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Process and outcomes in general practice consultations: Problems in defining high quality care

Winefield, H.; Murrell, T.; Clifford, J.
Fonte: Pergamon Publicador: Pergamon
Tipo: Artigo de Revista Científica
Publicado em //1995 EN
Relevância na Pesquisa
55.81%
In order to explore the relationships between the verbal interactions of the consultation and several outcomes (patient health change, patient compliance and the satisfaction of both doctor and patient), 21 General Practitioners contributed ten audiotaped consultations each, from consecutive consenting adult patients. The effects of GP sex and postgraduate training were also investigated, but were found to be minimal. Patient health change was most clearly related to acuteness of symptoms at presentation, whereas reported compliance was predicted by patient satisfaction after the consultation. Different consultations were maximally satisfying for doctors and for patients, and patient and doctor satisfaction with specific consultations showed little correlation. This result implies that the measurement of quality of care, in general practice at least, is a more complex task than has been assumed, and in turn raises issues about whose definition of outcome is relevant in discussing quality of care.; Winefield, Helen R. ; Murrell, Timothy G. ; Clifford, Julie

Factors influencing the provision of dental services in private general practice / by David S. Brennan.

Brennan, David S. (David Simon), 1961-
Fonte: Universidade de Adelaide Publicador: Universidade de Adelaide
Tipo: Tese de Doutorado Formato: 165077 bytes; application/pdf
Publicado em //1999 EN
Relevância na Pesquisa
65.86%
Addresses the documented variation in dental service rates and the questions of appropriateness of care arising from this variation. Examines the association of services provided with dentists, practice and patient factors. Based on a survey pf private general practice dentists who provided a data log for one typical day.; Thesis (Ph.D.)--University of Adelaide, Dept. of Dentistry, 2000; Bibliography: p. 320-341.; xvii, 341 p. : ill. ; 30 cm.

Longitudinal comparison of factors influencing choice of dental treatment by private general practitioners

Brennan, D.; Spencer, A.
Fonte: Australian Dental Assn Inc Publicador: Australian Dental Assn Inc
Tipo: Artigo de Revista Científica
Publicado em //2006 EN
Relevância na Pesquisa
55.77%
Background: Service rate variations and appropriateness of care issues have focused attention on factors that influence treatment decisions. The aims of this study were to examine what factors dentists consider in choosing alternative treatments, the stability of these factors over time and whether stability of treatment choice was related to age of dentist. Methods: Baseline data were collected by mailed self-complete questionnaires from a random sample of Australian dentists (response rate=60.3 per cent, n=345 private general practitioners provided service data from a typical day) in 1997–1998 and followup data were collected in 2004 (response rate=76.8 per cent, n=177 matched longitudinal cases). Results: The most frequent factors considered important across six alternative treatment pair choice scenarios were caries rate for ‘exam v. x-ray’, age of patient for ‘preventive v. restorative intervention’, cost of treatment for ‘crown v. buildup’, ‘root canal v. extraction’ and ‘bridge v. denture’, and calculus for ‘prophylaxis v. scaling’. The only differences over time were (t-test, P<0.05): higher proportions of responses in the mouth status group at follow-up for ‘exam v. x-ray’; higher proportions of responses in the visit history group at follow-up for ‘preventive v. restorative intervention’; a lower proportion of responses in the caries group at follow-up for ‘crown v. build-up’; and a higher proportion of responses in the treatment constraints group at follow-up for ‘prophylaxis v. scaling’. Conclusions: While a wide range of responses were offered as factors influencing the choice of alternative treatments...

Trends in service provision among Australian private general dental practitioners over a 20-year period

