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Term Definition used in the CMCS Acuity Severity, intensity, and immediacy of care required for a presenting condition in a patient. Complexity Interaction between existing conditions and the condition the patient presents with. Hierarchy Ranking by relative status of acuity and complexity. Categorisation Assigning each presenting condition to a category defined by acuity. Classification Assigning each person into a hierarchical system according to their condition category or categories. Case-mix The mix of patients, according to their classification. Case-mix and complexity index classification Definition of the classification Definition of the classification for each patient Acute 1. Recent or rapid onset and of short duration (<4 weeks), such as acute pain.
2. Serious, sometimes requiring immediate intervention, such as acute abdomen.52≥1 problem the patient presents with is classified as acute by de Jong et al 22 or by current authors. Chronic (synonym: longterm)
As used in ICPC relating to an illness or disability of ≥6 months duration.52Patient has no acute problems; AND patient has a chronic condition, as recorded on a disease register, (with any presenting problem) OR ≥1 problem the patient presents with is classified as chronic. Minor problem or symptom Minor acute illnesses include some of the commonest problems presented in general practice, such as upper respiratory tract infections or skin rashes.53 Patient has no acute problems, no record on a disease register, no chronic problems, AND ≥1 problem the patient presents with is classified as a minor problem or symptom by de Jong et al 22 or the current authors. Prevention Action to avoid occurrence or development of a health problem and/or its complications. Can be divided into four categories: Primary prevention: action taken to avoid or remove the cause of a health problem in an individual or a population before it arises. Includes health promotion and specific protection, such as immunisation.
Secondary prevention: action taken to detect a health problem at an early stage in an individual or a population, thereby facilitating cure, or reducing or preventing it spreading, or reducing or preventing its long-term effects (for example, methods, screening, case finding, and early diagnosis).
Tertiary prevention: action taken to reduce the chronic effects of a health problem in an individual or a population by minimising the functional impairment consequent to the acute or chronic health problem (for example, prevent complications) diabetes). Includes rehabilitation.
Quaternary prevention: action taken to identify patient at risk of overmedicalisation, to protect them from new medical invasion, and to suggest to them interventions, which are ethically acceptable.52
Patient has no acute problems, no record on a disease register, no chronic problems, no minor problems or symptoms, AND ≥1 problem the patient presents with is classified as prevention. Process of care (synonym: procedure)
In medical care, constitutes the actions undertaken by a physician.52Patient has no acute problems, no record on a disease register, no chronic problems, no minor symptoms or problems, and no prevention problems, AND ≥1 problem the patient presents with is classified as a process of care. - Table 1. Listing of presenting condition classification and disease register combinations forming patients’ case-mix classification
Patient case-mix classification Condition category Disease register Total, n GP, n PA, n Change in hierarchy from condition category or categories to patient-level classification Acute Acute No 31 19 12 No Acute Yes 27 17 10 Acute + chronic No 1 0 1 Acute + chronic Yes 3 2 1 Acute + chronic + minor No 0 0 0 Acute + chronic + minor Yes 5 3 2 Acute + minor No 13 9 4 Acute + minor Yes 15 11 4 Subtotal acute 95 61 34 Chronic Chronic No 23 14 9 No Chronic Yes 69 62 7 Chronic + minor No 19 10 9 Chronic + minor Yes 56 43 13 Chronic + process Yes 1 1 0 Chronic + minor + process Yes 2 2 0 Minor Yes 608 355 253 Yes (n = 639) Minor + process Yes 9 4 9 Prevention Yes 3 3 0 Process Yes 19 10 9 Subtotal chronic 809 Minor Minor No 1146 571 575 No Minor + process No 14 5 9 Minor + prevention No 3 0 3 Subtotal minor 1165 Prevention Prevention No 4 3 1 No Process Process No 13 7 6 No - Table 2. Crude, CMCS-adjusted, other variable-adjusted and CMCS and other variable-adjusted odds ratios or rate ratios of process and outcome measure differences between PAs and GPs 24
Process or outcome measure
(as defined elsewhere24)Crude/univariate finding OR or RR (95% CI) GP (reference group) PA OR or RR Unadjusted Adjusted for CMCS only Adjusted for other variables of relevancea, but not CMCS Fully adjusted: CMCS and other variables of relevance Processes % cases General advice 22.9 51.4 OR 3.56 (2.58 to 4.29) 3.58 (1.82 to 7.01) 3.30 (1.68 to 6.47) 3.30 (1.69 to 6.46) Advice on medication management 12.6 17.1 OR 1.43 (1.12 to 1.82) b 1.62 (1.05 to 2.49) 1.72 (1.08 to 2.72) Advice on over the counter medication 9.5 20.5 OR 2.45 (1.92 to 3.18) b 6.63 (0.56 to 4.69) 1.74 (0.62 to 4.89) Mean per case Number of diagnostic tests 0.34 0.36 RR 1.06 (0.82 to 1.38) 1.11 (0.86 to 1.43) 1.07 (0.90 to 1.29) 1.08 (0.89 to 1.30) Number of referrals 0.11 0.9 RR 0.84 (0.57 to 1.22)
b0.94 (0.63 to 1.41) 0.95 (0.63 to 1.43) Number of prescriptions 0.78 0.89 RR 1.18 (0.86 to 1.58) 1.17 (0.88 to 1.55) 1.16 (0.86 to 1.56) 1.16 (0.87 to 1.53) Number of procedures 0.1 0.1 RR 0.76 (0.32 to 1.84)
c
c
cOutcome Reconsultation for the same or a
linked problem at the practice or urgent care facility within 14 days of the index consultation0.29 0.32 RR 1.03 (0.75 to 1.43) 1.09 (0.77 to 1.54) 1.12 (0.81 to 1.54) 1.25 (0.91 to 1.72) aWith an independent association with outcome (see full report for detail).24 bCould not be estimated in SPSS. cNumbers too small for further adjustment. CMCS = case-mix classification system. OR = odds ratio. RR = risk ratio.
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