting time	164 (62.4)	88 (33.5)	N/A
Suspicion of cancer	37 (11.2)	282 (85.5)	11 (3.3)
The patients’ wish	150 (58.6)	49 (19.1)	57 (22.3)
Severity of the disease	32 (10.5)	262 (85.9)	N/A
Service	195 (82.6)	22 (9.3)	19 (8.1)
Distance	131 (66.5)	43 (21.8)	23 (11.7)
If waiting time and distance were the same; where would you prefer to refer?	239 (85.1)	42 (15.0)	–

GP: General Practitioner; RSG: Resident Specialist in Gynaecology; HOC: Hospital/Outpatient Clinic; N/A: not available, missing or insufficient data.

Table 3. General Practitioners’ reason for referring gynaecological patients to a Resident Specialist in Gynaecology, to a hospital/outpatient clinic or both.

	RSG OR (95% CI)	HOC OR (95% CI)	Both OR (95% CI)
Most often referred to
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	0.31* (0.10; 0.98)	0.81 (0.05; 13.27)	6.19* (1.34; 28.59)
Southern Region	0.15* (0.05; 0.48)	3.81 (0.41; 35.07)	9.23* (2.03; 42.04)
Central Region	0.04* (0.01; 0.11)	8.45* (1.04; 68.65)	33.43* (7.60; 146.98)
Northern Region	0.04* (0.01; 0.12)	22.41* (2.89; 173.80)	17.86* (4.01; 79.49)
Waiting time
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	0.44* (0.22; 0.91)	4.06* (1.10; 14.96)	1.81 (0.32; 10.19)
Southern Region	0.34* (0.16; 0.70)	8.19* (2.30; 29.23)	0.49 (0.04; 5.48)
Central Region	0.15* (0.07; 0.32)	11.97* (3.42; 41.84)	1.86 (0.33; 10.48)
Northern Region	0.22* (0.11; 0.47)	10.98* (3.10; 38.81)	N/A
Suspicion of cancer
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	0.65 (0.28; 1.49)	1.26 (0.61; 2.59)	3.39 (0.37; 31.12)
Southern Region	0.30* (0.11; 0.84)	2.17 (0.97; 4.83)	4.84 (0.55; 42.62)
Central Region	0.04* (0.01; 0.34)	8.96* (2.88; 27.93)	N/A
Northern Region	0.10* (0.02; 0.44)	6.35* (2.22; 18.19)	0.92 (0.06; 15.09)
The patients’ wish
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	0.97 (0.50; 1.90)	1.02 (0.38; 2.77)	3.04* (1.05; 8.84)
Southern Region	0.85 (0.42; 1.69)	1.60 (0.61; 4.16)	2.69 (0.90; 8.06)
Central Region	0.65 (0.33; 1.30)	0.82 (0.29; 2.32)	2.43 (0.81; 7.25)
Northern Region	0.92 (0.46; 1.85)	1.18 (0.44; 3.22)	2.00 (0.64; 6.22)
Severity of the disease
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	1.06 (0.37; 3.02)	1.42 (0.66; 3.06)	0.40 (0.04; 4.52)
Southern Region	1.86 (0.69; 5.01)	0.62 (0.30; 1.29)	1.88 (0.33; 10.61)
Central Region	N/A	1.92 (0.85; 4.32)	0.83 (0.11; 6.09)
Northern Region	0.37 (0.09; 1.49)	2.33 (0.98; 5.55)	0.92 (0.13; 6.76)
Service
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	0.96 (0.48; 1.91)	0.40 (0.04; 4.52)	1.23 (0.20; 7.62)
Southern Region	1.08 (0.53; 2.21)	0.45 (0.04; 5.06)	0.91 (0.12; 6.66)
Central Region	0.53 (0.27; 1.05)	2.17 (0.41; 11.62)	3.13 (0.63; 15.67)
Northern Region	0.48* (0.24; 0.97)	7.22* (1.56; 33.47)	2.42 (0.45; 12.95)
Distance
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	0.96 (0.49; 1.89)	1.65 (0.15; 18.61)	0.81 (0.11; 5.93)
Southern Region	0.54 (0.27; 1.09)	7.00 (0.84; 58.59)	1.88 (0.33; 10.61)
Central Region	0.19* (0.09; 0.41)	13.00* (1.65; 102.43)	3.64 (0.74; 17.80)
Northern Region	0.24* (0.11; 0.51)	25.96* (3.36; 200.35)	3.50 (0.70; 17.54)

