Differences in medical services in Nordic general practice: a comparative survey from the QUALICOPC study

Full Te ms & Condi ions o access and use can be ound a h p://www. and online.com/ac ion/jou nalIn o ma ion?jou nalCode=ip i20 Download by: [Tampe e Uni e si y] Da e: 08 Augus 2017, A : 00:38 Scandina ian Jou nal o P ima y Heal h Ca e ISSN: 0281-3432 (P in ) 1502-7724 (Online) Jou nal homepage: h p://www. and online.com/loi/ip i20 Di e ences in medical se ices in No dic gene al p ac ice: a compa a i e su ey om he QUALICOPC s udy To unn Bje e Eide, Jø und S aand, Cecilia Bjö kelund, Elise Kosunen, O eigu Tho gei sson, Pe e Veds ed & Elin Olaug Ros old To ci e his a icle: To unn Bje e Eide, Jø und S aand, Cecilia Bjö kelund, Elise Kosunen, O eigu Tho gei sson, Pe e Veds ed & Elin Olaug Ros old (2017) Di e ences in medical se ices in No dic gene al p ac ice: a compa a i e su ey om he QUALICOPC s udy, Scandina ian Jou nal o P ima y Heal h Ca e, 35:2, 153-161, DOI: 10.1080/02813432.2017.1333323 To link o his a icle: h p://dx.doi.o g/10.1080/02813432.2017.1333323 © 2017 The Au ho (s). Published by In o ma UK Limi ed, ading as Taylo & F ancis G oup. Published online: 14 Jun 2017. Submi you a icle o his jou nal A icle iews: 158 View ela ed a icles View C ossma k da a RESEARCH ARTICLE Di e ences in medical se ices in No dic gene al p ac ice: a compa a i e su ey om he QUALICOPC s udy To unn Bje e Eide a , Jø und S aand a , Cecilia Bj€ o kelund b , Elise Kosunen c,d , O eigu Tho gei sson e , Pe e Veds ed and Elin Olaug Ros old a a Depa men o Gene al P ac ice, Ins i u e o Heal h and Socie y, Uni e si y o Oslo, Oslo, No way; b Depa men o P ima y Heal h Ca e, Ins i u e o Medicine, Uni e si y o Go henbu g, Go henbu g, Sweden; c School o Medicine, Uni e si y o Tampe e, Tampe e, Finland; d Cen e o Gene al P ac ice, Pi kanmaa Hospi al Dis ic , Pi kanmaa, Finland; e G a a ogu P ima y Ca e Cen e, Reykja ik, Iceland; Resea ch Uni o Gene al P ac ice, Aa hus Uni e si y, Aa hus, Denma k ABSTRACT Objec i e: We aim o desc ibe medical se ices p o ided by No dic gene al p ac i ione s (GPs), and o explo e possible di e ences be ween he coun ies. Design and se ing: We did a compa a i e analysis o selec ed da a om he No dic pa o he s udy Quali y and Cos s o P ima y Ca e in Eu ope (QUALICOPC). Subjec s: A o al o 875 No dic GPs (198 No wegian, 80 Icelandic, 97 Swedish, 212 Danish and 288 Finnish) answe ed iden ical ques ionnai es ega ding hei p ac ices. Main ou come measu es: The GPs indica ed which equipmen hey used in p ac ice, which p ocedu es ha we e ca ied ou , and o wha ex en hey we e in ol ed in ea men / ollow-up o a selec ion o diagnoses. Resul s: The Danish GPs pe o med mino su gical p ocedu es signi ican ly less equen han GPs in all o he coun ies, al hough hey inse ed IUDs signi ican ly mo e o en han GPs in Iceland, Sweden and Finland. Finnish GPs pe o med a majo i y o he medical p ocedu es mo e equen ly han GPs in he o he coun ies. The GPs in Iceland epo ed in ol emen in a mo e na ow selec ion o condi ions han he GPs in he o he coun ies. The Finnish GPs had mo e ad anced echnical equipmen han GPs in all o he No dic coun ies. Conclusions: GPs in all No dic coun ies a e well equipped and o e a wide ange o medical se ices, ye wi h a subs an ial a ia ion be ween coun ies. The e was no clea pa e n o GPs in one coun y doing consis en ly mo e p ocedu es, ha ing consis en ly mo e equipmen and ea ing a la ge di e si y o medical condi ions han GPs in he o he coun ies. Howe e , s uc u al ac o s seemed o a ec he se ices o e ed. ARTICLE HISTORY Recei ed 26 Janua y 2017 Accep ed 30 Ap il 2017 KEYWORD Gene al p ac ice; O ganisa ion and Adminis a ion; heal h se ices; No dic coun ies; diagnosis; equipmen ; p ocedu es; QUALICOPC Backg ound Gene al p ac i ione s (GPs) a e usually conside ed key se ice p o ide s in p ima y ca e [1]. The e is a ying o ganisa ion o gene al p ac ice bo h wi hin and be ween coun ies, and he o ganisa ional amewo k is o signi icance o he se ices o e ed [2–4]. A ailable app op ia e medical equipmen is posi i ely co ela ed wi h he quali y o medical pe o mance [5], and GPs wi h good access o basic diagnos ic es s bo h diag- nose, ea and e e pa ien s mo e app op ia ely [6]. In 1993, he Eu opean Task P o ile S udy in es i- ga ed se ice p o ision o GPs in 30 Eu opean coun- ies [2]. Finland and Iceland