Brennan, D.; Spencer, A.
Fonte: F D I World Dental Press Ltd Publicador: F D I World Dental Press Ltd
Tipo: Artigo de Revista Científica
Publicado em //2006 EN
Relevância na Pesquisa
85.89%
AIM: To-investigate time trends in service provision. DESIGN: Five cross-sectional surveys across a 20-year period. SETTING: Australian private general practice PARTICIPANTS: A random sample of dentists. METHODS: Mailed questionnaires were collected in 1983, 1988, 1993, 1998 and 2003 (response rates 71%-76%). MAIN OUTCOME MEASURES: Services per visit, annual services per dentist; annual services per patient. RESULTS: Total services per visit increased over the study period from 1.78 to 2.37 (Poisson regression; P<0.05). However the annual number of services provided per dentist did not vary significantly, reflecting a trend among dentists to supply fewer patient visits per year. The annual number of services provided per patient increased from 3.47 to 5.50 (OLS regression; P<0.05), reflecting both increased service rates per visit and increased numbers of visits by patients. Dentists provided less restorative, prosthodontic and extraction services per year, but more diagnostic, preventive, endodontic and crown and bridge services. The annual care received per patient also included more diagnostic, preventive, endodontic and crown and bridge services but differed from the dentist pattern through increased rates of restorative services over the study period. CONCLUSIONS: The content of dentist workloads has changed to include less emphasis on removal and replacement of teeth and more effort on diagnosis and prevention aimed at retention of natural dentitions.; D S Brennan...

Restorative service trends in private general practice in Australia: 1983-1999

Brennan, D.; Spencer, A.
Fonte: Elsevier Sci Ltd Publicador: Elsevier Sci Ltd
Tipo: Artigo de Revista Científica
Publicado em //2003 EN
Relevância na Pesquisa
55.86%
Objectives. Restorative services are a major component of the annual workload of a dentist, but are undergoing a period of change as population oral health continues to improve and restorative materials and techniques are developed. The aim of this study was to examine trends in the provision of restorative services over a 15-year period spanning 1983–84 to 1998–99. Methods. A series of cross-sectional surveys was performed in 1983–84, 1988–89, 1993–94 and 1998–99 with response rates of over 70%. Data were collected by a mailed survey from a random sample of dentists from each state/territory in Australia. Dentists provided data on patients treated on a typical clinical day from which annual rates of provision of services per dentist were derived for restorative and related services. Results. The overall number of annual restorative services provided per dentist declined over the four points of the study period. This trend reflected a steady decline in the annual number of amalgams provided per dentist. However, composite resins increased between 1993–94 and 1998–99, while glass ionomers, other-restorative services, crowns and fissure sealants all showed increases over the first three points of the study period. Conclusions. Over the study period the highest provision of restorative and related services changed from amalgams to composite resins...

Practice belief scales among private general dental practitioners

Brennan, D.; Spencer, A.
Fonte: Australian Dental Assn Inc Publicador: Australian Dental Assn Inc
Tipo: Artigo de Revista Científica
Publicado em //2001 EN
Relevância na Pesquisa
55.95%
Background: Practice beliefs have been related to service rate variation. The aims of this study were to replicate practice belief scales in Australia and investigate associations with dentist and practice characteristics and services. Method: A random sample of Australian dentists completed mailed questionnaires (response rate 60.3 per cent). Results: Private general practitioners (n=345) provided service data from a typical day. Eight practice belief items were recorded on a five-point Likert scale, yielding four factor-based scales. Approximately 85 per cent of responses were on the agreement side of the midpoint for the scales of Information giving and Patient influence, 45 per cent for Preventive orientation and approximately 10 per cent for Controlling active disease rather than developing better preventive advice. Capital city dentists had higher agreement with the Preventive orientation scale, while males and older dentists showed less disagreement with the Controlling active disease item (Mann-Whitney, Kruskal-Wallis P<0.05). Those agreeing with the scales (that is scores ≤ the median) showed (Poisson regression P<0.05): a higher rate of crown and bridge, a rate ratio (RR) of 1.31, but lower rates of extraction (RR=0.76) and prosthodontic services (RR=0.64) for the Information giving scale; a higher rate of restorative (RR=1.22) and total services per visit (RR=1.06) for the Preventive orientation scale; a higher rate of preventive services (RR=1.14)...

Diagnostic and preventive service trends in private general practice: 1983-1984 to 1998-1999

