https://orcid.org/0000-0003-4626-248X
Abstract
Context/Objective
Strategies to combine primary and specialized care are crucial to meet the needs of individuals with spinal cord injury (SCI) located in rural areas. We explored the collaboration between general practitioners (GPs) and SCI specialists who will participate in an intervention study to improve their collaboration.
Design
A questionnaire survey from August to October 2020.
Setting
Primary Care, Specialized SCI care.
Participants
Eight GPs and 13 SCI specialists.
Interventions
Baseline results from the SCI-Co study.
Outcome Measures
N/A.
Results
Overall, satisfaction ratings for the collaboration between GPs and SCI specialists were high, and all physicians agreed that they work together well. Especially, SCI specialists were satisfied in collaborating with GPs. Despite Switzerland’s fragmented primary and secondary care system, only a few physicians reported about issues with delays and waiting lists. While GPs wanted to improve the quality of their referral, most SCI specialists reported being content with it. GPs were also discontent about discharge organization by specialists.
Conclusion
Satisfaction with collaboration was high, both in GPs and specialists. Areas for improvement include discharge and referral processes.
Introduction
Individuals with spinal cord injury (SCI) require lifelong care for secondary health conditions from healthcare professionals and often arrange a personal care network for their needs.Citation1 In Switzerland, a survey in individuals with SCI showed a high prevalence of spasticity, chronic pain, sexual dysfunction, bowel and bladder problems.Citation2 These individuals are frequent users of medical services, but there seems to be no group of medical specialists able to cover all patient needs in an outpatient setting.Citation2,Citation3 Most persons with SCI visit the general practitioner (GP) and often for acute care.Citation2 Urologists and physiotherapists were other frequently consulted providers for acute and follow-up care. Community-dwelling individuals with SCI, requiring general medical attention or presenting mild secondary conditions in Switzerland, consulted GPs as the first point of contact. Medical specialists are visited for routine annual check-ups or the treatment of SCI-specific complications.Citation4
The role of the GP is essential for individuals with SCI living in rural areas. Providers of specialized SCI services are located in urban regions of Switzerland, and research showed that individuals with SCI are prone to relocate to live near these four specialized centers.Citation5 Those, who stay in rural areas with no access to specialized services, often substitute them with GP services.Citation2 However, the quality of SCI-related care and primary care services was rated unfavorably in areas without sufficient transportation possibilities.Citation6 Similarly, individuals with SCI in Norway expressly declared to be satisfied with their GPs but rated their knowledge low.Citation7 These low patient-reported ratings are not surprising because rural GPs are not frequently exposed to SCI and its associated needs.
On the one hand, the low exposure hinders physicians from gaining and retaining required knowledge and experience.Citation8 On the other hand, GPs in Switzerland reported regularly caring for health conditions with low prevalence.Citation9 Therefore, some GPs might be interested in extending their services towards SCI care. As it is not feasible to expect GPs to be knowledgeable in SCI, they rely on the support and collaborative healthcare professionals.Citation10
We initiated the Spinal Cord Injury – Collaboration (SCI-Co) intervention studyCitation11 to develop a new primary care model that embeds specialized medicine into the long-term care of persons with SCI. Rural GPs in the intervention group will receive continuing medical education and practice visits by specialists, allowing for continuous exchange and networking. Ultimately, this shared care approach should enable close collaboration with SCI centers to ensure that patients receive adequate secondary care when necessary. This study explored participants’ baseline perceptions on collaboration as part of the intervention study. More specifically, we aimed to compare self-reported collaboration between participating GPs and specialists to evaluate whether a care model based on collaboration is within reach. Furthermore, we aim to explore possible areas to improve collaboration as part of our intervention.
Methods
Design and participants
We employed a questionnaire survey asking physicians to rate their collaboration satisfaction. visualizes the recruitment process. 120 GPs who offered comprehensive services in their practice (e.g. ultrasound, physio-, or occupational therapy) and were located more than 60 min by car from the nearest specialized SCI center were eligible for the intervention study. GPs who volunteered to participate in the intervention study and filled out the questionnaire as part of their enrolment are referred to as “participating” GPs. Those GPs not participating in the intervention but still answering the questionnaire were referred to as “non-participating” GPs. Research assistants employed in the four specialized centers distributed the questionnaire among physicians. Medical specialists in regular contact (i.e. direct phone, e-mail, mail communication) with GPs were invited to fill out the questionnaire. We did not provide a numerical range of contacts to define “regular” as the centers differ in size. Therefore, specialists from a large center might have GP contacts five times a week, whereas a smaller center has five GP contacts per month. We anticipated that 16 specialists (4 specialists per center) would participate in the survey with this snowball sampling technique.
Figure 1 Physicians’ recruitment for intervention study and baseline survey.
