How Should Referral Chain be Implemented in Family Medicine in Turkey?

Abstract

Objectives: The objective of this study is to examine the views of the family physicians on the applicability of the referral chain which is likely to be introduced in Turkey in the period ahead and how to apply it.

Materials and Methods: This descriptive cross‐sectional study was conducted via one‐on‐one interviews and e‐mailings with 201 family physicians of various ranks on 10.01.2018 ‐ 18.03.2018, in form of a survey that inquired their views on the referral chain likely to be introduced to the family practice system.

Results: While 85.07% of the all 201 family physicians favored the introduction of the referral chain system, 55.72% of them stated that the referral system is applicable in Turkey. 50.87% of the participants, who were against any restrictions regarding the institutions that they would refer to, demand referring their patients to the hospitals and relevant branch specialists that they prefer as medical doctors. 96.01% of the participants favored informing the public through public spots another 98% stressed that the patient population per each family physician should be reduced. 91.04% of the participants supported the increased emphasis on preventive medicine in family practice whereas 75.62% of them were in favor of the promotion of the referral chain by charging the patients submitting in the secondary health institutions before they resort to family practice, 81.59% thought that the time spent for home care health services should be increased in parallel to the size of the disabled and elderly (65+) population which is primarily subject to family practice, 69.65% of them supported the idea that the family physicians should be entitled to refer their patients directly to the relevant sub branch specialists, 27.86% said that the family physician should be able to see the relevant specialist together with his patient and attend his/her patients' appointment with that specialist, and 24.37% endorsed improving the quality of telephonic health services in family practice and that the patients subject to family practice should be able to access their physicians and get information and the physicians should be able to directly refer their patients whose symptoms they spotted, when needed.

Conclusion: The family physicians attending our survey overwhelmingly supported the introduction of referral chain to the family practice system, as they also shared their views that in order to improve the family practice system and to get the referral chain function appropriately, additional steps should be taken based on the current examples in family practice and referral chain systems in various regions of the world.

Keywords

• Family practice,gatekeeping system,mandatory referral system

Türkiye’de Aile Hekimliğinde Sevk Zinciri Nasıl Uygulanmalıdır?

Öz

Amaç: Bu çalışmanın amacı aile hekimlerinin, Türkiye’de gelecekte uygulanması muhtemel sevk zinciri ile alakalı olarak uygulanabilirliği ve nasıl uygulanabileceği noktasında görüşlerini araştırmaktır.

Materyal ve Metot: Bu kesitsel tanımlayıcı çalışma 10.01.2018 – 18.03.2018 tarihleri arasında aile hekimi, aile hekimi uzmanı ve aile hekimi asistanı toplam 201 hekime yüz yüze görüşme yöntemi ve e‐posta yoluyla aile hekimliği sisteminde uygulanması muhtemel sevk sistemine dair görüşlerini sorgulayan anket uygulanmıştır.

Bulgular: Ankete katılan toplam 201 hekimin %85,07’si aile hekimliği sistemine sevk zincirinin gelmesi gerektiğini savunurken %55,72’si sevk sisteminin Türkiye’de uygulanabileceği yönünde görüş beyan etmiştir. Sevk edecekleri kurumlar konusunda kısıtlanmak istemeyen katılımcıların, %50,87’si il içerisinde istedikleri hastaneye ve uzmanlık branşına hastaları sevk edebilmeyi istemektedir.

Katılımcıların %96,01’i kamu spotları ile halkın bilinçlenmesi gerektiğini savunurken %98’i aile hekimi başına sorumlu olunan nüfusun azaltılması gerektiğini düşünmektedir. Çalışmaya katılan hekimlerin

%91,04’ü aile hekimliğinde, koruyucu hekimliğin daha çok ön plana çıkartılmasını, %75,62’si aile hekimliğine başvurulmadan 2.basamak sağlık kuruluşlarına giden hastalardan ek ücret alınarak sevk zincirinin teşvik edilmesi gerektiğini, %81,59’u evde sağlık hizmetlerine ayrılan zamanın aile hekimliğine bağlı 65 yaş üstü ve engelli nüfus ile paralel olarak arttırılması gerektiğini, %96,01’i sevk zincirinde 65 yaş üstü ve engelli hastaların sevk edildikten sonra ilgili sağlık kuruluşuna ulaşımı ile ilgili bir birimin yerel yönetimler ve Sağlık Bakanlığı işbirliğiyle kurulması gerektiğini, %69,65’i Aile hekimlerinin, hastalarını doğrudan yan dal uzmanlarına sevk edebilmesi gerektiğini düşünürken %27,86’sı Aile hekimi sevk ettiği hastası ile birlikte ilgili uzmana gidebilmeli ve ilgili uzmanının muayenesine katılabilmesi gerektiğini, %24,37’si Aile hekimliğinde telefonla sağlık hizmetlerinin geliştirilmesi ve aile hekimliğine bağlı hastaların telefonla hekime ulaşarak bilgi alması gerektiğinde hekimin telefonla semptomlarını öğrendiği hastalarının lüzum halinde sevkini gerçekleştirebilmesi gerektiği yönünde fikir beyan etmiştir.

