The role of family practice in different health care systems: A comparison of reasons for encounter, diagnoses, and interventions in primary care populations in the Netherlands, Japan, Poland, and the United States

Okkes IM, Polderman GO, Fryer GE, Yamada T, Bujak M, Oskam SK, Green LA, Lamberts H

OBJECTIVE: Our goal was to compare the content of family practice in different countries using databases containing information on reasons for encounter, diagnoses, and interventions that are coded with or can be addressed by the International Classification of Primary Care (ICPC). STUDY DESIGN: In the Netherlands, Japan and Poland data were collected identically with an electronic patient record (Transhis). For all face-to-face encounters the reasons for encounter, diagnoses, and interventions were coded according to the ICPC within an episode of care structure; prescriptions were coded with the ICPC drug code. We derived comparable estimates for the United States using visit data from the National Ambulatory Care Survey (NAMCS), with specific emphasis on the contribution of family physicians. NAMCS data were mapped to the ICPC and the ICPC drug code, and Dutch, Polish, and Japanese data were directly standardized for the 1996 US population. Data on utilization, reasons for encounter, encounters per episode of care, new episodes of care, and prescriptions were compared. We also present World Health Organization and Organisation for Economic Co-operation and Development data on health care delivery, efficiency, expenditure, and health status for each country. RESULTS: We found important differences and striking similarities. Differences in the numbers of episodes and of encounters per patient per year were small compared with differences in utilization per episode of care, including diagnostic and therapeutic interventions. Substantial differences were found in prescribing antibiotics, oral contraceptives, cardiovascular medications, and gastrointestinal therapies. Prescribing behavior in the Netherlands and the United States are similar, while very different patterns were found in Japan and Poland. Similarities were much higher in patients’ reasons for encounter than in diagnoses. Only 35 groups of symptoms/complaints covered the top 30 in all databases, at the same time including 45% to 60% of all symptom/complaint reasons for encounter. The contribution of the US family physicians to care for common symptoms and episodes was generally high, but patients evidently also see other providers; the overall US distribution was similar to the Dutch data. With approximately 50 diagnoses, 45% to 60% of all new episodes of care were covered. Large differences existed in the contribution of family practice to gynecology/obstetrics and psychosocial problems. The proportion of all encounters per 1000 patients per year covered by the top 30 was 70% to 75%. CONCLUSION: Even under different conditions there was substantial overlap in the top 30 symptom/complaint reasons for encounter, incidence rates, and encounters per diagnosis in the 4 countries we studied. This striking resemblance supports the concept of the reason for encounter as a core element of the consultation with a family physician. Similarities between the databases are much better reflected by the way patients formulate their demand for care than in the diagnoses by the family physician. US patients also see providers other than family physicians for common problems; it remains unclear whether a limited group brings most of their health problems to a family physician or whether most people visit a series of primary care physicians. Possibilities to further develop episode-oriented epidemiology in family practice have considerably increased with this study. The potential for comparative studies has also increased with the introduction of complete electronic patient records based on the documentation of episodes of care with the ICPC and with its mapping to International Classification of Disease-10th revision (or the 9th revision clinical modification.)

Okkes IM, Polderman GO, Fryer GE, Yamada T, Bujak M, Oskam SK, Green LA, Lamberts H. The role of family practice in differenct health care systems. A comparison of reasons for encounter, diagnoses, and interventions in primary care populations in the Netherlands, Japan, Poland and the United States. J Fam Pract 2002; 51:72-73.