Survey instrument and administration
The survey took approximately 15 min to complete and had five parts: personal characteristics, employment, characteristics of the place of work, the “Doctoŕs Opinion on Collaboration” (DOC) questionnaire,Citation12 and an estimate of the satisfaction with the collaboration. We chose the DOC questionnaire because it can be used among GPs and medical specialists. It consists of five domains (Organization, Communication, Professional expertise, Image, Knowing each other) and 20 questions. To use the DOC questionnaire in German, two researchers (AG, RT) independently translated the statements from English. A preliminary German language version was agreed on and translated back to English. Any differences from the original version were discussed, and a third researcher (SE) tested the final German language version.
GPs were asked to fill out the survey for collaborating with specialists for SCI and specialists in general chronic care, as not all GPs had previous experience with SCI. Specialists in SCI were asked to fill out the questionnaire for working with GPs. GPs received a link to the web-based survey, a paper-based version of the survey, and a stamped return envelope in September 2020 via postal mail. Two weeks after receiving the letter, we sent an e-mail reminder to all GPs. Research assistants employed at the specialized SCI centers received a cover letter, which included the link to the web-based survey and paper-based versions of the survey, and the instruction to distribute them to eligible specialists from August to October 2020. Data generated by the paper versions of the survey were entered into the web-based survey tool.
Statistical analysis
Statistical analyses were performed using Stata version 17 for Windows (College Station, TX). Basic statistic procedures were used to describe the study sample and their Likert scale ratings of collaboration. Descriptive statistics in the tables are reported with raw numbers and percentages. Continuous variables are reported with mean and standard deviation or median and minimum/maximum. We visualized the DOC questionnaire and satisfaction rating to overview all five Likert scale ratings. The Likert scales are simplified for reporting answer distributions to the questions in the body text (answer categories 4 and 5 = agree; answer categories 2 and 1 = disagree). We excluded from the analysis responses with no data for DOC.
As an additional step of the statistical analysis, we determined whether participation in the intervention influences baseline data. Therefore, we assessed all information in the group of non-participating GPs. Their characteristics and answer distributions can be found in Appendix Table 1, Appendix Figure 3 (domains), and Appendix Figure 4 (questions).
Ethical approval
The ethical approval was awarded by the Ethics Committee of Northwest and Central Switzerland (EKNZ; # 2019-01527-2). The approval confirms that the study fulfills the general ethical and scientific standards for human research.
Results
Descriptive summaries of characteristics and workplaces of 8 GPs and 13 specialists taking part in the survey are presented in and .
Table 1 Characteristics of GPs and specialists.
Table 2 Characteristics of GPs’ and specialists’ work place.
Characteristics of participating GPs and specialists
The majority of participants were male. One of 13 specialists and 5 of 8 GPs were qualified in Switzerland. Specialists were from various medical disciplines, but most were specialized in internal medicine, physical medicine, rehabilitation, or neurology. Furthermore, most of them were senior or leading physicians. On average, GPs attended approximately 42 h and specialists 32 h of continuous medical education per year. Specialists reported higher employment percentages and more working hours per week than GPs. The estimates of the average weekly contact with each other differed between GPs and specialists. GPs reported nine weekly specialist contacts, and specialists reported five GP contacts. All physicians indicated to use phone and e-mail as their main communication channels with each other.
GPs’ answers to the DOC questionnaire and rating of collaboration satisfaction
All eight GPs answered the survey for general chronic care collaboration, and four GPs answered the survey for SCI care. visualizes the answer distributions to the questions’ domains (Organization, Communication, Professional expertise, Image, Knowing each other, Satisfaction), and Appendix Figure 1 shows the answer distributions to the 21 original questions. The majority of GPs reported a high Satisfaction in general chronic care (71% agreed to be satisfied) and SCI-specific collaboration (75% agreed to be satisfied). As part of the Organization domain, all GPs agreed that they work well with specialists in general chronic care and the majority (75%) agreed to work well with specialists in SCI-specific care. The collaboration between specialists in the hospital was perceived to be good (88% for the general care and 100% for SCI care agreed). Few GPs reported experiencing challenges regarding the delay and waiting lists.
Figure 2 GPs’ answer distributions visualized in survey domains for SCI care and general chronic care. SCI: spinal cord injury.
Consequently, the period between GP’s referral and first consultation with the specialist was too long for a few GPs in general care (29% agreed) and SCI care (25% agreed). Additionally, the majority of GPs agreed that they could solve problems concerning delay by having solid agreements with specialists (71%) and SCI specialists (67%). Regarding the waiting list, the period between the first consultation with the specialist and follow-up, few GPs agreed that it is too long for general care (14%) and SCI care (25%). Likewise, few reported solid agreements with specialists (14%) and SCI specialists (25%) to resolve issues around waiting lists. Unlike delay and waiting lists, there seem to be challenges for GPs concerning discharge organization. Few GPs agreed that discharge is well organized by specialists (29% for general care and 25% for SCI care agreement).