Sonuç: Çalışmamıza katılan aile hekimleri büyük oranda aile hekimliği uygulamasına sevk zincirinin gelmesi gerektiğini düşünmekte olup aile hekimliği uygulamasının geliştirilmesi ve sevk zincirinin sağlıklı bir şekilde işletilebilmesi için Dünya’da mevcut aile hekimliği ve sevk zincirleri sistemleri örnekleri değerlendirilerek ek adımlar atılması gerektiği yönünde fikir beyan etmektedirler.

Anahtar Kelimeler

• Aile Hekimliği,sevk zinciri sistemi,zorunlu sevk sistemi

References

1. 1. Peabody FW. The care of the patient. JAMA 1927; 88:877–82.
2. 2.Millis JS, Wiggins WS, Wolfle D et al. The graduate education of the physicians: the report of the citizens commission on graduate medical education. Chicago: American Medical Association; 1966:38-39.
3. 3. Willard WA, Johnson AN, Wilson VE et al. Meeting the challenge of family practice. report of the ad hoc committee on education for family practice of the council on medical education. Chicago: American Medical Association; 1966:1-4.
4. 4. Aile Hekimliği Pilot Uygulaması Hakkında Kanun. Kanun No: 5258, Kabul Tarihi: 24.11.2004. Resmi Gazete’de Yayımlandığı Tarih: 09.12.2004. Sayı:25665 [İnternet]. http://www.resmigazete.gov.tr/eskiler/2004/12/20041209.htm#1 (Erişim Tarihi: 21.03.2018).
5. 5. Sağlık Hizmetlerinin Sosyalleştirilmesi Hakkında Kanun. Kanun No: 224. Kabul Tarihi: 05.01.1961. Resmi Gazete’de Yayımlandığı Tarih: 12.01.1961, Sayı:10705 [İnternet]. http://www.mevzuat.gov.tr/MevzuatMetin/1.4.224.pdf (Erişim Tarihi: 21.03.2018).
6. 6. World Health Assembly, 55. (‎2002)‎. Fifty-fifth World Health Assembly, Geneva, 13-18 May 2002: resolutions and decisions, annexes. World Health Organization. Available from: http://www.who.int/iris/handle/10665/259364 Accessed on March 2018.
7. 7.Etter JF, Perneger TV. Health care expenditures after introduction of a gate keper and a global budget in a Swiss health insurance plan. J Epidemiol Community Health 1998;52:370–6.
8. 8.Schwenkglenks M, Preiswerk G, Lehner R et al. Economic efficiency of gate keeping compared with fee for service plans: a Swiss example. J Epidemiol Community Health 2006;60:24–30.