Data presented as odds ratio (OR) with 95% confidence interval (CI).

Capital Region: 20.000, Region of Zealand: 46.000, Southern Region: 52.000, Central Region: 71.000 and Northern Region: 145.000 women per Resident Specialist in Gynaecology.

GP: General Practitioner; RSG: Resident Specialist in Gynaecology; HOC: Hospital/Outpatient Clinic; *Significant Result; N/A: not available, missing or insufficient data.

Table 4. Referral pattern of GPs analysed by diagnosis.

	RSG	HOC	GP
	Total	Total	Total
	N (%)	N (%)	N (%)
Excessive and frequent menstruation with regular cycle	203 (58.5)	56 (16.1)	184 (53.0)
Lichen simplex chronicus	263 (75.8)	51 (14.7)	88 (25.4)
Postmenopausal bleeding	174 (50.1)	162 (46.7)	38 (11.0)
Menopausal and perimenopausal disorder	149 (42.9)	N/A	272 (78.4)
Dyspareunia	248 (71.5)	74 (21.3)	82 (23.6)
Insertion of IUD	145 (41.8)	N/A	258 (74.3)

GP: General Practitioner; RSG: Resident Specialist in Gynaecology; HOC: Hospital/Outpatient Clinic; N/A: not available, missing or insufficient data.

Table 5. Table showing proportions of GPs who report to refer to (i) Resident Specialist in Gynaecology, (ii) Hospital/Outpatient Clinic or (iii) provide own treatment of five specific conditions divided by region.

	RSG OR (95% CI)	HOC OR (95% CI)	GP OR (95% CI)
Excessive and frequent menstruation with regular cycle
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	0.93 (0.46; 1.88)	0.06 (0.01; 0.28)	1.62 (0.82; 3.20)
Southern Region	0.83 (0.40; 1.70)	0.67 (0.31; 1.45)	0.74 (0.37; 1.49)
Central Region	0.67 (0.33; 1.35)	0.81 (0.39; 1.70)	1.18 (0.60; 2.31)
Northern Region	0.39 (0.19; 0.80)	N/A	1.23 (0.62; 2.47)
Lichen simplex chronicus
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	0.80 (0.22; 2.99)	0.40 (0.04; 4.52)	2.90 (1.07; 7.83)
Southern Region	0.29 (0.09; 0.95)	4.58 (0.95; 22.08)	1.61 (0.55; 4.72)
Central Region	0.36 (0.11; 1.17)	4.69 (0.99; 22.27)	3.46 (1.29; 9.26)
Northern Region	0.03 (0.01; 0.08)	22.89 (5.16; 101.53)	9.62 (3.65; 25.33)
Postmenopausal bleeding
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	0.31 (0.14; 0.71)	4.09 (1.63; 10.23)	1.10 (0.43; 2.82)
Southern Region	0.24 (0.11; 0.56)	5.84 (2.32; 14.69)	0.79 (0.28; 2.18)
Central Region	0.05 (0.02; 0.13)	21.21 (8.29; 54.26)	0.52 (0.17; 1.55)
Northern Region	0.09 (0.04; 0.21)	17.21 (6.72; 44.09)	0.28 (0.07; 1.07)
Menopausal and perimenopausal disorder
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	2.13 (1.07; 4.24)	N/A	0.59 (0.24; 1.43)
Southern Region	1.52 (0.75; 3.09)	0.32 (0.03; 3.14)	0.51 (0.21; 1.25)
Central Region	1.46 (0.73; 2.93)	1.22 (0.26; 5.66)	0.57 (0.23; 1.39)
Northern Region	0.89 (0.43; 1.84)	N/A	0.59 (0.24; 1.46)
Dyspareunia
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	1.05 (0.43; 2.53)	5.23 (0.61; 44.63)	0.98 (0.47; 2.04)
Southern Region	0.76 (0.32; 1.82)	11.77 (1.47; 94.06)	0.48 (0.21; 1.11)
Central Region	0.51 (0.22; 1.16)	25.81 (3.36; 197.96)	0.67 (0.31; 1.45)
Northern Region	0.16 (0.07; 0.37)	62.85 (8.23; 479.83)	0.44 (0.19; 1.03)
Insertion of IUD
Capital Region	1 (Ref)	1 (Ref)	1 (Ref)
Region of Zealand	0.81 (0.41; 1.59)	0.17 (0.02; 1.45)	2.19 (1.04; 4.61)
Southern Region	0.79 (0.40; 1.57)	0.38 (0.07; 2.01)	1.41 (0.68; 2.92)
Central Region	0.72 (0.37; 1.42)	0.52 (0.12; 2.28)	2.96 (1.35; 6.51)
Northern Region	0.40 (0.19; 0.82)	N/A	2.39 (1.10; 5.21)