sco ed highe han he Scandina ian coun ies when i came o applica ion o medical echniques and p ocedu es. Wi h ega d o comp ehensi e disease managemen in No dic gene al p ac ice, No way sco ed he highes and Finland he lowes . No wegian GPs’a ailable equipmen was desc ibed in an ex ensi e epo om 1981 [7], bu bo h he o ganisa ion o he p ima y heal h ca e sys- em and he a ailable diagnos ic and he apeu ic equipmen has changed signi ican ly since hen. A s udy om 2001 explo ed di e ences in consul a ion a es and diagnoses gi en by No dic GPs [8]. Some mo e ecen s udies om o he Eu opean coun ies desc ibe he spec um o medical equipmen in he espec i e coun ies [9,10]. I emains unknown how his compa es wi h he si ua ion in he No dic coun- ies. Upda ed and sys ema ic knowledge abou a ail- able echnical equipmen , es s, medical p ocedu es CONTACT To unn Bje e Eide [email p o ec ed] Depa men o Gene al Medicine, Ins i u e o Heal h and Socie y, Uni e si y o Oslo, PB 1130, Blinde n, 0318 Oslo, No way ß2017 The Au ho (s). Published by In o ma UK Limi ed, ading as Taylo & F ancis G oup. This is an Open Access a icle dis ibu ed unde he e ms o he C ea i e Commons A ibu ion-NonComme cial License (h p://c ea i ecommons.o g/licenses/by-nc/4.0/), which pe mi s un es ic ed non-comme cial use, dis ibu ion, and ep oduc ion in any medium, p o ided he o iginal wo k is p ope ly ci ed. SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE, 2017 VOL. 35, NO. 2, 153–161 h ps://doi.o g/10.1080/02813432.2017.1333323 Downloaded by [Tampe e Uni e si y] a 00:38 08 Augus 2017 and condi ions p ima ily handled in No dic gene al p ac ices is needed. Heal h sys ems in he No dic coun ies The No dic coun ies (No way, Denma k, Finland, Sweden and Iceland) ha e compa able poli ical s uc- u es, and heal h ca e sys ems a e based on he No dic wel a e model, aiming o equal access o heal h ca e se ices o all esiden s. Howe e , when i comes o p ima y ca e and gene al p ac ice, he e a e impo an o ganisa ional di e ences (Box 1). Aim The aim o his s udy is o desc ibe se ices p o ided by No dic GPs in e ms o a ailable diagnos ic and he apeu ic equipmen , es s and p ocedu es in he GPs’o ices. We also aim o desc ibe di e ences be ween No dic GPs’clinical in ol emen in ea men and ollow-up o a selec ion o diagnoses. Ma e ial and me hods Ou ma e ial o igina es om he s udy Quali y and Cos s o P ima y Ca e in Eu ope (QUALICOPC) [11]. A se o ou ques ionnai es was de eloped by he QUALICOPC Pa ne Conso ium, led by he Ne he lands Ins i u e o Heal h Se ices Resea ch (NIVEL). The cons uc ion o he ques ionnai es, as well as a de ailed accoun o hei con en s, is ex ensi ely desc ibed elsewhe e [12], as a e he de ails conce ning he implemen a ion o he QUALICOPC s udy [11]. The de elopmen o he ques ionnai es was based on exis ing, alida ed ques ionnai es. Pa icipa ing GPs comple ed a ques ionnai e epo ing in o ma ion abou hei indi idual p ac ices. Sample In Sweden and Denma k, andom na ional samples o GPs we e in i ed o pa icipa e. In Iceland, he en i e GP popula ion was in i ed. In Finland, he e was a mixed p ocedu e o andom sampling plus selec ed GPs. In No way, he e was con enience sampling wi hin o mal and in o mal GP ne wo ks. Based on cal- cula ions in p e ious esea ch [11], he s udy aimed o ealize a esponse o 220 GPs om each pa icipa ing coun y excep Iceland (aim 75 GPs). Inclusion s opped when a sa is ying numbe o esponde s was eached, o when no u he ec ui men was conside ed easible. In Denma k and No way, he GPs ecei ed an economic incen i e o pa icipa ion, and in Iceland pa icipan s we e in i ed o a semina [13]. In Sweden and Finland, no incen i es o pa icipa ion we e o e ed. All ques ionnai es we e answe ed anonym- ously. Da a collec ion ook place om 2011 o 2013. Measu es We eco ded he ollowing demog aphic a iables: GP’s gende and age, solo o pa ne ship p ac ice, Box 1. O ganisa ion o gene al p ac ice in he No dic coun ies GP employmen Pa ien a ilia ion Pa ien co-paymen Ga e-keeping No way 5.2 mill inhab GDP e49 200 (2013) a Mos ly sel -employed. Recei e a combina ion o capi a ion ee and ee- o - se ice Indi idual pa ien lis sys- em. All inhabi an s a e assigned o o choose a egula GP Co-paymen o adul s 16 yea s Fo all speciali ies Sweden 9.8 mill inhab GDP e32 700 (2013) a Mos ly employees in public (60%) o p i a e heal h cen es All pa ien s