General practitioners in Styria – who is willing to take part in research projects and why?

The provision of primary health care by general practitioners (GPs) is an essential component of the healthcare system, and is rising in importance as a result of the increasing prevalence of chronic diseases and multimorbidity in an aging society [1]. Political attention [2] is increasingly focusing on shoring up primary care, but valid and informed decisions can only be made if relevant research is conducted in family practices. There is a long tradition of practice-relevant health services research (HSR) in many countries, but this is not the case in Germany and Austria [3], where the number of publications by GPs is much smaller than in Great Britain, the United States, Australia, Canada and The Netherlands [4]. Although primary care offers many opportunities for research, far too few studies are concerned with relevant everyday medical problems, and those few are often based on idealized and underrepresented patient groups [5]. The HSR plays an important role in studies of this kind: it is an interdisciplinary approach that uses scientific methodology to study processes, results and the external conditions of healthcare [6]. In the United States, the importance attached to HSR is reflected in the substantial financial support it has received since the 1960s [7, 8]. State support for such research has been available in Great Britain since the 1980s and for more than a decade in Germany, where HSR studies are financed via national funding programs [9, 10]. In Austria in 2013, the little-known subject of HSR was included in the Federal Target Control Contract 2013–2016 [11], but there remains a glaring lack of available funding.

The Austrian health system is characterized by a focus on inpatient care, and the quality of primary care is clearly below the Organization for Economic Cooperation and Development (OECD) average [12]. Unlike other countries, there is no gatekeeping system in Austria which means the flow of patients is unguided, leading to immense costs [13]. As the “specialist of the discipline of general practice” qualification does not exist in Austria and academic general practice has only a short history at medical universities in the country, there is only a tiny number of HSR projects in which GPs are actually involved. Even though many studies (such as those on polypharmacy [14, 15]) have clearly demonstrated the need for HSR research in primary care, both the working methods in general practice and the complexity of a setting with many variables and potential confounders represent a challenge [16]. The implementation of HSR in Austria will therefore require greater personnel resources in research institutions. Amongst other things, this will make it possible to involve GPs in research projects and to establish practice-based research networks (PBRN) such as those in the Netherlands and the UK. The existing research networks that have been set up by several Institutes of General Practice should be standardized and accredited, so that relevant clinical studies can be conducted in family practice in Austria [17]; however, it is only possible to carry out such projects if GPs are prepared to participate. Numerous international studies have investigated the factors that encourage GPs to participate in HSR projects conducted within the structure of PBRNs. Most importantly, it is the research projects themselves and their practical significance, i. e. content factors, that motivate GPs to participate [18‐20]. The number of participating doctors can be increased significantly by focusing on clinically relevant research topics [21], gauging the interest of potential participants in the subject matter [22], and allowing them to participate in the research [23]. In addition, a personal relationship between researcher and research practice, and the personal recruitment of practices, appear to have a strong motivating influence on readiness to participate [24‐26]. For example, the response rate can be raised significantly, simply by personally addressing a letter asking potential participants to fill in a questionnaire. Financial incentives, on the other hand, seem to be of little value [23, 24]. As the current workload of GPs is already substantial, the additional work required by participation in research projects reduces readiness to participate [24, 27, 28].

The aim of the survey by the Institute of General Practice and Evidence-Based Health Services Research (IAMEV) was to determine the willingness of Styrian GPs to take part in HSR projects, and to collect the sociodemographic data of those GPs who were interested; however, we also aimed to investigate the motivating and inhibiting factors for participation in research, and to study the research subjects proposed by Styrian GPs themselves.

Of a total of 1015 questionnaires that were sent to Styrian GPs, including 561 males (55.3%) and 454 females (44.7%), 29 were returned to us online, and 113 by mail or fax (total 142), corresponding to a response rate of 14%. After discarding questionnaires that were missing one or more pages, duplicates, and questionnaires that were returned too late, 135 (13%) were included in the final evaluation. Of the responding GPs, 71.1% (n = 96) were male and 28.9% (n = 39) female. Table 1 shows the sociodemographic and practice-specific parameters.

At 23.9%, the response rate from urban areas was below average. On the other hand, 47% of GPs from rural areas and particularly from towns with a population of <4999, showed an above-average willingness to take part in research.

In our questionnaire, 10% of all Styrian GPs indicated their willingness to take part in research projects, whereby 46.7% of them were older than 55 years. According to Statistik Austria [34], 52% of all physicians in Styria are older than 55. This highlights a major problem with regard to sustainability, since new GPs would have to be recruited regularly, to replace retiring physicians.

Although the proportion of women with their own practices has increased from 15.8% in 1988 to 43.3% in 2015, two thirds of the 10.4% of GPs interested in participating in research were male. The relatively weak interest in answering the questionnaire (returned by only 7.5% of women, as compared to 17.1% of men), combined with even less interest in cooperating on research projects, has already been identified in Germany [30]. Although the proportion of women among both first and senior physician authors of original research in the United States has significantly increased in the last four decades, women are still in the minority [35]. One can only hazard a guess as to the reasons for this worldwide phenomenon, but it may reflect the burden women bear in balancing work and family. Since women are increasingly choosing general practice as a specialty [36], further research should be performed in this area.

Contrary to expectations, GPs from rural areas, and especially from towns with <4999 residents, showed above-average willingness, and more willingness than GPs based in urban areas, to take part in research. As the working conditions of urban and rural GPs vary considerably, it is difficult to determine why this should be the case. Working conditions in rural areas vary depending on specific geographic factors and these influence health in general, as well overall health care, the appropriateness of health care, and health behavior. Consequently, the need for health services research in rural areas is substantial and has considerable potential for improvement [37]. Interest in participating in research was much greater among GPs with relatively low and high incomes. This suggests that the former are motivated to do more than their routine medical work, and that the latter, e. g. private consultants, have more time to participate in research.

It is debatable how and to what extent academia supports research and promote continuing medical education. Discussion is ongoing on the advantages, if any, of the new training regulations for general practice [38]. Whatever these advantages may be, the regulations do not consider the need for scientific research. This is different from other countries, where it has been suggested that GPs involved in training students should receive more instruction in research [39]. Furthermore, trainees involved in research projects are interested in taking part in standardized research training programs [40].

A clear relationship was found between GPs’ special professional interests and their research suggestions. This reflected an interest in developing their personal knowledge as a question of professional interest, and is mirrored in the motivating factors. Research projects are likely to result in an improvement in care for patients receiving treatment in general practice. As improvement in the quality of patient care was a central motivating factor, participating GPs would benefit twice. Studies in Germany have shown that the availability of a health care assistant and/or a secretary may increase willingness to take part in research [41‐43]. Health care assistants would benefit from greater job satisfaction, and the quality of research could be expected to increase.

Of the 1015 GPs we wrote to in Styria, 14% responded to our cross-sectional survey, and 10% were interested in participating in health services research projects. They were motivated to do so by an anticipated improvement in patient care and the image of general practice, as well as fresh insights in general. Factors that inhibited them were mainly lack of time and the administrative effort involved, followed by lack of assistance. In the questionnaire, the GPs suggested 132 subjects for research, most of which concerned their own fields of specialization. The willingness of GPs to participate in future HSR projects could be increased by taking the motivating and inhibiting factors into account.