Minor surgical procedures and musculoskeletal injections by primary care physicians - an Israeli experience

Setting

At the time of this study, 54% of the Israeli population (3,774,600 enrollees) was insured by CHS HMO. The Southern District (Negev) of CHS HMO insures about 280,000 persons above the age of 16 in southern Israel.

Approximately 2,000 primary care physicians work in one of the four HMOs in Israel. About half of them are board certified in family medicine. The rest are general practitioners or board certified internists. Most of the primary care physicians are salaried employees. In CHS HMO primary care physicians are not compensated for the MSP and MSI that they perform. Each primary care physician has a practice of about 1300 persons that he/she is responsible for.

Selection of study subjects

During the year 2010 a self-report questionnaire was sent by HMO internal mail to all 277 primary care physicians who treat adults in the Southern District (Negev) of CHS HMO. The human resources section of the HMO’s district administration provided the list of physicians. Two months later a reminder was sent to physicians who had not responded. The study included residents and specialists in family medicine, general practitioners without formal training in family medicine, and specialists in internal medicine.

Measurements

The questionnaire included socio-demographic data, questions relating to the performance of MSP and MSI, and barriers to their performance.

Statistical analysis

Data was analyzed using the SPSS statistical software package (SPSS, Inc., Version 17.0, Chicago, IL). T-tests and chi-square tests were used to assess statistically significant differences for continuous and categorical variables, respectively. Two-tailed p-values below 0.05 were considered statistically significant. Two logistic regression models were developed to predict MSP and MSI. The models included demographic variables that were significantly associated with MSP and MSI in bivariate data analysis.

The study was approved by the IRB of the Meir Medical Center, Kefar Saba, Israel.

Study population compared to all primary care physicians in the southern district (negev) of the CHS HMO

Primary care physicians’ performance of MSP and MSI

Primary care physicians who do not perform MSP usually refer most cases to specialists, except for lacerations that require suturing, which are referred, in 67% of the cases, to the emergency room. The other cases are referred to another primary care physician who does perform suturing. For abscess drainage 61% are referred to a specialist surgeon and 34% to the emergency room. For the different MSI, 80-90% of the patients are referred to a specialist if the primary care physician does not do it. Physicians who performed MSP were more likely to perform MSI (p < 0.0001).

Facilitating factors and barriers to MSP and MSI performance

Male physicians were more likely than female physicians to perform MSP (75% vs. 55%, p < 0.007) and MSI (55% vs. 38%, p < 0.032). Physicians born in Israel performed more MSP than physicians born elsewhere (89% vs. 58%, p < 0.001). While this was also the case for MSI, the difference did not reach statistical significance. Graduates of israeli medical schools performed more MSP and MSI than those who graduated from medical schools outside of israel. Specialists in family medicine performed more MSI than residents in family medicine, general practitioners, and specialists in internal medicine (63% vs. 33%, p < 0.0001). This was also the case for MSP, but the difference did not reach statistical significance. Physicians practicing in rural areas performed more MSP than physicians practicing only in urban areas (78% vs. 58%, p < 0.01), while the difference was not significant for MSI. Age, seniority as a physician, the number of patients in the practice, and the number of patients seen in the course of a day were not associated with the performance of MSP and MSI.

Comparison with existing literature

Several surveys have addressed the issue of MSP in primary care. Two Israeli family physicians reported their experience with surgical procedures in their clinics over a 22-month period in 1984–5. They treated both rural and urban patients. In the rural setting they performed more elective surgical procedures than in the urban setting. More urgent surgical procedures were performed in the urban clinics[15]. Their complication rate was about 3%, which is the expected rate[16]. The most common surgical procedures included suturing lacerations, excision of skin lesions and sebaceous cysts, removal of nails, draining of abscesses, removal of foreign bodies, and drainage of thrombosed hemorrhoids.

A prospective survey from the United Kingdom checked the cost effectiveness of minor surgery with remuneration in general practice compared to hospital practice. Minor surgery in general practice was cost effective but general practitioners sent a smaller proportion of specimens to a histopathology laboratory, incorrectly diagnosed a larger proportion of malignant conditions as benign and inadequately excised 5% of the lesions[19].

Another prospective randomized comparison of minor surgery for 568 patients between primary and secondary care was conducted in the United Kingdom. Again, minor hospital surgery was of slightly better quality with a difference that reached statistical significance. However, the clinical importance of the difference was uncertain and the cost was higher. The complication rate was similar in both groups except for wound infection, which was higher in primary care minor surgery. Patients were more satisfied doing procedures in primary care setting because it was more convenient[14].

The results of a survey from Spain showed that the average waiting time for procedures performed by family physicians was lower by a mean of 45 days than surgeons, without any significant difference in effectiveness[20]. Several surveys from Canada reported similar findings to those of the present study. They also reported that primary care physicians in rural areas perform more surgical procedures than those in urban areas[21, 22]. In a survey from Ontario Canada, 79 family physicians were interviewed. The overall self-reported performance rates were 63.3% for dermatological excisions, 43% for knee injections, and 31.6% for shoulder injections. These rates were higher than in our survey (20.8%, 28.4%, and 19.9% respectively). Similar to our findings, the main barriers to performing these procedures were lack of updated skills and lack of time (about 50%)[23]. In Saudi Arabia, a randomly selected group of 231 primary care physicians working in Riyadh health centers completed a confidential questionnaire about their performance of minor surgical procedures. The results were similar to ours with 74% of the physicians performing some sort of minor surgery. Physicians living in remote areas performed more minor surgery compared to other areas and male physicians performed more minor surgery than female physicians (p = 0.05)[24].