can egis e wi h a p ima y ca e cen e (some cen es o e egis- e ing wi h a speci ic GP) Co-paymen o adul s 20 yea s No Denma k 5.6 mill inhab GDP e32 100 (2013) a Mos ly sel -employed. Recei e a combina ion o capi a ion ee and ee- o - se ice Pa ien s lis ed wi h a gen- e al p ac ice. 1% a e no lis ed (g oup 2-insu ed) No co-paymen (g oup 2-insu ed pay pa o he ee and ha e ee choice o GP) Fo mos speciali ies. Pa ien s can con ac oph halmologis s and ea -nose- h oa specialis s di ec ly Finland 5.4 mill inhab GDP e37 559 (2014) a Mos ly employees in pub- lic/p i a e heal h cen es o in occupa ional heal h ca e Pa ien a ilia ion wi h public heal h cen es o occupa ional heal h ca e cen es. Pa ly subsidised p i a e se ices also a ailable Co-paymen o adul s 18 yea s in public heal h cen es, a ia ions be ween municipali ies. No co-pay- men in occupa ional heal h ca e Re e al is needed o special- is consul a ions h ough he public heal h sys em. Sel -paying pa ien s can con ac all p i a e specialis s di ec ly Iceland 329100 inhab. GDP e30 000 (2013) a Mos ly employees in public heal h cen es Pa ien a ilia ion wi h heal h cen es Co-paymen o adul s 18 yea s. Reduced co-paymen >67 yea s No a In o ma ion om he No dic co-ope a ion www.no den.o g/en/ ak a-om-no den-1/ he-no dic-coun ies- he- a oe-islands-g eenland-and-aaland (Janua y 2017). 154 T. B. EIDE ET AL. Downloaded by [Tampe e Uni e si y] a 00:38 08 Augus 2017 whe he he GPs we e sel -employed o employees, and size o pa ien lis . The GPs es ima ed how many ace- o- ace pa ien con ac s hey had on a no mal wo king day, usual leng h o a consul a ion in hei o ice and he dis ance o he nea es hospi al. The GPs indica ed om p ede ined lis s which equipmen was in use by hemsel es o hei s a , which p ocedu es ha we e ca ied ou by hemsel es o hei s a as opposed o e e ing o seconda y ca e specialis s, and o wha ex en hey we e in ol ed in he ea men and ollow-up o pa ien s wi h a lis ed selec ion o diagnoses. The eligible selec ion o equip- men , p ocedu es and diagnoses is indica ed in Tables 2,3and 4, espec i ely. All ques ions ocused on egu- la p ac ice and no he si ua ion in ou -o -hou s ca e. The GPs we e gi en ou possible answe s conce n- ing o wha ex en hey pe o med he indica ed p ocedu es, and o wha ex en hey we e in ol ed in ea men and ollow-up o he gi en diagnosis: 1. (Almos ) always; 2. Usually; 3. Occasionally; and 4. Seldom/ne e . These we e me ged in o wo ca ego ies du ing analysis: always/usually (1 þ2) and occasion- ally/ne e (3 þ4). S a is ics We p esen desc ip i e s a is ics wi h numbe s, pe - cen , min–max in e als and 95% con idence in e als (95%CI). To iden i y di e ences be ween coun ies, we used bina y logis ic eg ession adjus ing o GPs’sex Table 2. Medical equipmen in GP p ac ices in he No dic coun ies a . No way, N¼198 GPs Sweden, N¼97 GPs Denma k, N¼212 GPs Finland, N¼288 GPs Iceland, N¼80 GPs Equipmen n%n%n%n%n% Hemoglobinome e 195 98.5 95 97.9 201 94.8 235 82.7 68 85.0 Blood glucose es 197 99.5 93 95.9 205 96.7 274 96.5 75 93.8 Choles e ol me e 19 9.6 31 32.0 8 3.8 108 38.0 19 23.8 Blood cell coun e 81 40.9 33 34.0 36 17.0 106 37.3 19 23.8 Oph halmoscope 197 99.5 79 81.4 131 61.8 275 96.8 61 76.3 P oc oscope 153 77.3 97 100.0 76 35.8 261 91.9 42 52.5 O oscope 198 100.0 96 99.0 210 99.1 277 97.5 74 92.5 Gas oscope 2 1.0 0 0.0 1 0.5 83 29.2 1 1.3 Sigmoidoscope 7 3.5 5 5.2 0 0.0 83 29.2 11 13.8 X- ay 11 5.6 3 3.1 0 0.0 178 62.7 8 10.0 Ul asound 33 16.7 4 4.1 24 11.3 164 57.7 10 12.5 Mic oscope 125 63.1 61 62.9 153 72.2 64 22.5 58 72.5 Audiome e 89 44.9 71 73.2 118 55.7 234 82.4 73 91.3 Bicycle e gome e 4 2.0 7 7.2 1 0.5 88 31.0 6 7.5 Eye onome e 160 80.8 36 37.1 3 1.4 259 91.2 36 45.0 Peak low me e 161 81.3 94 96.9 204 96.2 280 98.6 67 83.8 Spi ome e 197 99.5 95 97.9 206 97.2 188 66.2 79 98.8 Elec oca diog aph 196 99 97 100.0 175 82.5 270 95.1 80 100.0 Blood p essu e moni o 197 99.5 96 99.0 209 98.6 283 99.6 80 100.0 In usion se 116 58.6 64 66.0 86 40.6 253 89.1 71 88.8 Doc o ’s bag 167 84.3 94 96.9 208 98.1 180 63.4 78 97.5 U ine ca he e 179 90.4 91 93.8 186 87.7 266 93.7 61 76.3 Coagulome e 134 67.7 60 61.9 157 74.1 76 26.8 3 3.8 Se o mino su ge y 194 98.0 95 97.9 206 97.2 269 94.7 72 90.0 Su u e se 195 98.5 96 99.0 210 99.1 278 97.9 77 96.3 De ib illa o 129 65.2 94 96.9 79 37.3 269 95.7 77 96.3 Disposable sy inges 195 98.5 94 96.9 