Brennan, D.; Spencer, A.
Fonte: Australian Dental Assn Inc Publicador: Australian Dental Assn Inc
Tipo: Artigo de Revista Científica
Publicado em //2003 EN
Relevância na Pesquisa
85.89%
Background: Aggregate trends have indicated increases in the provision of diagnostic and preventive services but there have been few reports based on their component sub-categories. The aims of this study were to investigate time trends in the provision of sub-categories of diagnostic and preventive services across a 15-year period. Methods: A random sample of Australian dentists was surveyed by mailed questionnaire in 1983-1984, 1988-1989, 1993-1994 and 1998-1999 (response rates 71-75 per cent). Data were weighted to provide representative estimates for the age by sex distribution of private general practitioners in 1983, 1988, 1993 and 1998. Results: Rates per visit were higher, Poisson regression, P<0.05, in 1998-1999 compared to baseline for examinations, radiographs, prophylaxis and topical fluoride. Diagnostic and preventive service rates varied by age of patient: compared to patients aged 65+ years, examinations were higher among children aged <5 years to adults aged 25-44 years, radiographs were lower among children <5 years and 5-11 years but higher among adults aged from 18-24 years to 45-64 years, prophylaxis services were lower among children <5 years but higher among adolescents 12-17 years to adults aged 45-64 years, while topical fluoride was higher among children 5-11 years and adolescents 12-17 years. Conclusions: Examination...

Insurance status and provision of dental services in Australian private general practice

Brennan, D.; Spencer, A.; Szuster, F.
Fonte: MUNKSGAARD INT PUBL LTD Publicador: MUNKSGAARD INT PUBL LTD
Tipo: Artigo de Revista Científica
Publicado em //1997 EN
Relevância na Pesquisa
85.99%
Annual expenditure on dental care in Australia amounts to AUD 1.9 billion. Approximately one-third of this expenditure involves private dental insurance, yet little is known about the impact of insurance on the provision of services. The aim of this analysis was to examine differences in dental service provision between insured and non-insured patients. Data collected from a random sample of dentists from a survey conducted in 1993-94 were used, providing 817 responses (response rate 74%). Logistic regression analysis controlling for patient age and sex and reason for visit indicated that in private general practice insured patients were more likely to receive preventive (OR = 1.37), crown and bridge (OR = 2.25), and endodontic services (OR = 1.27), but less likely to receive extraction services (OR = 0.52). However, no significant differences by insurance status were found for diagnostic, restorative, or prosthodontic services in the multivariate models. These differences in service provision by insurance status indicate a more favorable pattern of services for insured patients, and point to equity issues in the provision of services.

Practice profiles of Australian private general dental practitioners

Brennan, D.; Spencer, A.
Fonte: Australian Dental Assn Inc Publicador: Australian Dental Assn Inc
Tipo: Artigo de Revista Científica
Publicado em //2006 EN
Relevância na Pesquisa
66.01%
In Australia, the vast majority of dental practitioners are in the private sector (83 per cent). The provision of oral health services is dominated by general practitioners (85 per cent), with a small percentage of practitioners in specialist and restricted practice (12 per cent), and the remainder in areas such as administration, teaching and research. This paper describes the profile of patients and their presenting conditions among private general dental practitioners in 2003–2004.; Prepared by David S Brennan and A John Spencer; The document attached has been archived with permission from the Australian Dental Association. An external link to the publisher’s copy is included.

Practice activity trends among Australian private general dental practitioners: 1983-84 to 1998-99

Brennan, D.; Spencer, A.
Fonte: F D I World Dental Press Ltd Publicador: F D I World Dental Press Ltd
Tipo: Artigo de Revista Científica
Publicado em //2002 EN
Relevância na Pesquisa
76%
Aim: To investigate time trends in practice activity. Design: Four cross-sectional surveys across a 15 year period. Setting: Australian private general practice. Participants: A random sample of dentists. Methods: Dentists were surveyed by mailed questionnaire in 1983, 1988, 1993 and 1998 (response rates 71%-75%). Data were weighted to provide representative estimates for the age by sex distribution of private general practitioners in 1983, 1988, 1993 and 1998. Main Outcome Measures: Hours per year worked, patient visits per hour and patient visits per year. Results: The number of patient visits per year declined across the period, related to parallel decreases in the number of patient visits per hour (ANOVA; P<0.05), while there was no significant difference during the period in the number of hours per year devoted to work. The interaction of dentist sex by time of survey indicated that while numbers of patient visits per year had remained stable for female dentists, there was a trend for the higher number of patient visits per year among male dentists at the beginning of the survey period to decline over time. Conclusions: Male dentists had higher levels of practice activity compared with female dentists, but a decline in the number of patient visits per year reflected a convergence of male practice patterns towards that of female dentists.; http://lib.bioinfo.pl/pmid:12013251; Copyright © 2002 F D I World Dental Press