In a study from Croatia, the effect of a surgical training course on the performance of minor surgical procedures was evaluated one year later in a group of 59 family physicians. There was a statistically significant increase in the number of minor surgical procedures performed, which almost doubled from baseline. Male physicians performed significantly more surgical procedures than female physicians, before and after the course. As in our study, there was no association between the number of procedures performed and the age of the participating physicians or their length of employment, but in contrast to our study there was no difference between urban and rural clinical settings. Fifty percent of the physicians did not perform surgical procedures irrespective of whether they participated in the course[18], compared to one third in the present study.

Similarly, several surveys have addressed MSI performance by primary care physicians. A survey from the United Kingdom explored joint and soft tissue injections by 251 general practitioners. Factors associated with higher levels of injection activity were: male gender, more than 10 year’s experience, a special interest in rheumatology or orthopedics, and working in a rural or mixed practice. The most important barriers to carrying out injections were lack of practical training, lack of confidence, and inability to maintain skills. The most injected musculoskeletal problems were tennis elbow, knee joint and glenohumeral joint[25].

In a survey among 798 primary care physicians from Ontario, Canada who completed a questionnaire about their level of confidence in treatment of musculoskeletal disorders rural physicians were more confident than urban physicians about doing a joint injection/aspiration (Odds ratio 2.24)[26]. In a study conducted in Northern Ireland 46% of the 309 participating physicians did not perform MSI at the time of the study. Five percent of the primary care physicians carried out most of the injections done in the community. Injections into the shoulder, knee and lateral epicondyle were the most commonly performed. The physicians preferred to train on “real patients” rather than on mannequins. The barriers to performing injections included (in descending order): inability to maintain injection skills, inability to make the correct diagnosis, medico-legal concerns, concerns about complications, cost/time involved in training, time needed to do the procedure, lack of evidence about efficacy, and lack of personal interest[17]. In our survey lack of time was the main barrier.

In a randomized study from Northern Ireland of two different training programs for general practitioners in the techniques of shoulder injection, physicians that received training on real patients were significantly more confident in performing injections than physicians who were trained using mannequins[27]. Two more studies from the United Kingdom and the Netherlands showed that training programs for primary care physicians on shoulder injections techniques increase their performance rate[28, 29]. Another survey of primary care internists from the United States showed that a training program in outpatient primary care could increase MSI performance[30].

A survey of 298 physicians working in a primary care setting in Riyadh, Saudi Arabia reported their MSI experience. The conclusion was that many physicians working in primary care settings in Saudi Arabia refer patients who require musculoskeletal injections to specialists for consultation, even though treating these patients at the primary care level is more time- and cost effective[31].

Interpretation of the study results in relation to existing literature

In our survey, as well as those reported from other countries, MSP and MSI performance rates were higher in male physicians and those who work in rural areas. The best performance improvement reported in the literature resulted from a course in which physicians practiced on actual patients. The physicians in the present study ranked setting aside dedicated procedure time and a training course as the most important facilitating factors, while they ranked live demonstrations on patients as third.

The performance rate for MSP and MSI was not associated with the physician’s age, years in practice, the number of patients in the practice, or the number of patients seen by the physician over the course of a day. This consistent finding suggests that those primary care physicians who are used to performing MSP and/or MSI continue to do so as they gain experience and confidence and manage to find the time despite their heavy work burden.

Strengths and limitations

Our study has some limitations. First, only 54% of the eligible physicians in the Southern District (Negev) of CHS HMO responded to the survey. Second, self-report is less accurate than actual measurement of performance and physicians may overestimate their performance. Third, those who answered the questionnaire could be more interested in the subject and tend to perform procedures more than those who did not. Forth, the study was limited to the south of Israel and included physicians from only one HMO, albeit the largest in the region. Potential socio-demographic differences between all primary care physicians in the Southern District (Negev) CHS HMO and those who participated in the study could affect the results, since our study population consisted of a higher percentage of specialists in family medicine and graduates of Israeli medical schools compared to all primary care physicians in the south. Thus, the performance rate for all primary care physicians might actually be lower than the observed rate in this study. Sending specimens to histopathological examination could be a barrier to MSP performance that was not addressed in the questionnaire.

However, the results of the present survey are similar to those of studies from other countries, a finding that strengthens the reliability of the results for our region.

Health policy implications of the findings

More than two thirds of the primary care physicians in the study stated that MSP and MSI should be an integral part of their job. In actual practice, the overall performance rate was low. By providing courses for residents and post-graduates and providing appropriate compensation, time and equipment, the performance of MSP and MSI could be increased. This would save money for the HMOs, which function in a setting of an ongoing financial crisis in the healthcare system in Israel and in other countries where specialist fees are much higher than those of primary care physicians, even though they have longer waiting times.

Implications for clinical practice

HMOs and individuals responsible for training curricula in family medicine could encourage primary care physicians to perform MSP and MSI by conducting dedicated courses, with practical “hands-on” experience on actual patients, specific remuneration, and dedicated time. An emphasis should be placed on women and primary care physicians working in urban areas. These procedures should be taught in the framework of residency programs as well as postgraduate continued medical education (CME) in primary care.

Implementation of these recommendations could save money for the healthcare system and time for patients, while strengthening the bond between primary care physicians and their patients.