GP: General practitioner; RSG: Resident Specialist in Gynaecology; HOC: Hospital/Outpatient Clinic.

Capital Region: 20.000, Region of Zealand: 46.000, Southern Region: 52.000, Central Region: 71.000 and Northern Region: 145.000 women per Resident Specialist in Gynaecology.

N/A: not available, missing or insufficient data.

Table A1. Questionnaire.

These questions are about you and your practice.
In which region is the practice you work in?	North Denmark Region
	Central Denmark Region
	Region of Southern Denmark
	Region Zealand
	Capital Region of Denmark
How long have you been a general practitioner?	Less than 2 yrs.
	2–5 yrs.
	6–10 yrs.
	More than 10 yrs.
What is your SEX?	Man
	Woman
How old are you?	Younger than 40 yrs.
	40–45 yrs.
	46–50 yrs.
	51–55 yrs.
	56–60 yrs.
	61–65 yrs.
	66–70 yrs.
	71 or older
How many doctors work in the practice you work in?	I'm the only doctor
	We are 2–3 doctors
	We are 4 doctors or more
How is the sex distribution in your practice?	All doctors are women
	All doctors are men
	Both female and male doctors
Do all doctors in your practice see gynaecological patients?	Yes
	No
	Don’t know
These questions are about where you prefer to refer your gynaecological patients.
When you refer a woman to a gynaecologist, where do you most often refer to?	Hospital/Outpatient Clinic Resident Specialist in Gynaecology
	Both equally
If there were the same conditions in terms of waiting time and distance, where would you prefer to refer to?	Hospital/Outpatient Clinic Resident Specialist in Gynaecology
If there was a Resident Specialist in Gynaecology closer to your practice, would you refer more women to the Resident Specialist in Gynaecology instead of the Hospital/Outpatient Clinic?	Yes No
When do you choose one treatment site over the other?
	Hospital/Outpatient Clinic	Resident Specialist in Gynaecology
Waiting time	O	O
Suspicion of cancer	O	O
Patients wish	O	O
Severity of the disease	O	O
Service	O	O
Distance	O	O
What do you mostly do with women for the diagnoses listed below?
	Referral to Hospital/Outpatient Clinic	Referral to Resident Specialist in Gynaecology	Treat in my own practice
DN920B, menorraghia et polymenorrhoea	O	O	O
DL280A, Lichen sclerosus et atrophicus	O	O	O
DN950, metrorrhagia menopausalis	O	O	O
DN959, menopausal and perimenopausal disorder	O	O	O
DN941, dyspareunia	O	O	O
DZ301, insertion of IUD	O	O	O