210 99.1 279 98.2 80 100.0 Disposable glo es 198 100.0 96 99.0 211 99.5 280 98.6 80 100.0 Re ige a o o medicines 198 100.0 96 99.0 212 100.0 279 98.2 79 98.8 Resusci a ion equipmen 166 83.8 84 86.6 193 91.0 270 95.1 76 95.0 a Ques ion: please ick he equipmen used in you p ac ice by you sel o you s a . Table 1. Demog aphics o pa icipa ing GPs in he No dic pa o he QUALICOPC s udy. No way Denma k Sweden Finland Iceland To al N198 212 97 288 80 Female (%) 39 43 55 71 28 Age mean ( ange) 45.7 (28–69) 53.1 (35–76) 52 (34–69) 45 (25–70) 54.5 (33–68) P ac ices wi h dis ance o hospi al >20 km (%) 28 20 33 32 12 Sha e p ac ice wi h o he GPs (%) 99 72 99 65 98 Sel -employed (%) 93 99 14 5 9 Numbe o consul a ions pe day a Mean ( ange) 19 (2–30) 23.8 (12–40) 13 (7–25) 12.7 (2–40) 13.2 (7–25) Du a ion o egula consul a ion in minu es. a Mean ( ange) 18.6 (10–30) 14.3 (7–20) 24.1 (15–30) 23.9 (10–60) 19.3 (10–30) a Es ima ed by he GPs. SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE 155 Downloaded by [Tampe e Uni e si y] a 00:38 08 Augus 2017 and age, numbe o consul a ions pe day and dis- ance o he nea es hospi al. We compa ed each coun y o all o he coun ies in ou sepa a e eg es- sion models. To adjus o his mul iple es ing, we used he Bon e oni co ec ion, gi ing a signi icance le el o p0.0125 o he logis ic eg ession analyses. Fo all o he analyses, he signi icance le el was se o p0.05. Odds a ios (OR) a e gi en wi h 95% CI. Analyses we e done in IBM SPSS S a is ics 22 (SPSS Inc., Chicago, IL). Resul s Demog aphics Responses om 875 No dic GPs (No way 198, Sweden 97, Denma k 212, Finland 288 and Iceland 80) we e included in he analyses. Cha ac e is ics o he GPs a e ound in Table 1. Medical equipmen Table 2 shows de ails conce ning he equipmen a ail- able o he GPs. Basic medical equipmen was a ail- able in i ually all p ac ices. A selec ion o poin -o - ca e labo a o y equipmen was a ailable in all coun- ies, bu he de ails a y. In Iceland, ha dly any o he GPs had a coagulome e (3.8%), and his was also less common in Finland (26.8%) han in he o he coun- ies. In No way and Denma k, choles e ol me e s we e uncommon ( espec i ely 9.6% and 3.8%). Basic echnical equipmen like blood p essu e moni- o s and o oscopes we e a ailable in mo e han 92% o GP p ac ices in all coun ies. Elec oca diog aphs we e p esen in mo e han 95% o all p ac ices in all coun ies excep Denma k (83%). Mo e ad anced ech- nical equipmen was almos exclusi ely p esen a Finnish GPs’o ices: X- ay (62.7%), gas oscope (29.2%), sigmoidoscope (29.2%) and bicycle e gome e (31%). Abdominal ul asound was a ailable o o e 50% o Finnish GPs, whe eas only 4% o he Swedish GPs had his equipmen . Mic oscopes we e p esen in 62–73% o p ac ices in all coun ies excep Finland (23%). De ib illa o s we e e y common in Sweden (96.9%), Finland (95.7%) and Iceland (96.3%), less so in Denma k (37.3%) and No way (65.2%). T ea men and ollow up o pa ien s wi h lis ed diagnoses The GPs indica ed om a p ede ined lis he di e en medical condi ions in which hey always o usually we e in ol ed in ea men and/o ollow-up (Table 3). Associa ion wi h demog aphic ac o s (c ude numbe s, no shown in able): GPs wi h p ac ices loca ed 20 km Table 3. Numbe and alid pe cen ages (95% CI) o GPs who epo ed ha hey usually o always pe o med he lis ed p oce- du es, o we e in ol ed in ea men / ollow-up o he lis ed diagnoses. No way, N¼198 Sweden, N¼97 Denma k, N¼212 Finland, N¼288 Iceland, N¼80 n% 95% CI n% 95% CI n% 95% CI n% 95% CI n% 95% CI P ocedu es a Wedge esec ion 127 64.1 57–71 91 94.8 91–99 36 17.2 12–22 257 91.5 89–95 69 86.3 78–94 Wound su u ing 186 94.4 91–97 95 99.0 97–100 141 66.8 61–73 258 91.8 89–95 60 75.0 78–94 Remo al sebaceous cys 144 73.1 67–79 84 87.5 81–95 118 55.9 49–63 226 80.4 75–85 52 66.7 57–77 Excision wa 163 82.3 77–87 30 31.9 23–41 135 64.0 58–70 175 62.9 57–69 64 81.0 72–90 Inse ion IUD 177 89.8 86–94 19 19.8 12–28 182 86.3 81–91 195 69.6 65–75 10 12.5 6–20 Fundoscopy 151 76.3 70–82 53 55.8 46–66 10 4.7 2–8 206 73.3 68–78 21 26.3 16–36 Join injec ion 109 55.1 48–62 87 90.6 85–97 106 50.2 43–57 267 95.7 94–98 61 7.2 68–86 S apping ankle 80 40.4 33–47 83 86.5 80–94 169 80.1 75–85 203 72.5 68–78 52 65.8 56–76 C yo he apy wa s 167 84.3 79–89 14 14.7 8–22 141 66.8 61–73 153 54.4 48–60 76 95.0 90–100 IV in usion 52 26.4 20–32 37 38.9 29–49 7 3.3 1–5 178 63.3 57–69 