The GPs’ agreement to answers in the Communication domain was high. All GPs agreed that the specialists’ and SCI specialists’ approach during telephone conversations is positive. The quality of the input during phone conversations was rated to be good for specialists (88%) and SCI specialists (100%). Lastly, GPs appreciated feedback on the way they handle cases from specialists (100%) and SCI specialists (75%).
As part of the Professional expertise domain, all GPs agreed that they want to improve their referral to medical specialists overall. Half of the GPs agreed that specialists (57%) should improve their referrals to GPs, whereas only a few GPs agreed that SCI specialists (25%) should do so. Furthermore, they wanted specialists (57%) and SCI specialists (100%) to have better insights into how GPs work. On the contrary, fewer GPs wanted better insight into how specialists (29%) and SCI specialists work (50%).
As part of the domains Image and Knowing each other, all GPs reported being confident in their working relationship with specialists. Furthermore, most GPs felt appreciated in the working relationship for general (100% of GPs agreed) and SCI-specific (75% of GPs agreed) collaboration. One GP reported that other specialists look down on GPs, none of the GPs reported that SCI specialists look down on them. All GPs agreed that they gain better insight into each other’s work and that contacts become easier and more accessible when getting to know a specialist personally. Furthermore, they reported that they gained insights into the specialists’ (75%) and SCI specialists’ (100% agreed) medical field when knowing each other.
Specialists’ answers to the DOC questionnaire and rating of collaboration satisfaction
Thirteen SCI specialists answered the survey and rated their collaboration with GPs. visualizes the answer distributions to the domains Appendix Figure 2 shows the answer distributions to the questions. The majority of specialists (69%) reported being satisfied with the collaboration. As part of the Organization domain, specialists agreed to work well with GPs (69%) and other specialists in their SCI centers (69%). Similar to the GPs’ answers, few SCI specialists reported challenges with delay and waiting lists. A third of the specialists (33%) agreed that delay was too long for patients, and half (54%) agreed that they avoid problems concerning delay by having solid agreements with GPs. A quarter of specialists agreed that the waiting list was too long and that they have solid agreements with GPs to avoid issues with waiting lists. Contradictory to the GPs’ answers, 83% of SCI specialists agreed that their discharge is well organized.
Figure 3 Specialists’ answer distributions visualized in survey domains for spinal cord injury care.
Similar to GPs’ answers in the Communication domain, specialists provided high ratings for GPs. The GPs’ approach during phone conversations was perceived as positive (84%), and feedback by GPs on the way specialists’ handled cases was appreciated (92%). Lastly, 84% of specialists rated the GPs’ input during telephone consultations to be of good quality.
Unlike all GPs who answered in the Professional expertise domain that they wanted to improve their referrals overall, half of the specialists (46%) agreed that GPs should improve their referrals. Reciprocally, half of the specialists (54%) wanted to improve their referrals to GPs and wanted to get more insights into how GPs work (50%). More specialists (64%) wanted GPs to have more insights into their own work.
Lastly, most specialists gave high ratings in the domains Image and Knowing each other. SCI specialists felt confident (100%) and appreciated (92%) in their working relationship with GPs. Furthermore, only one specialist reported that GPs look down on specialists. Compared to the GPs, specialists gave slightly lower but still high ratings on the benefits for collaboration of knowing each other personally. Expressly, 75% of specialists agreed that they gain better insight into each other’s work and medical expertise when knowing each other. 83% of specialists agreed that contacts become easier and more accessible.
Influence of participation in intervention study
We compared the characteristics and answer distributions of the participating GPs with non-participating GPs. Twenty-three non-participating GPs answered the survey for general chronic care collaboration, and 14 answered the survey for SCI care. Appendix Figure 3 shows the domains’ answer distributions, and Appendix Figure 4 shows the questions’ answer distributions.
Participating GPs spend more time for continuous medical education than non-participating GPs per year (42 h compared to 36 h), had slightly more contact with specialists per week (9 times compared to 8 times), their practice was located farther away from the next hospital (16 kilometers compared to 9 kilometers), cared for more patients personally (426 patients compared to 356 patients) and as a team of their entire practice per month (852 patients compared to 813 patients). Furthermore, the participating GPs consulted patients with a broader age distribution as indicated by the standard deviation of the patients’ age (44 (±17) compared to 53 (±8)).
Some answer distributions differed notably between participating and non-participating GPs. Non-participating GPs rated satisfaction with specialists higher than participating GPs, and lower for SCI specialists. Fewer non-participating GPs felt confident in their working relationship with specialists (76% agreed) and SCI specialists (57% agreed) compared to participating GPs. In comparison, all participating GPs felt confident in working with SCI specialists.
