Study shines a light on paediatric case mix

Integrated models of care, as well as upskilling GPs to better support children with behavioural or mental health challenges, could result in cost savings and reduce wait lists for non-GP specialists.
 
That is according to findings in an Australian-first study published in this month’s issue of the Australian Journal of General Practice (AJGP).
 
Led by the Murdoch Children’s Research Institute (MCRI), the research examined the reasons why children visit a GP and how often they are referred to a non-GP specialist.
 
The study followed 130 GPs across 22 general practices in Melbourne and Sydney, examining almost 50,000 paediatric-related consultations. It aimed to address knowledge gaps of the case mix of paediatric consultations in general practice, GP referral patterns, and associated costs.
 
While most patients aged between zero and less than 18 years visited the GP for upper respiratory issues such as cough or common cold, the study found that a significant amount also sought support for developmental, behavioural or mental health concerns.
 
GPs referred 10% of visits during the study period, predominantly for mental health, with most referrals for private specialists, such as psychologists, psychiatrists, or paediatricians. This represented an estimated cost to the healthcare system of $1.4 million and a mean cost of almost $300 for each patient.
 
The AJGP authors are calling for primary healthcare to be strengthened to adopt a more proactive role in supporting children and families with mental health, developmental or behavioural concerns.
 
They recommend GPs receive the latest training on young people’s health to ensure they have the confidence to manage these issues without always needing to make a referral.
 
Lead author, consultant paediatrician and MCRI Professor Harriet Hiscock told newsGP there are a number of barriers to enable GPs to provide paediatric care.
 
‘Training will only take you so far, it is an important step to consider, especially for child developmental–behavioural and mental health problems for which trainee GPs tell us that they feel under equipped to manage,’ she said.
 
‘Integrated GP–paediatrician models of care could address barriers for GPs such as lack of knowledge and lack of time.’
 
Professor Hiscock’s team at MCRI have recently completed a trial of an integrated GP–paediatrician model of care, Strengthening Care 4 Children, of which the AJGP paper draws on baseline data. In the model, a paediatrician travels to the general practice on a weekly-to-fortnightly basis for one session to co-consult on children whom the GP wants support and advice on. The paediatrician also runs a monthly case discussion on a topic of the GP’s choice, such as developmental disorders in children, and is available by phone and email on business days to provide advice to GPs.
 
‘We believe models such as these can support GPs to work at top of scope and reduce referrals to specialists and hospitals,’ Professor Hiscock said.
 
‘However, to make these models work, GPs need to be adequately funded to provide long (30 minute) consultations with children presenting with complex issues. Funding to support specialist GP consultations without the patient present is also key and does not exist in the Australian system.
 
‘Any new model of care [also] requires change management, and Primary Health Networks are well positioned to take on this role in primary care.’
 
The study found that of the 49,932 consultations analysed, medical issues such as upper respiratory tract infections, reviews and cough were the most frequent reason (29,289), for consultations, followed by immunisations (7745), developmental and behavioural concerns (1170), check-ups (1143), and mental health concerns including anxiety and ADHD (888).
 
‘GPs see children for a range of conditions,’ Professor Hiscock said.
 
‘[But] we have very little available data on children seen by Australian GPs because there is no system-wide mechanism for extracting and sharing this data from GP electronic medical records.
 
‘In this study, we developed and applied for the first time in Australia a Natural Language Processing algorithm that mapped the child’s “reason for visit” recorded in the GP’s electronic medical record into structured clinical data, based on Systematized Nomenclature of Medicine Clinical Terminology.
 
‘This enabled us to see why children attend a GP.’
 
The team also created a ‘pop-up’ box in the GP’s electronic medical records that they completed at the end of every consultation with a child. This enabled them to see if and where a GP referred a child – for example to a public hospital emergency department, public outpatient clinic, private hospital, private non-GP specialists, public mental health services, or allied health.
 
The total cost of referrals was estimated at an average of $297.96 per patient referred, and the largest category of referral cost was ‘private specialists’, predominantly paediatricians.
 
These findings come as wait lists continue to soar for paediatricians and mental health services for young people. One proposed solution of expanding GPs’ prescribing powers for ADHD medications was recently welcomed by the RACGP in New South Wales, with the college continuing calls for a nationally consistent framework.
 
The MCRI authors conclude that models of care that increase ‘the equity of referrals’ for mental health and developmental–behavioural conditions, such as integrated primary and specialist care, are ‘crucial’ and their findings present an ‘important opportunity for strengthening primary care to be more equitable and efficient’.
 
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