21 26.6 17–37 Diagnoses b B onchi is 194 99.0 98–100 96 100.0 NA 209 99.1 98–100 269 95.4 92–98 77 96.3 92–100 Pneumonia 195 99.5 98–100 96 100.0 NA 212 100.0 NE 249 88.9 85–93 77 100.0 NA Myoca dial In a c ion 172 87.8 83–93 78 81.3 73–89 163 76.9 71–83 205 73.0 68–78 38 47.5 37–59 Hea ailu e 183 93.4 89–97 94 98.9 97–100 199 94.3 91–97 266 94.3 91–97 57 71.3 61–81 Rheuma oid a h i is 195 99.0 98–100 68 70.8 62–80 139 65.6 60–72 230 81.6 77–87 45 56.3 45–67 Pa kinson’s disease 153 78.1 72–84 58 61.1 51–71 134 63.5 58–70 185 65.8 61–71 25 31.3 21–41 Diabe es ype 2 197 100.0 NA 96 100.0 NA 210 100.0 NA 266 94.3 91–97 78 98.7 97–100 Pep ic ulce 183 93.4 91–97 92 95.8 92–100 203 95.8 93–99 239 84.8 81–89 66 82.5 75–91 Disc he nia ion 195 99.5 98–100 95 99.0 97–100 209 98.9 98–100 251 89.0 85–93 80 100.0 NA Dep ession 195 99.0 98–100 95 99.0 97–100 210 99.1 98–100 259 91.8 89–95 79 98.8 97–100 Ho deolum 166 84.7 80–90 87 90.6 85–97 201 94.8 92–98 213 75.8 71–81 77 96.3 92–100 Pe i onsilla abscess 117 60.3 53–67 59 61.5 52–72 167 78.8 74–84 179 63.5 58–70 22 27.8 18–38 NA: no applicable due o sepa a ion o he ma e ial. a Ques ion: To wha ex en a e he ollowing ac i i ies ca ied ou in you p ac ice popula ion by you (o you s a ) and no by a medical specialis (p ac ice popula ion means: people who no mally apply o you o p ima y medical ca e)? b Ques ion: To wha ex en a e you in ol ed in he ea men and ollow-up o pa ien s in you p ac ice popula ion wi h he ollowing diagnoses? 156 T. B. EIDE ET AL. Downloaded by [Tampe e Uni e si y] a 00:38 08 Augus 2017 om he nea es hospi al we e less likely o be in ol ed in he ea men and ollow-up o Pa kinson’s disease, OR 0.6 (0.4–0.8); pe i onsilla abscess, OR 0.6 (0.4–0.8); and myoca dial in a c ion, OR 0.6 (0.4–0.9). Male GPs we e mo e likely han emale GPs o be in ol ed in he ea men o pe i onsilla abscess, OR 1.4 (1.4–2.0); Pa kinson’s disease, OR 2.1 (1.5–2.9); heuma oid a h i is, OR 1.5 (1.1–2.1); and myoca dial in a c ion, OR 1.5 (1.02–2.1). Di e ences on coun y le el: Di e ences be ween coun ies a e shown in Table 4. Be ween 95 and 100% o he GPs in all i e coun ies indica ed ha hey we e in ol ed in ea men o ollow-up o ch onic obs uc i e pulmona y disease (COPD), pneumonia, and ype-2 diabe es. Icelandic GPs we e signi ican ly less in ol ed in he ea men o myoca dial in a c ion, hea ailu e and pe i onsilla abscesses han he GPs in all o he coun ies. The No wegian and Finnish GPs we e signi i- can ly mo e in ol ed in he ea men o heuma oid a h i is han he GPs in he o he coun ies. No wegian GPs we e signi ican ly mo e in ol ed in he ea men o Pa kinson’s disease han GPs in Denma k and Iceland. P ocedu es The p ocedu es pe o med by he GPs a e shown in Table 3. Associa ion wi h demog aphic ac o s (c ude numbe s, no shown in able): The ollowing p ocedu es we e ca ied ou less equen ly when he dis ance o hospi al was 20 km compa ed wi h >20 km: wound su u es, OR 0.2 (0.1–0.5); emo al o sebaceous cys s, OR 0.5 (0.3–0.7); inse ion o in au e ine de ices (IUDs), OR 0.5 (0.3–0.8); join injec ions, OR 0.4 (0.3–0.6); s apping o ankle, OR 0.6 (0.4–0.9); and in a- enous in usion, OR 0.3 (0.2–0.5). Male GPs inse ed IUDs less o en han emale GPs, OR 0.4 (0.3–0.6). Howe e , wound su u es, OR 1.67 (1.1–6.7); wedge esec ion o oe nails, OR 2.2 (1.4–3.3); emo al o sebaceous cys , OR 1.8 (1.3–2.6); wa exci- sions, OR 1.5 (1.1–2.0); undoscopy, OR 1.5 (1.02–2.2); s apping o ankles, OR 1.5 (1.04–2.04); and join injec- ions, OR 1.9 (1.3–2.8) we e done signi ican ly mo e o en by male GPs. Di e ences on coun y le el: Table 5 shows he in e - coun y di e ences in pe o med p ocedu es. Danish and No wegian GPs we e signi ican ly mo e likely o inse IUDs han GPs in all o he coun ies. Danish GPs did emo al o sebaceous cys s, wedge esec ion o oenails, undoscopy and in a enous in usion less o en han GPs in all o he coun ies, and less wound Table 4. Associa ions (odds a io (95% CI)) be ween coun y and ea men / ollow-up o di e en diagnoses. Logis ic eg ession adjus ed o GP sex, age, numbe o consul a ions pe day and dis ance o hospi al. Model B onchi is Pneumonia Myoca dial In a c ion Hea ailu e Rheuma oid a h i is Pa kinson’s disease Diabe es ype 2 Pep ic ulce Disc he nia ion Dep ession Ho deolum Pe i onsilla abscess 1. Re No way Sweden NA NA 0.8 (0.4–1.6) 9.2 (1.1–75.1) 0.3 (0.2–0.6) 0.5 (0.3–1.0) NA 