Discussion
Main findings
Overall, ratings for the collaboration between GPs and SCI specialists were high, and physicians agreed that they work together well. Especially, SCI specialists were satisfied in collaborating with GPs. Despite Switzerland’s fragmented primary and secondary care system, only a few physicians reported about issues with delays and waiting lists. While GPs wanted to improve the quality of their referral, most SCI specialists reported being content with it. GPs were also discontent about discharge organization by specialists.
Comparison with existing literature
Our findings demonstrate that the collaboration between rural GPs and SCI specialists is promising. Other researchers provide guidance for good collaboration, including typologies and theoretical frameworksCitation13,Citation14 and explorations on providers’ competencies and preferences for collaboration.Citation15,Citation16 In line with this guiding research, the physicians in our study were satisfied and collaborated with each other. In particular, the ratings regarding communication, a crucial factor for good collaboration,Citation15,Citation17 were high. Furthermore, interpersonal factors that positively influence collaboration,Citation15,Citation16 such as knowing and appreciating each other, had high ratings. These findings are promising for individuals with SCI living in rural Switzerland. Research in this study populationCitation18 has shown that GPs are an important point of contact in the community as there is low availability of specialized services. These individuals with SCI wish to have a GP that can be contacted,Citation4,Citation18 and substitute specialized services and GP visits are exceptionally high in this population.Citation2 However, GPs might not have the specific knowledge and skills to sufficiently compensate for the required services.Citation7 Therefore, rural GPs, in particular, rely on support from SCI specialists to tackle the potential undersupply of services. As other research has pointed out,Citation10,Citation19 a structured long-term collaboration is needed. The roles and responsibilities of involved healthcare professionals, patients, and caregivers need to be clarified. As GPs and SCI specialists in our study were interested in collaborating and educating each other about their competencies, a shared care model seems feasible.
Our study showed improvement potential in referral and discharge processes in general chronic care and SCI care. Most care approaches for complex chronic conditions rely on the GP to be a gatekeeper for specialized services, supporting and navigating patients to choose appropriate professionals.Citation20 These findings have not been systematically implemented in Swiss healthcare. Instead, highly fragmented healthcare can be observed.Citation21,Citation22 Most patients with chronic conditions can choose healthcare providers freely, and duplication of services frequently occurs.Citation23 Similar to other findings,Citation24 the GPs in our study indicated decision-related distress regarding their referral to specialists. The GPs wanted to improve the quality of their referral, but most SCI specialists reported to be content with it.
Furthermore, GPs were somewhat discontent about discharge organization by specialists and SCI specialists. In other research on this topic,Citation22 GPs reported to lack information about treatments and further requirements within a reasonable time, which might be the case for our GPs as well. A lack of discharge communication between primary and secondary care resulted in delayed follow-up treatment, disrupting the continuity of care.Citation25 Thus, intervention studies focused on improving or re-organizing discharge and referral processes back to primary care.Citation26
Ratings differed in our survey between participating and non-participating GPs, confirming that voluntary participation in our intervention study affects baseline values. Similarly, other researchers observed that GPs who do and do not participate in an intervention differ in characteristics and performance levels at baseline. The authors also showed that participation bias caused by the voluntary nature of research participation meant that those who did not engage were the ones who would have benefited from the intervention.Citation27
Implications
There are implications for research and daily practice derived from our study. Physicians indicated that they are willing to learn from each other. Therefore, future collaborative education should incorporate both general and specialized topics to stimulate exchange between physicians. Furthermore, more approaches to improve SCI community care need to be developed. Researchers should explore how roles and responsibilities are defined in daily practice and if physicians are willing to shift roles to optimize access to care for individuals with SCI living in rural areas. Lastly, we need to find possibilities to engage some of the GPs who are not as interested (our non-participating GPs) as those already participating in the intervention study. This might be achieved with a policy-driven improvement scheme.
Limitations and strengths
We realize that the study’s sample size is limited by the design of our intervention study. SCI is a health condition with low prevalence, but we are confident that clinicians and researchers can learn from the complexity and necessity of interdisciplinary care it imposes. To our knowledge, this is the first study to explore SCI-specific collaboration of primary and secondary care physicians in Switzerland.
Conclusion
The ratings for collaboration were high in participating GPs and specialists. Areas for improvement include discharge and referral processes.
Disclaimer statements
Declaration of interests None.
Conflicts of interest Authors have no conflict of interests to declare.
Supplementary information
Supplemental data for this article can be accessed on the publisher’s website. https://doi.org/10.1080/03772063.2022.2098190.
Supplemental Material
Download Zip (329.2 KB)Acknowledgments
We would like to thank all physicians who participated in this study.
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