Elsevier

Social Science & Medicine

Volume 54, Issue 8, April 2002, Pages 1225-1241
Social Science & Medicine

Construction of a GP integration model

https://doi.org/10.1016/S0277-9536(01)00092-2Get rights and content

Abstract

There are frequent calls to improve integration of health services, within and between primary and secondary care sectors. In Australia, general medical practitioners (GPs) are central to these endeavours. This paper aims to better conceptualise GP integration and to develop a model and index based on this.

A conceptualisation of integration is proposed based on integration fundamentally as an activity or process not structure. Integration process is the frequency and quality of episodes of information exchange involving the GP and another practitioner or patient and aimed at fulfilling the objectives of the health care system with regard to patient care. These are both direct responses to structural forces and emergent GP capacities and dispositions.

The content of this typology was studied using Concept Mapping in 11 groups of GPs, consumers and other practitioners. Clusters of related statements within thematic domains were used as the basis for a provisional model. This was tested using confirmatory factor analysis in a data set derived from a national probability sample of 501 GPs.

Some re-specification of the model was necessary, with three integration process factors needing to be subdivided. One factor congeneric model assumptions were used to identify the constituent items for these factors. The result was a model in which 50 items measured nine integration process factors and 20 items measured five enabling factors. Two distinct but correlated higher order factors, relating to individual patient care and public (or community) health—in contrast to a single higher order factor for integration—were identified. The re-specified model was tested with a new sample of 151 GPs and exhibited strong psychometric properties. Reliability and validity were acceptable to this stage of the indices’ development. Further testing of the index is necessary to demonstrate factor invariance of the indices in other contexts as well as their utility in cross-structural analysis. That said, the indices have immediate uses.

Introduction

Complex, multi-dimensional social concepts or phenomena deemed to have positive impacts on community health (such as ‘community empowerment’, ‘service responsiveness’) are in widespread use. Surprisingly, there have been few attempts to examine their meaning closely or to identify their dimensions. Perhaps their very complexity deters such efforts. However, study of the concept would have value in demonstrating that it has, or does not have a stable reality, judged by agreement about its meaning and existence of stable patterns of observations implying such a construct.

The complex, multi-dimensional concept studied in this paper is ‘integration of general practitioners with the health care system’. In the words of the emergent realists, the paper investigates whether ‘GP integration’ is something ‘real’ not merely a convenient shorthand term to describe a class of programs (Cronbach, 1989). Given the lack of preexisting theory, its methodology is exploratory and iterative and inevitably involves judgements of the investigators which are influenced by their presuppositions and values. There is however no alternative approach save abandoning the task.

In this paper, Concept Mapping is used to specify a theoretical model, which can be subsequently tested by confirmatory factor analysis, using structural equation modelling (SEM) in an appropriate data set. This hypothesis generation and testing approach contrasts with the traditional hypothesis generating step only of exploratory factor analytic (EFA) approach (McArdle, 1996). In the latter, a convenience sample of subjects or researchers is typically used to generate statements or questions for which no model is specified. Factors are subsequently derived from these statements in a data set using EFA.

Concept Mapping is a nominal group technique that permits the rapid development of a conceptual framework for any given topic (Trochim, 1989a). It is expressed entirely in the language of the participants and yields a graphic or pictorial product which simultaneously shows all major ideas and their interrelationship. To construct the map, ideas (statements) have first to be described or generated and the interrelationship between them articulated. Multi-variate statistical techniques are then applied to this information and the results are depicted in map form.

The paper describes a measurement model of GP integration as distinct from a structural causal model which would investigate the relationship between the whole (or indeed parts) of the GP integration model with other concepts and variables. It is necessary for the measurement model to be tested and refined before detailed exploration of causal models is possible.

Section snippets

The role of the general medical practitioner (GP) in the Australian health care system

The Australian health care system is a mixed public/private system. It is further fragmented by a federal system of government where the Commonwealth Government's role is to fund public health services within a large number of programs and to underwrite private care, and the States and Territories’ role is to be responsible for the delivery of public health services. Universal medical insurance covers medical practitioner services but fee rebates for these services are only obtainable if the

Developing a conceptual schema to describe GP integration

To begin, the Macquarie Dictionary (1997) defines integration as ‘the act of bringing together parts (into a whole)’. Coordination, by comparison, is defined as ‘the act of arranging according to a plan especially one drawing together a number of different events, organisations, people, etc.’ and ‘working together smoothly in combination’.

Descriptions of integration of health services (not GP integration) that exist in the research literature are primarily used for purposes of classification.

Specifying a model of GP integration through application of Concept Mapping techniques in small groups

Concept Mapping was used to specify the model of GP integration to be subsequently tested using SEM. It is a nominal group technique that permits the rapid development of a conceptual framework for any given topic (Trochim, 1989a). It is expressed entirely in the language of the participants and yields a graphic or pictorial product which simultaneously shows all major ideas and their interrelationship. To construct the map, ideas (statements) have first to be described or generated and the

Confirming and re-specifying GP integration models using SEM in a national GP survey data set

Two variants of the hypothesised models for the integration process factors and the enabling factors were proposed. The simpler without higher order factors is shown in Fig. 3 above. A more complex variant of the integration process factor model (not diagrammed) encompassed the simple variant plus three mediating higher order factors between the higher order factor integration and the five individual factors. These three higher order factors represented several though not all of the five

Scoring the index

Each factor was scored from 1 to 5, these scores being derived by averaging the scores on the five-point Likert scale of the constituent items. This adjustment was necessary as factors varied in the number of constituent items and some missing data existed. Higher order factors were scored by averaging the scores of the contributing scales rather than averaging the scores of all items within the scales. This was done to avoid weighting the score in favour of scales with more items.

In principle

Discussion

To what extent then has the aim of the study been realised? What is the content and what are the boundaries of the complex, multi-dimensional social concept GP integration with the health care system. Does it have a stable reality and describe a stable pattern of events? In the words of the emergent realists, is ‘integration’ real and not merely a convenient shorthand term to describe a class of programs (Cronbach, 1989)?

The results firstly indicated that GP integration could be conceptualised

Acknowledgements

We thank all GPs, consumer representatives, allied health professionals, nurses, specialist doctors, hospital administrators and associated professionals participating in Concept Mapping sessions. We also thank all GPs completing the national mail questionnaire surveys. The members of the GP Steering Group comprised A/Profs. Phillip Hegarty, Remi Guibert, Drs. Peter Waxman, Michael Montalto, Stephen Wales and Mr. Richard Smith. The members of the project's Reference Group comprised Drs. Rob

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