1.9 (0.6–6.4) 0.5 (0.03–9.1) 0.9 (0.1–10.6) 1.8 (0.08–4.2) 1.1 (0.7–2.0) Denma k 0.9 (0.1–7.1) NA 0.6 (0.3–1.0) 0.9 (0.4–2.1) 0.2 (0.1–0.4) 0.5 (0.3–0.8) NA 1.1 (0.4–2.8) 0.4 (0.04–4.0) 1.2 (0.2–8.8) 3.0 (1.4–6.4) 2.8 (1.7–4.5) Finland 0.4 (0.1–2.1) 0.1 (0.01–0.9) 0.4 (0.3–0.8) 2.0 (0.8–4.7) 0.7 (0.4–1.2) 0.7 (0.5–1.2) NA 0.6 (0.3–1.3) 0.04 (0.01–0.4) 0.1 (0.02–0.5) 0.6 (0.4–1.1) 1.3 (0.8–2.0) Iceland 0.7 (0.1–6.2) NA 0.2 (0.1–0.3) 0.2 (0.1–0.5) 0.2 (0.1–0.3) 0.1 (0.1–0.3) NA 0.3 (0.1–0.9) NA 0.7 (0.1–7.9) 4.4 (1.3–15.6) 0.3 (0.2–0.5) 2. Re Finland a Sweden NA NA 1.7 (0.9–3.1) 4.7 (0.6–36.4) 0.5 (0.3–0.8) 0.7 (0.4–1.2) NA 3.3 (1.1–9.5) 12.2 (1.6–92.3) 8.9 (1.2–68.5) 2.9 (1.3–6.1) 0.9 (0.6–1.5) Denma k 2.3 (0.3–16.1) NA 1.3 (0.7–2.3) 0.5 (0.2–1.3) 0.3 (0.2–0.5) 0.7 (0.4–1.2) NA 1.9 (0.7–5.2) 9.0 (2.0–40.8) 11.5 (2.0–64.8) 4.7 (2.0–10.8) 2.2 (1.3–3.9) Iceland 2.0 (0.4–9.8) NA 0.4 (0.2–0.6) 0.1 (0.1–0.3) 0.2 (0.1–0.4) 0.2 (0.1–0.3) 4.7 (0.5–40.1) 0.6 (0.3–1.2) NA 6.6 (0.8–53.2) 7.0 (2.1–23.6) 0.2 (0.1–0.4) 3. Re Denma k b Sweden NA NA 1.4 (0.7–2.8) 10.5 (1.2–92.1) 1.6 (0.8–3.1) 1.1 (0.6–2.0) NA 1.7 (0.4–6.6) 1.4 (0.1–15.3) 0.8 (0.1–10.1) 0.6 (0.2–1.7) 0.4 (0.2–0.8) Iceland 0.9 (0.1–7.8) NA 0.3 (0.1–0.6) 0.3 (0.1–0.7) 0.8 (0.4–1.5) 0.3 (0.1–0.5) NA 0.3 (0.1–0.9) NA 0.6 (0.1–7.4) 1.5 (0.4–6.0) 0.1 (0.1–0.2) 4. Re Sweden c Iceland NA NA 0.2 (0.1–0.4) 0.02 (0.0–0.2) 0.5 (0.3–0.9) 0.3 (0.1–0.5) NA 0.2 (0.1–0.6) NA 0.7 (0.04–12.3) 2.5 (0.6–9.5) 0.2 (0.1–0.5) Bold igu es:p0.0125. NA: no applicable due o sepa a ion o he ma e ial. a Compa ison wi h No way in model 1. b Compa isons wi h No way and Finland in models 1 and 2, espec i ely. c Compa isons wi h No way, Finland and Denma k in models 1, 2 and 3, espec i ely. SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE 157 Downloaded by [Tampe e Uni e si y] a 00:38 08 Augus 2017 Table 5. Associa ions (odds a io (95% CI)) be ween coun y and p ocedu es pe o med by he GPs o hei s a . Logis ic eg ession adjus ed o sex, age, numbe o consul a ions pe day and dis ance o hospi al. Model Su u e IUD Fundoscopy Join injec ion S apping o ankle C yo he apy o wa s In a enous in usion Wedge esec ion oenail Remo al o sebaceous cys Wa excision 1. Re No way Sweden NA 0.02 (0.01–0.1) 0.3 (0.2–0.6) 11.6 (5.1–26.3) 11.5 (5.6–23.8) 0.04 (0.02–0.1) 1.6 (0.9–3.0) 14.9 (5.4–41.0) 3.9 (1.8–8.4) 0.2 (0.1–0.3) Denma k 0.1 (0.0–0.2) 0.6 (0.3–1.2) 0.01 (0.0–0.02) 0.7 (0.4–1.1) 5.2 (3.2–8.5) 0.3 (0.2–0.6) 0.1 (0.04–0.2) 0.09 (0.1–0.2) 0.4 (0.2–0.6) 0.3 (0.2–0.4) Finland 1.2 (0.5–2.8) 0.2 (0.1–0.4) 1.1 (0.7–1.8) 32.1 (15.4–66.7) 5.2 (3.2–8.4) 0.3 (0.2–0.4) 5.1 (3.1–8.4) 10.7 (5.7–19.9) 2.6 (1.5–4.3) 0.7 (0.4–1.2) Iceland 0.3 (0.1–0.8) 0.02 (0.01–0.1) 0.1 (0.04–0.2) 4.4 (2.2–9.0) 3.1 (1.7–5.8) 8.3 (1.9–36.4) 1.1 (0.6–2.2) 4.8 (2.2–10.8) 0.9 (0.5–1.8) 1.5 (0.7–3.1) 2. Re Finland a Sweden NA 0.1 (0.1–0.2) 0.3 (0.2–0.5) 0.4 (0.1–0.9) 2.2 (1.1–4.3) 0.2 (0.1–0.3) 0.3 (0.2–0.5) 1.4 (0.5–3.8) 1.5 (0.8–3.1) 0.2 (0.1–0.4) Denma k 0.1 (0.03–0.2) 2.7 (1.4–5.4) 0.01 (0.0–0.02) 0.02 (0.01–0.1) 1.0 (0.6–1.8) 1.3 (0.8–2.2) 0.02 (0.01–0.04) 0.01 (0.0–0.02) 0.1 (0.1–0.3) a 0.4 (0.2–0.7) Iceland 0.3 (0.1–0.6) 0.1 (0.04–0.2) 0.1 (0.04–0.1) 0.1 (0.1–0.3) 0.6 (0.3–1.1) 31.2 (7.4–131.6) 0.2 (0.1–0.4) 0.5 (0.2–1.0) 0.4 (0.2–0.7) 2.1 (1.1–4.1) 3. Re Denma k b Sweden NA 0.04 (0.02–0.1) 36.9 (14.9–91.8) 16.9 (7.0–41.0) 2.2 (1.0–4.9) 0.1 (0.1–0.2) 19.1 (7.2–50.3) 174.9 (56.9–537.7) 11.3 (5.0–25.5) 0.6 (0.3–1.1) Iceland 3.7 (1.7–8.2) 0.03 (0.01–0.1) 8.9 (3.5–23.0) 6.4 (3.0–13.9) 0.6 (0.3–1.2) 24.2 (5.5–106.1) 12.9 (4.7–35.5) 11.7 (6.7–20.6) 2.7 (1.3–5.3) 5.6 (2.6–12.0) 4. Re Sweden c Iceland NA 0.9 (0.4–2.1) 0.2 (0.1–0.5) 0.4 (0.2–0.9) 0.3 (0.1–0.6) 213.5 (46.7–976.8) 0.7 (0.3–1.4) 0.3 (0.1–1.0) 0.2 (0.1–0.5) 10.1 (4.8–21.3) Bold igu es:p<0.0125. NA: no applicable due o sepa a ion o he ma e ial. a Compa ison wi h No way in model 1. b Compa isons wi h No way and Finland in models 1 and 2, espec i ely. c Compa isons wi h No way, Finland and Denma k in models 1, 2 and 3, espec i ely. 158 T. B. EIDE ET AL. Downloaded by [Tampe e Uni e si y] a 00:38 08 Augus 2017 su u es han GPs in Iceland and Finland. Finnish GPs adminis a ed in a enous in usion mo e equen ly han GPs in any o he o he coun ies. Discussion We ound se e al di e ences be ween he se ices p o ided by GPs in he No dic coun ies. Danish GPs pe o