Provision of diagnostic and preventive services in general dental practice

Brennan, D.; Spencer, A.
Fonte: F D I World Dental Press Ltd Publicador: F D I World Dental Press Ltd
Tipo: Artigo de Revista Científica
Publicado em //2003 EN
Relevância na Pesquisa
55.79%
Objective: Diagnosis and prevention are among the most frequently provided services in Australian private general dental practice, and have increased over recent times. The aims of this study were to examine the provision of examinations, radiographs, prophylaxis and topical fluoride, and to assess whether these services varied by patient, visit and oral health characteristics. Basic Research Design: Data were collected by a mailed survey of a random sample of dentists from each State/Territory in Australia in 1998-99 with a response rate of 71%. Main Outcome Measures: Data were collected from a log of service items provided on a typical day. Results: Multivariate analyses of services showed that emergency visits were associated with higher rates [RR = Rate ratio, 95%CI] of radiographs (RR = 1.32, 1.06-1.66) but lower rates of prophylaxis (RR = 0.37, 0.29-0.48) and topical fluoride (RR = 0.20, 0.08-0.47) compared to non-emergency visits. Capital city patients had a higher rate of topical fluoride (RR = 2.06, 1.17-3.64) services than non-capital city patients. Patients with decayed teeth had a lower rate of prophylaxis services (RR = 0.82, 0.68-0.99) than patients with no decay. Compared to the reference of caries, patients with aesthetic problems had lower rates of radiographs (RR = 0. 19...

Service provision trends among Australian private general dental practitioners: 1983/84 to 1998/99

Brennan, D.; Spencer, A.
Fonte: F D I World Dental Press Ltd Publicador: F D I World Dental Press Ltd
Tipo: Artigo de Revista Científica
Publicado em //2003 EN
Relevância na Pesquisa
75.98%
Aim: To investigate time trends in service provision. Design: Four cross-sectional surveys across a 15-year period. Setting: Australian private general practice. Participants: A random sample of dentists. Methods: Dentists were surveyed by mailed questionnaire in 1983, 1988, 1993 and 1998 (response rates 71%-75%). Data were weighted to provide representative estimates for the age by sex distribution of private general practitioners in 1983, 1988, 1993 and 1998. Main Outcome Measures: Services per visit, annual services per dentist, annual services per patient. Results: Total services per visit increased over the study period from 1.78 to 2.14 (Poisson regression; p < 0.05). However the annual number of services provided per dentist did not vary significantly, reflecting a trend among dentists to supply fewer patient visits per year. The annual number of services provided per patient increased over the period from 3.47 to 5.22 (OLS regression; p < 0.05), reflecting both the increased service rate per visit and increased numbers of visits by patients. Dentists provided less restorative, prosthodontic and extraction services per year, but more endodontic and crown and bridge services. The pattern of annual care received per patient also included more endodontic and crown and bridge services but differed from the dentist pattern through increased service rates over the study period in areas such as restorative...

To teach or not to teach? A cost-benefit analysis of teaching in private general practice

Laurence, C.; Black, L.; Karnon, J.; Briggs, N.
Fonte: Australasian Med Publ Co Ltd Publicador: Australasian Med Publ Co Ltd
Tipo: Artigo de Revista Científica
Publicado em //2010 EN
Relevância na Pesquisa
86.07%
Objective: To identify the financial costs and benefits associated with teaching in private general practice. Design: Cost–benefit analysis of teaching in private general practice across three levels of training — undergraduate medical training, prevocational training and general practice vocational training — using data from a 2007 survey of general practitioners in South Australia. Setting and participants: GPs and practices teaching in association with the Adelaide to Outback GP Training Program or the Discipline of General Practice at the University of Adelaide. Main outcome measure: Net financial outcome per week. Results: The net financial outcome of teaching varied across the training levels. Practices incurred a net financial cost from teaching medical students that was statistically significantly different from zero. With respect to vocational training and teaching junior doctors, there were small net financial benefits to practices, although the mean estimates were not statistically significantly different from zero. Conclusions: This study shows a net financial cost for practices teaching medical students, while at the prevocational and vocational training levels, adequate levels of subsidies and income generated by the trainees help offset the costs of teaching. Our results suggest that a review of subsidies for undergraduate teaching is necessary...

