Elsevier

Health Policy

Volume 92, Issues 2–3, October 2009, Pages 141-148
Health Policy

Social network analysis in primary care: The impact of interactions on prescribing behaviour

https://doi.org/10.1016/j.healthpol.2009.03.005Get rights and content

Abstract

Objectives

In many healthcare systems of affluent countries, general practitioners (GPs) are encouraged to work in collaborative arrangements to increase patients’ accessibility and the quality of care. There are two lines of thought regarding the ways in which belonging to a network can affect GP behaviour: (1) the social capital framework posits that, through relationships, individuals acquire resources, such as information, that allow them to perform better; and (2) the social influence framework sees relationships as avenues through which individual actors influence other individuals and through which behavioural norms are developed and enforced. The objective of this study is to provide an evaluation of the effects of GP network organisation on their prescribing behaviour.

Methods

We used administrative data from a Local Health Authority (LHA) in Italy concerning GPs organisation and prescriptions.

Results

We found that GPs working in a collaborative arrangement have a similar prescribing behaviour while we did not find a significant relationship between the centrality of a GP and her capability to meet LHA's targets.

Conclusions

Our data support the conclusion that, in the case of GP collaboration initiatives, the social influence mechanism is more relevant than the social capital mechanism.

Introduction

In the last 20 years healthcare reforms in Western Europe have reshaped primary care in general and the role of GPs in particular. Such reforms have broaden GPs’ service portfolio [1], introduced innovative financial incentive schemes [2], [3], [4], attributed to GPs a leading role in purchasing and/or coordinating providers, especially in Beveridge systems, [1], and promoted cooperative arrangements across the interface [1], [5]. All these measures are changing the organizational role of GPs and the content of their professional and managerial activities. A major common theme across countries is the promotion of cooperation among GPs as a means to spread knowledge, facilitate accountability and, in the end, improve patients care with limited resources [6], [7], [8]. In this paper, we use social network analysis to study whether the collaboration initiatives launched by a local health authority (LHA) in Italy between 2001 and 2004 have had any effect on individual and district-level GP performance, as measured in terms of meeting drug expenditure targets.

In the Italian National Health Service, LHAs are responsible for providing comprehensive healthcare to the resident population of their area and are divided into subunits called districts where initiatives to coordinate GPs work and other community care activities are generally managed. Among other activities, LHAs manage general practitioners, who are family doctors working for LHAs as independent contractors and acting as gatekeepers to higher levels of care. Traditionally, GPs in Italy have worked in solo practices without any auxiliary staff or institutional links to other GPs. However, organisational models and management systems have significantly changed over the past 10 years [9]. Several LHAs have introduced budgeting systems and financial incentives to make GPs more accountable for their prescribing and referral behaviour, and have invested in sophisticated information systems to provide detailed reports on GPs prescribing patterns.

Many LHAs are also trying to reshape the traditional model of primary care by encouraging GPs to participate in collaborative arrangements such as group practices in which GPs share practice space and other resources. The basic idea behind these initiatives is that organisational and professional development in primary care requires cooperation and the sharing of resources and knowledge. A vast body of research has investigated the impact of financial incentives, other interventions and individual factors on GP behaviour [10], [11]. Instead, the present study focuses on the implications of relationships created through collaboration initiatives launched by an LHA. We investigate determinants of medical practice variation in primary care from a supply perspective, which states that physician characteristics and the environment in which physicians operate may shape patterns of healthcare utilisation [12]. Within this perspective, we adopt a relational (or network) framework that can be seen as complementary to economic models of incentives created by payment systems [2], [13], as well as to clinical explanations based on physicians’ response to uncertainty [13], [14].

The various collaborative arrangements in which GPs participate are forging sophisticated primary care networks, a development that raises two important questions: what are the consequences of these relationships, and how are these relationships influencing GP behaviour?

We argue that the social network paradigm represents a useful approach to answering these questions. Social network analysis has been variously used to describe the structure of relationships, to investigate the consequences of a given structure [15], and to understand individual outcomes as a function of an actor's social network characteristics (see Borgatti and Foster [16] for a review of this literature). Indeed, recent contributions in primary care have started to use Social Network Analysis as a tool to describe and analyze patters of relationships among physicians in primary care [17], [18]. We follow this line of research and explore the structure and consequences of collaborative arrangements in an Italian LHA that launched a number of GP collaboration initiatives.

Section snippets

Theoretical framework and hypotheses

The social network perspective is based on the premise that actors are embedded within networks of social relationships [19], [20] and that these networks have ‘important behavioural, perceptual, and attitudinal consequences’ [21]. There are two fundamental theoretical strands on the mechanisms underlying the behavioural and attitudinal consequences of networking: (1) the social capital perspective, and (2) the social influence perspective [16].

The social capital perspective views networks of

Materials and methods

The network data used in this paper were provided by a LHA of Empoli in the Tuscany region of Italy, which comprises two districts (henceforth designated as districts A and B) with a total population of 227,038. Data on GP activities, including information about formal networks, are collected regularly and archived digitally by the LHA for its operational activities. From these archives, we obtained data about the membership of individual GPs in different types of collaboration initiatives from

Results

In the present analysis, the dependent variable was expressed by the difference between an individual GP's per capita pharmaceutical expenditure and the LHA's assigned target. Within the social capital framework, Hypothesis 1 posited that the more central a GP is to his or her network, the more the GP is able to meet the target assigned by the LHA. As shown in Table 2, centrality has a very small and insignificant effect, which means that Hypothesis 1 is not supported by our data.

Grounded in

Discussion

In this study we investigated the individual and district-level impact of the collaboration initiatives launched by an Italian LHA between 2001 and 2004. In line with recent research in primary care [17], [18], social network analysis provided us with the theoretical and instrumental framework for identifying specific hypotheses, measures, and empirical models. The main contribution of our study is its comparison of two mechanisms – i.e. social capital and social influence – by which different

Conclusions

A first contribution made by this study is in the provision of a preliminary evaluation of the consequences of an LHA's initiatives on GP performance, expressed in terms of GP prescribing behaviour. Analyses of formal ties created by collaboration initiatives are important because policy makers and managers have some control over the development of these relationships, as opposed to the control over informal ties, which is weaker. Many LHAs are considering or are already implementing

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