med se e al p ocedu es signi ican ly less e- quen han GPs in all o he coun ies, al hough hey inse ed IUDs signi ican ly mo e o en han GPs in Sweden, Iceland and Finland. Finnish GPs pe o med a majo i y o he medical p ocedu es mo e equen ly han GPs in he o he coun ies. GPs in Iceland epo ed in ol emen in a mo e na - ow selec ion o he medical condi ions han GPs in he o he coun ies. Finnish GPs had mo e ad anced echnical medical equipmen han GPs in all o he coun ies. I was o he wise di icul o iden i y ob ious pa - e ns in he di e ences be ween he coun ies; he e was no clea indica ion o GPs in one coun y doing consis en ly mo e p ocedu es, ha ing consis en ly mo e equipmen and ea ing a la ge di e si y o medical condi ions han GPs in he o he coun ies. S eng hs and weaknesses Ou ma e ial allows o in e na ional compa ison, as we used he same ques ionnai e in all coun ies du ing he same pe iod. In No way, Finland, Denma k and Iceland, GPs we e ec ui ed na ionwide. The dis ibu- ion o he GPs’age and gende was ep esen a i e o he coun ies [13]. Finland and Iceland ob ained he equi ed numbe o GPs, whe eas No way ob ained 90% and Denma k 96%. This was deemed su icien o he use in s a is ical analysis. In Sweden, only 97 GPs (44% o goal) ook pa in he s udy, in spi e o se e al eminde s. The Swedish esul s mus , he e o e, be in e p e ed wi h ca e. The ques ionnai es we e designed and alida ed o an in e na ional s udy [12]. Thus, he ques ions we e no speci ically designed o map gene al p ac ice in he No dic coun ies. Fo No dic ci cums ances, some o he i ems in he p ede ined ick-o lis s may be cons ued as edundan o i ele an (e.g. disposable glo es, e ige a o ), whe eas o he s we e missed (e.g. de ma oscope, CRP measu emen ). We used dis ance o hospi al as a ma ke o an u ban/ u al loca ion. Howe e , in he QUALICOPC ques ionnai e, ‘>20 km o he nea es hospi al’was he maximum dis ance indica ed. In a No dic con ex , many p ac ices will be si ua ed conside ably u he away om a hospi al. Ou da a gi e in o ma ion abou day ime gene al p ac ice, he si ua ion in ou -o -hou s ca e is no co - e ed by ou s udy. All in o ma ion was based on he GPs sel - epo ing. We ha e no eason o belie e ha he di e ences a e due o un eliable answe s om he doc o s. In e p e a ion o esul s and compa ison wi h o he s udies In 2014, he No dic Council o Minis e s o Heal h and Social A ai s eleased a common s a egy [14] ha s essed he impo ance o wo king oge he o enhance quali y and sa e y in heal h se ices. Howe e , in e na ional compa isons o se ices can be challeng- ing, as di e en coun ies ha e di e en alloca ion o asks wi hin he heal h ca e sys em. In 1993, he Eu opean Task P o ile S udy in es i- ga ed he ange o se ices o e ed by GPs in 30 Eu opean coun ies, showing a s ong posi ion o p i- ma y ca e in he Scandina ian coun ies (No way, Denma k and Sweden) [2]. When compa ing da a om 1993 wi h he QUALICOPC da a om 2013, a ela i e inc ease in he GPs’pa icipa ion in disease manage- men was ound in all he No dic coun ies [3]. Fo pe o mance o mino echnical p ocedu es, Iceland, Denma k and Finland showed a ela i e dec ease in he same pe iod, whe eas he e was an inc ease in Sweden and No way. Geog aphical loca ion may a ec he se ice p o i- sion in gene al p ac ice. Lowe e e al a es in u al a eas ha e p e iously been ound in Canada [15], and he use o ou pa ien specialis ca e was lowe in smalle and mo e dis an municipali ies communi ies in No way [16]. In Denma k, he dis ance o he nea - es specialis o hospi al is o en conside ably sho e han in spa sely popula ed a eas such as la ge pa s o No way, Finland and Sweden. In a eas wi h long a el-dis ance o he nea es specialis , i is likely ha he GPs will o e mo e diagnos ic and he apeu ic p ocedu es i espec i e o emune a ion sys ems. An associa ion wi h dis ance o hospi al was ound o se e al p ocedu es in ou s udy. In Denma k and No way, ee- o -se ice emune - a ion (public eimbu semen and, in No way, pa ien co-paymen ) cons i u es an es ima ed 70 o he di ec income o he GPs [17,18]. The se ices o e ed by he GPs in hese coun ies may be in luenced by he emune a ion o he p ocedu es in ela ion o he GPs expenses. This may explain some o he di e ences seen in ou s udy. Wedge esec ions o oenails we e SCANDINAVIAN JOURNAL OF PRIMARY HEALTH CARE 159 Downloaded by [Tampe e Uni e si y] a 00:38 08 Augus 2017 less