9. 9.Kapur K, Joyce GF, Van Vorst KA et al. Expenditures for physician services under alternative models of managed care. Med Care Res Rev 2000;57:161–81.
10. 10. Escarce JJ, Kapur K, Joyce GF et al. Medical care expenditures under gate keper and point of service arrangements. Health Serv Res 2001;36:1037–57.
11. 11. Joyce GF, Kapur K, Van Vorst KA et al. Visits to primary care physicians and to specialists under gatekeeper and point of service arrangements. AmJ Manag Care. 2000;6:1189–96.
12. 12. Holdsworth LK, Webster VS, McFadyen AK et al. Are Patients Who Refer Themselves to Physiotherapy Different from Those Referred by gps? Results of a National trial. Physiotherapy 2006;92:26–33.
13. 13. Holdsworth LK, Webster VS, McFadyen AK et al. Self referral to physiotherapy: deprivation and geographical setting: is there a relationship? Results of a nationaltrial. Physiotherapy 2006;92:16–25.
14. 14. Holdsworth LK, Webster VS, McFadyen AK et al. What are the costs to nhs scotland of self referral to physiotherapy? Results of a nationaltrial. Physiotherapy 2007;93:3–11.
15. 15. Paone GH, Higgins RS, Spencer T et al. Enrollment in the health alliance plan: hmo is not an ındependent risk factor for coronary artery bypass graftsurgery. Circulation 1995;92:69–72.
16. 16. Rask KJ, Deaton C, Culler SD et al. The effect of primary care gatekeepers on the management of patients with chestpain. Am J Manag Care 1999;5:1274–82.
17. 17.Olivarius ND, Jensen FI, Gannik D et al. Self-referral and self-payment in danish primary care. HealthPolicy. 1994;28:15–22.
18. 18.Linden M, Gothe H, Ormel J. Path ways to care and psychological problems of general practice patients in a “gatekeeper” and an “openaccess” health care system: a comparison of germany and the netherlands. SocbPsychiatr Epidemiol 2003;38:690–7.
19. 19.Laditka SB, Laditka JN. Utilization, costs and access to primarycare in fee-for-service and managed care plans. J HealthSocPolicy 2001;13:21–39.
20. 20.Etter JF, Perneger TV. Introducing managed care in switzerland: ımpact on use of health services. Public health 1997;111:417–22.
21. 21. Hurley RE, Freund DA, Taylor DE. Emergency room use and primary care case management: evidence from four medicaid demonstration programs. AmJ Public Health 1989;79:843–6.
22. 22. Hurley RE, Freund DA, Gage BJ. Gatekeeper effects on patterns of physician use. J Fam Pract 1991;32: 167–74.
23. 23. Global Health Observatory(GHO) Data, Density of Physicians(total number per 1000 population, latest Available Year), World Health Organisation 2018. Available from: http://www.who.int/gho/health_workforce/physicians_density/en/, Date of Access: March 21, 2018.
24. 24. Schlette S, Lisac M, Blum K. Integrated primary care in germany: the road ahead. Int J Integr Care 2009;9(2):1-11.
25. 25. Höhne A, Jedlitschka K, Hobler D et al. General practitioner-centred health-care in germany. The general practitioner as gatekeeper. Gesundheitswes 2009;71:414-22.
26. 26. Dinkel A, Schneider A, Schmutzer G et al. Family physician–patient relationship and frequent at tendance of primary and specialist health care: Results from a German population-based cohort study. Patient education and counseling 2016; 99(7):1213-19.
27. 27. Mossialos E, Djordjevic R, Osborn R et al. International profile of health care systems. The Common wealth fund, May 2017 [İnternet]. Available from: https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2017_may_mossialos_intl_profiles_v5.pdf Date of access: March 21, 2018.
28. 28. vanLoenen T, van den Berg MJ, Heinemann S et al. Trends towards stronger primary care in three western European countries; 2006–2012. BMC Fam Pract 2016;17:59.
29. 29. Reed G. Challenges for Cuba’s family doctor and nurse program. MEDICC Review 2000;2:1–5.
30. 30. Demers RY, Kembel S, Orris M, Orris P. Familypractice in Cuba: evolutionintothe 1990s. Fam Pract 1993;10:164–8.
31. 31. Dresang, L. T, Brebrick, L, Murray, D, Shallue A, & Sullivan-Vedder L. Familymedicine in Cuba: community-orientedprimarycareandcomplementaryandalternativemedicine. The Journal of theAmerican Board of Family Practice 2005; 18(4): 297-303.
32. 32. Glenngård AH, Hjalte F, Svensson M, Anell A, Bankauskaite V. Health systems in transition. Sweden. WHO, on behalf of the European Observatory on Health Systems and Policies. 2005. Available from: http://www.hpi.sk/cdata/Documents/HIT/Sweden_2005.pdf Date of access: March 21, 2018.
33. 33. Smith PC, Anell A, Busse R, Crivelli L et al. Leadership and governance in seven developed health systems. HealthPolicy 2012;106(1):37-49.
34. 34. Anell AH, Glenngård A, Merkur S. Sweden: Health System Review. Health systems in transition 2012;14(5):1–161.
35. 35. Swedish Association of Local Authorities and Regions (SALAR), National Initiative for Improved Patient Safety. SALAR 2011. Available from: https://skl.se/tjanster/englishpages/aboutsalar/administrativeorganisation/healthandsocialcaredivision.1292.html, Date of access: March 21, 2018.
36. 36. Kringos DS, Boerma WGW, Hutchinson RB et al. Building Primary Care in a Changing Europe. European Observatory on Health Systems and Policies, United Kingdom 2015. Available from: http://www.euro.who.int/__data/assets/pdf_file/0018/271170/BuildingPrimaryCareChangingEurope.pdf, Date of access: March 21, 2018.
37. 37. Pedersen KM, Andersen JS, Søndergaard J. General practice and primary health care in Denmark. The Journal of the American Board of Family Medicine 2012;25(1):34-8.
38. 38. Van Uden CJ, Ament AJ, H. A, Hobma SO. Patient satisfaction without of hours primary care in the Netherlands. BMC Health Serv Res 2005;5(1):6.
39. 39. Uden CV, Giesen PH, Metsemakers JF et al. Development of out of hours primary care by general practitioners (GPs) in The Netherlands: from small call rotations to large scale GP cooperatives. Family Medicine 2006;38(8):565-9.
40. 40. Grol R, Giesen P, Van Uden C. After-hours care in the United Kingdom, Denmark, and the Netherlands: New models. Health Aff 2006;25:1733–7.
41. 41. van den Berg MJ, de Boer D, Gijsen R et al. Dutch health care performance report 2014. Bilthoven, the Netherlands: National Institute for Public Health and the Environment, 2015. Available from: http://www.rivm.nl/dsresource?objectid=rivmp:277134, Date of access: March 21, 2018.
42. 42. van den Berg MJ, Kolthof ED, de Bakker DH et al. Tweede Nationale Studiena arziekten en verrichtingen in de huisart spraktijk. De Werkbelasting van Huisartsen 2004, https://www.nivel.nl/nationalestudie, Date of access: March 21, 2018. 43. Haliloğlu S. Lovah-wes hollanda değişim programı deneyimlerim. Türkiye Aile Hekimliği Dergisi 2014;18(1):3-6. 44. Bruijn‐Geraets D, Daisy P, Eijk‐Hustings V. Evaluating newly acquired authority of nurse practitioners and physician assistants for reserved medical procedures in the Netherlands: a study protocol. Journal of Advanced Nursing 2014;70(11):2673-82.