Is different better? Models of teaching and their influence on the net financial outcome for general practice teaching posts

Laurence, C.; Black, L.; Cheah, C.; Karnon, J.
Fonte: BioMed Central Ltd. Publicador: BioMed Central Ltd.
Tipo: Artigo de Revista Científica
Publicado em //2011 EN
Relevância na Pesquisa
65.96%
Background: In Australia, training for general practice (GP) occurs within private practices and their involvement in teaching can have significant financial costs. At the same time there are growing demands for clinical places for all disciplines and for GP there is concern that there are insufficient teaching practices to meet the demand at the medical student, prevocational and vocational training levels. One option to address this may be to change how teaching occurs in the practice. A question that arises in posing such an option is whether different models of teaching change the costs for a teaching practice. The aim of this study is to determine the net financial outcome of teaching models in private GP. Methods: Modelling the financial implications for a range of teaching options using a costing framework developed from a survey of teaching practices in South Australia. Each option was compared with the traditional model of teaching where one GP supervisor is singularly responsible for one learner. The main outcome measure was net financial outcome per week. Decisions on the model cost parameters were made by the study’s Steering Group which comprised of experienced GP supervisors. Four teaching models are presented. Model 1 investigates the gains from teaching multiple same level learners...

Responsibility loadings for dental services by general dentists

Brennan, D.; Spencer, A.
Fonte: BioMed Central Ltd. Publicador: BioMed Central Ltd.
Tipo: Artigo de Revista Científica
Publicado em //2010 EN
Relevância na Pesquisa
65.79%
BACKGROUND: Responsibility loadings determine relative value units of dental services that translate services into a common scale of work effort. The aims of this paper were to elicit responsibility loadings for a subset of dental services and to relate responsibility loadings to ratings of importance of the components of responsibility. METHODS: Responsibility loadings and ratings of components of responsibility were collected using mailed questionnaires from a random sample of Australian private general practice dentists in 2007 (response rate = 77%). RESULTS: Median responsibility loadings were 1.25 for an initial oral examination and for a 3+-surface amalgam restoration, 1.50 for a simple extraction and for root canal obturation (single canal), and 1.75 for subgingival curettage (per quadrant). Across the five services coefficients from a multivariate logit model showed that ratings of importance of knowledge (0.34), dexterity (0.24), physical effort (0.28) and mental effort (0.48) were associated with responsibility loadings (P < 0.05). CONCLUSIONS: The elicited median responsibility loadings showed agreement with previous estimates indicating convergent validity. Components of responsibility were associated with loadings indicating that components can explain and predict responsibility aspects of dental service provision.; David S. Brennan and A. John Spencer; Extent: 6p.

Dentist service rates and distribution of practice styles over time

Brennan, D.; Spencer, A.; Szuster, F.
Fonte: MUNKSGAARD INT PUBL LTD Publicador: MUNKSGAARD INT PUBL LTD
Tipo: Artigo de Revista Científica
Publicado em //1996 EN
Relevância na Pesquisa
55.85%
Studies of dentist service rates have identified clusters of dentists with particular styles of practice, but these practice styles need to be investigated to determine whether patterns of care become established and remain characteristic among dentists. The aims of this study were to establish dentist practice styles and to assess the distribution of these styles of practice between 1983 and 1988. A total of 202 private general practitioners who provided service rate data in both 1983 and 1988 were used in a cluster analysis to group dentists into practice styles. For both 1983 and 1988 three clusters of dentists were obtained, characterized by service rates as "High Restorative", "Low Total Rates", and "High Diagnostic and Preventive". However, the distribution of cluster membership changed over time. The percentage of dentists in the "High Restorative" cluster decreased from 27.9% in 1983 to 16.6% in 1988, the "Low Total Rates" cluster decreased for 60.7% in 1983 to 49.2% in 1988, while the "High Diagnostic and Preventive" cluster increased from 11.4% in 1983 to 34.2% in 1988. The distribution of dentists between these practice styles may be related to aging of dentists, practice maturation, population demographics, need or demand changes...