commonly done in No way and Denma k han in he o he coun ies. Time-consuming su gical p oce- du es may be dep io i ised i no conside ed su i- cien ly eimbu sed. Some di e ences in equipmen can be explained by o ganisa ional a ia ions. The Finnish GPs had a a he di e en p o ile han he o he coun ies, wi h high a ailabili y o ad anced echnical equipmen . This may in pa be because some Finnish heal h cen es used o be small local hospi als, and as such ha e a ad- i ion o o e ing mo e specialised se ices. S ill, only 66% o he Finnish GPs had spi ome e s, whe eas his was a ailable o mo e han 95% o GPs in all o he coun ies. The se ice is in Finland adi ionally o e ed in o he loca ions han he p ima y ca e cen es. In Denma k, only 1% o he GPs had eye onome e s, p obably e lec ing ha he Danish pa ien s can go di ec ly o he oph halmologis wi hou e e al. In ou esul s, we see a possible e ec o ga e-keep- ing. In Iceland, whe e he e is e ec i ely no ga e-keep- ing, he GPs ea ed condi ions such as heuma oid a h i is, Pa kinson’s disease, hea ailu e and myoca - dial in a c ion signi ican ly less o en han in he o he No dic coun ies. We assume ha Icelandic pa ien s wi h hese condi ions a e ollowed by ele an specialis s. T ea men adi ions and habi s also seem o a ec he se ices p o ided in gene al p ac ice. In No way, he p ocedu e ‘s apping o ankle’was pe o med less o en han in all o he coun ies. This may no neces- sa ily be conside ed a doc o ’s ask; i is qui e common o ins uc he pa ien s o do his hemsel es. Conclusion and implica ions GPs in he No dic coun ies we e gene ally well equipped, pe o med a wide spec um o medical p o- cedu es and we e in ol ed in he ollow-up o a wide selec ion o diagnosis. The e a e, howe e , di e ences ha may be associa ed wi h a ia ions in emune a ion sys ems, geog aphical a ia ions and o he o ganisa- ional ac o s. I GPs a e o ake on an inc eased amoun o asks, a be e unde s anding o wha is a p esen o e ed in gene al p ac ice is impe a i e. Expe iences om o he coun ies can be aluable. Di e ences should be in es- iga ed as a poli ical and o ganisa ional as much as a medical issue. E hics The QUALICOPC s udy was p esen ed o he ele an e hic commi ees in he No dic coun ies. The s udy was app o ed by he Danish Da a Agency, he E hical Commi ee o he Pi kanmaa Hospi al Dis ic in Finland, he Regional E hical Re iew Boa d o Link€ oping in Sweden (Dn 2011/481-31; Dn 2013/120-32) and he Icelandic Na ional Bioe hics Commi ee. The Regional Commi ee o Medical and Heal h Resea ch E hics in Sou h-Eas e n No way concluded ha hei app o al was no equi ed o his s udy. Acknowledgemen s The au ho s a e g a e ul o all he pa icipa ing GPs o he QUALICOPC s udy in he No dic coun ies. We also wish o hank he coo dina ing QUALICOPC Conso ium membe s o hei ole h oughou he s udy. PhD Ib ahimu Mdala a he Uni e si y o Oslo p o ided aluable assis ance in planning he s a is ical analyses. Disclosu e s a emen The au ho s epo no con lic s o in e es . Funding The s udy was conduc ed as pa o he Eu opean QUALICOPC p ojec . QUALICOPC was co- unded by he Eu opean Commission Se en h F amewo k P og am (FP7/ 2007–2013) unde g an ag eemen 242141. TBE ecei ed unding om The No wegian Commi ee on Resea ch in Gene al P ac ice and he No wegian Resea ch Fund o Gene al P ac ice. No es on con ibu o s To unn Bje e Eide is a GP specialis and PhD s uden a he Depa men o Gene al P ac ice, Ins i u e o Heal h and Socie y, a he Uni e si y o Oslo, No way. Jø und S aand is a p o esso and Head o Depa men a he Depa men o Gene al P ac ice, Ins i u e o Heal h and Socie y, a he Uni e si y o Oslo, No way. Cecilia Bj€ o kelund is a p o esso a he Depa men o P ima y Heal h Ca e, Ins i u e o Medicine, Uni e si y o Go henbu g, Sweden. Elise Kosunen is a p o esso a he Depa men o Gene al P ac ice, Uni e si y o Tampe e, Finland. O eigu Tho gei sson is a GP a he G a a ogu P ima y Ca e Cen e, Reykja ik, Iceland. Pe e Veds ed is a p o esso o P ima y Ca e a he Resea ch Uni o Gene al P ac ice, and P o esso o Inno a i e Pa ien Pa hways a Silkebo g Diagnos ic Cen e, Aa hus Uni e si y, Denma k. Elin Olaug Ros old is a p o esso a he Depa men o Gene al P ac ice, Ins i u e o Heal h and Socie y, a he Uni e si y o Oslo, No way, and Head o he No wegian Resea ch School in Gene al P ac ice. 160 T. B. EIDE ET AL. Downloaded by [Tampe e Uni e si y] a 00:38 08 Augus 2017