CONCEPTUAL, INSPIRATIONAL, EDUCATIONAL
PERSPECTIVES, GUIDANCE.
Introduction: Cost-effectiveness in health care is defined as the degree to which any treatment or therapy is effective in relation to the cost the therapy bears. Family Physicians are a new group of Physicians in India who have received two to three years of residency training in Family Medicine or General Practice. Family Medicine is a specialty that provides continuing, comprehensive medical care including all ages, both sex, all organs and all systems of care integrating preventing, promotive, curative, rehabilitation and palliative care. (AAFP 2019). This paper discusses various ways the Family Physicians (FP) could reduce the cost of healthcare in India using a few person vignettes we have seen in our practice.
Current scenario in healthcare: Healthcare expenditure in India is high because of the increased emphasis on hospital-based health care. The current model of health care, the public chooses public health care mostly for preventive health. The vertical programs of the government have more accountability and they enjoy the trust of the common people e.g. immunization program.
When it comes to curative care, Indians access more privatised health care in view of poor accountability from the government hospitals. The private system is not regularised by any audit or guidelines for management leading to increased investigations and medication use adding to the cost. In the study done in Chandigarh by Shankar Prinja et al in 2012 found that the annual cost of health care using generic drugs is INR 6852 per family. This data included predominantly hospital based data of direct cost spent in the hospitals, dispensaries and clinics in the year 2012 in Chandigarh. The use of generic drugs reduced the cost by 24% (Prinja. S 2012).
What are the ways the family physicians are cost-effective? Any physician is cost-effective if the physician gathers information from the patient appropriately, perform physical examination, order relevant investigation and write a rational prescription with generic drugs and uses clinical evidence in practice.
Family physicians can be cost-effective if they are using following generic skills and competencies of family medicine.
i. Patient-centred communication:
This includes active listening to the opening statement, identifying the reason for the visit, exploring patient’s agenda, finding a common ground and concluding the consultation with a forward planning and safety netting. The forward plan could be a diagnostic plan, communication plan, or therapeutic plan. These consultation skills are cost-effective as they have been shown to improve the health outcomes, improve the compliance with therapy and reduces anxiety and stress levels in the patient (Stewart MA 1995).
Mr G is a 70-year-old Male on treatment for diabetes and hypertension for 15 years from elsewhere, presented to the family doctor with complaints of recent onset dyspepsia for a week. There was no red-flag suggestive of malignancy. His appetite was normal. There were no weight loss, anaemia, jaundice or malena. Actually the patient came to family medicine as the appointment with gastroenterologist was not available on the same day.
He described the dyspepsia as retrosternal burning pain, associated with sweating and palpitation. This pain is aggravated by food as well as exertion, walking upstairs and relief with rest for a few minutes. This description was fitting into angina pectoris, not gastro oesophageal reflex. ECG done in our centre showed ST depression and T wave inversion on lateral leads. The cardiac enzyme was sent on the same day was found to be ten times higher than normal. The patient was referred to the cardiology and diagnosed to have NSTEMI. Mr G had angioplasty and two stents were inserted for Severe Double Valve disease on the very same day. This example explains how “listening to the opening statement” helps the physician to diagnose the disease accurately. It would have been a disaster if the patient had been sent away with a prescription of proton pump inhibitor.
ii. Continuity of Care (COC):
COC is defined as the physician team and the person with health problem together achieve the desired health outcomes over a period of time with the goal of high quality and cost effective care (AAFP 2015). This is a very unique character of a family physician as no other specialist has the opportunity to provide care for a variety of health issues over a period of time. COC helps the physician to understand the person including his/her Individual, Clinical and Contextual problems and risk factors. The understanding gained by this experience helps the physician to choose appropriate investigations and follow expectant management. If the patient chooses to see their primary care physician for more than 75% of their illnesses, that patient will have 13% fewer hospital admissions, 27% fewer visits to the Emergency Department. The home-based care integrated through family physicians can reduce the costs by up to 19%. (WHO 2018)
iii. Comprehensive care:
Family Physicians are known to provide care across the age and sex, for all organs and all specialities. This avoids multiple visits to different physicians and reduces the cost. The National Health Policy 2017 (MoHFW 2017) has stressed the need for shifting from vertical health programs to comprehensive primary healthcare that is cost-effective. Family physicians integrate preventive care along with curative care.