Evaluation of patients by private general practitioners: associations with patient, visit, and service characteristics

Brennan, D.; Spencer, A.
Fonte: F D I World Dental Press Ltd Publicador: F D I World Dental Press Ltd
Tipo: Artigo de Revista Científica
Publicado em //2002 EN
Relevância na Pesquisa
65.77%
Objective: To examine evaluations of patients by dentists, and analyse these by patient, visit and service characteristics. Basic Research Design: Mailed questionnaires collected from a random sample of Australian dentists in 1997-98 (response rate = 60.3%; n = 345 private general practitioners provided service data). Main Outcome Measures: Three factor-based sub-scales ('payment', 'no problems', and 'knowledge') and an overall scale ('evaluation') were derived from a 5-item battery. Scale and sub-scale scores ranged between I and 5. Lower scores indicated better evaluation ratings. Results: Nearly 60% of patients had better ratings (scores < or = 2) on the 'payment' and 'no problems' sub-scales, 39.9% on the 'knowledge' sub-scale, and 36.4% on the 'evaluation' scale. Better ratings on all sub-scales and the overall scale were associated with dentate patients, non-emergency visits, insurance, and no decayed teeth (chi2; P<0.05). Those with better 'evaluation' scale ratings (scores < or = 2.0), had higher [Poisson regression, P < or = 0.05; RR=Rate ratio] preventive (RR = 1.30), and crown and bridge rates (RR = 1.88), but lower extraction rates (RR = 0.52). Conclusions: Desirable characteristics of patients were associated with more favourable evaluation scores by their dentists. Patients with better evaluation scores received a more favourable service pattern.; D.S. Brennan and A.J. Spencer; Copyright © 2002 FDI World Dental Press

Productivity among Australian private general dental practitioners across a ten year period

Brennan, D.; Spencer, A.; Szuster, F.
Fonte: Universidade de Adelaide Publicador: Universidade de Adelaide
Tipo: Artigo de Revista Científica
Publicado em //1996 EN
Relevância na Pesquisa
66.01%
Historical trends in Australia have shown declining levels of dentists' annual productivity from the 1960s to the 1980s. In a period of changing population demographics and oral health status appropriate levels of supply of dental services remains a key issue. Changes in practice patterns of dentists, through variables such as productivity, may influence the capacity to supply services. The aim of this study was to investigate time trends in productivity for private general practitioners at three points in time across a ten year period. A weighted, stratified random sample of Australian dentists was surveyed in 1983-84 (response rate 73 per cent), 1988 (response rate 75 per cent) and 1993-94 (response rate 74 per cent). The data were re-weighted to provide representative estimates for the age by sex distribution of private general practitioners in 1983, 1988 and 1993. Analysis of variance showed that the number of patient visits per year declined across the ten year period, related to parallel decreases in the number of patients treated per hour, while there was no significant difference during the period in the number of hours per year devoted to work.

Service provision in private general practice: 1983-1984 to 1998-1999

Brennan, D.; Spencer, A.
Fonte: Australian Dental Assn Inc Publicador: Australian Dental Assn Inc
Tipo: Artigo de Revista Científica
Publicado em //2005 EN
Relevância na Pesquisa
55.88%
Prepared by David S. Brennan and A. John Spencer; The document attached has been archived with permission from the Australian Dental Association. An external link to the publisher’s copy is included.

Health care marketing: the theory of planned behavior applied to patients' choise between private and public providers in the portuguese health care system.

Ferreira, Filipa Monteiro
Fonte: Universidade Nova de Lisboa Publicador: Universidade Nova de Lisboa
Tipo: Dissertação de Mestrado
Publicado em 12/10/2011 ENG
Relevância na Pesquisa
55.95%
Dissertation submitted in partial fulfillment of the requirements for degree of Master in Statistics and Information Management.; Purpose - The Portuguese health care system has been evolving throughout the last 35 years with two relevant facts: the public sector has progressed with improvement in all relevant OECD indicators; the private sector has been widened and reinforced. In this framework, it is important to understand how patient’s intention and behavior are built, so health care organizations in both sectors (public and private) can improve their health care provision (particularly in health care marketing), invest and develop those areas that might become sustainable competitive advantages. The most established theory of social psychology explaining human behavior will be applied: Theory of Planned Behavior (TPB). Within this conceptual approach, attitude toward the behavior, subjective norm, perceived behavior control, habit and past experience evaluation (satisfaction on the private and public sectors) will be analyzed in explaining the intention to go to the private sector. As the health care system is not homogeneous across the private and public sectors, five models will be tested in the areas that have been identified with distinct supplies: general practice...