For example, we perform foot examination for all diabetic patients and detect sensory neuropathy using 10-gram monofilament. When they can’t feel 8 out of 10 sites, we provide protective footwear and educate the patients about daily foot examination, how to avoid foot ulcers and injuries.
We give Flu and Pneumococcal vaccine to our asthma and COPD patients as a routine to avoid admissions. All geriatric patients have an eye check yearly once to screen for glaucoma, cataract, refractive error and retinopathy. These are a few examples of health promotion activities done in our family practice centre.
iv. Red-flag approach:
Family physicians are generally known to be cost-effective and they do not order costly investigations. But family physicians should know the indications of these expensive investigations like Computed Tomography of the brain, Magnetic Resonance Imaging (MRI). Red-flag can be a symptom or sign that tells the physician that there could be a serious underlying cause.
Eg:recent onset back pain with urinary or faecal incontinence needs urgent MRI of lumbosacral spine to rule out a “Cauda-Equina” lesion. If not intervened early the person may end up with paraplegia. Thunderclap headache or severe headache ever experienced need Computed Tomography of the brain urgently to rule out “Sentinel bleeding” from an aneurysm. An early referral with sentinel headache will help the neurosurgeon to clip the aneurysm before the sub-arachnoid bleed develops.
v. Bio-psycho-social model:
Family Physicians perform “Three Stage Assessment” in their consultation to explore the clinical (Biological), individual (Psychological) and contextual (Social) assessment. That will help them to make a diagnosis in all of these three dimensions.
Mr K is a 36-year-old Lecturer working in a reputed university. He had been extensively investigated for episodic palpitations and anxiety symptoms including blood sugars, Cholesterol, thyroid profile, CBC, Echo, ECG and cardiac enzymes. All investigation were normal, but he was not better with the treatment. When he visited the family practice centre, the contextual history revealed that he is married for three years and has a two-year old daughter. His wife had not been working for those two years but she got a job in a faraway town about a month ago. For the past one month he was living alone in their house, as his wife has moved with the daughter to the workplace. Mr K admitted that his symptoms started after his wife has moved out and that he felt lonely since then. His wife was called for a family conference and family therapy that helped the couple to understand the problem. They decided to spend weekends together and his wife decided to apply for a transfer. Mr K was also prescribed Tab. Escitalopram for his symptom relief.
If this patient is referred to cardiology, he would have had further testing, like Holter monitor and Treadmill test. The positive predictive value for these tests to find any abnormality is low in this patient. When the Family Physician is challenged with difficulty in diagnosis, he/ she investigates deeper and thinks laterally by exploring the individual and contextual aspects. Sometimes the diagnosis can be there.
vi. Therapeutic trial:
Family Physician has the knowledge of the common diseases in the population he/she serves. FP is skilled at choosing when to investigate and when to give a therapeutic trial. For E.g. in a patient presenting with episodic recurrent headaches, FP chooses when to order brain imaging and when to give a trial of migraine prophylaxis. This is a very cost-effective strategy. In the hospital-based approach, every patient with headache undergoes brain imaging.
Discussion:
A family physician will be cost-effective if he does patient-centred consultation with the bio-psycho-social approach, provides comprehensive and continuous care, and uses therapeutic trial and red-flag approach. These skills are important to be taught and assessed in the curriculum of the family physicians in India. Currently, these skills are not being assessed during the residency in Family Medicine. Many training programs are using a hospital based approach and there is less opportunity to teach or assess these skills.
The “Triple C curriculum” of the College of Family Physicians of Canada includes Comprehensive education and patient care, Continuity of education and patient care, and Centred in family medicine. (Tannenbaum D 2011) These are part of the training and assessment of family physicians in Canada. Our principles mentioned here are similar to what is being used by the College of Family Physicians of Canada.
The person vignettes were real patients seen in our Shalom Family Medicine Centre, Department of Family Medicine, Christian Medical College, Vellore. The main strength of our centre is “Accessibility”. The patients can take the appointment and see the doctor on the same day. This accessibility is important to provide early diagnosis and continuity of care.
Conclusion:
Family Medicine is cost-effective if it is practised with patient-centred consultation with the bio-psycho-social approach, provides comprehensive and continuous care, and uses therapeutic trial and red-flag approach. These principles need to be inculcated with teaching and assessment in the Family Medicine Residency in India.
References:
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