Regular primary care plays a significant role in secondary prevention of ischemic heart disease in a Western Australian cohort

Implementation of a data-driven quality improvement program in primary care for patients with coronary heart disease: a mixed methods evaluation of acceptability, satisfaction, barriers and enablers

Background The study aimed to understand the acceptability, satisfaction, uptake, utility and feasibility of a quality improvement (QI) intervention to improve care for coronary heart disease (CHD) patients in Australian primary care practices and identify barriers and enablers, including the impact of COVID-19. Methods Within the QUality improvement for Effectiveness of care for people Living with heart disease (QUEL) study, 26 Australian primary care practices, supported by five Primary Health Networks (PHN) participated in a 1-year QI intervention (November 2019 - November 2020). Data were collected from practices and PHNs staff via surveys and semi-structured interviews. Quantitative and qualitative data were analysed with descriptive statistics and thematic analysis, respectively. Results Feedback was received from 64 participants, including practice team members and PHN staff. Surveys were completed after each of six workshops and at the end of the study. Interviews were conducted with a subgroup of participants (n =9). Participants reported positive satisfaction with individual QI features such as learning workshops and monthly feedback reports. Overall, the intervention was well-received, with most participants expressing interest in participating in similar programs in the future. COVID-19 and lack of time were identified as common barriers, whereas team collaboration and effective leadership enabled practices' participation in the QI program. Additionally, 90% of the practices reported COVID-19 effected their participation due to vaccination rollout, telehealth set-up, and continuous operational review shifting their focus from QI. Conclusion Data-driven QI programs in primary care can boost practice staff confidence and foster increased implementation. Barriers and enablers identified can also support other practices in prioritising effective strategies for future implementation.

Primary care physician density and mortality in the United States

BACKGROUND

Geographic physician availability differences are associated with healthcare outcomes. However, the association between primary care physician (PCP) density and mortality outcomes is less well-established.

METHODS

The study analyzed 2019 county-level nonfederal PCP data from the Health Resources and Services Administration Area Health Resource File and mortality data using the CDC WONDER (Wide-ranging Online Data for Epidemiologic Research). All-cause and cardiovascular disease (CVD)- related age-adjusted mortality rates (AAMR) per 100,000 population stratified by the number of PCPs per 100,000 quartiles were extracted. Using AAMRs as continuous variables, linear regression was performed to determine the association of AAMRs with PCPs per 100,000 (reference, first quartile), adjusting for the social vulnerability index (SVI).

RESULTS

A total of 3142 counties were included in the analysis. Among counties stratified by PCPs per 100,000 quartiles, all-cause AAMRs were 828 (95% CI, 824-832) in the first quartile, 798 (95% CI, 796-801) in the second quartile, 737 (95% CI, 735-739) in the third quartile, and 679 (95% CI, 678-680) in the fourth quartile. Similar trends were seen in CVD-related AAMRs, which were 446 (95% CI, 443-449), 439 (95% CI, 437-441), 403 (95% CI, 402-404), and 365 (95% CI, 364-366), respectively. Counties without PCP (221, included in first quartile) had all-cause and CVD-related AAMR of 797 (95%CI, 783-812) and 430 (95%CI, 419-440), respectively. Compared with the first quartile, SVI-adjusted analyses showed β-coefficient (95%CI) of all-cause mortality for the second, third, and fourth quartiles of -4.11 (95% CI, -18.31, 10.08), -35.37 (95% CI, -49.57, -21.17) and -85.79 (95% CI, -100.10, -71.48). Similar results were observed for CVD-related AAMR.

CONCLUSION

Higher PCP per 100,000 is generally associated with better all-cause and CVD-associated mortality outcomes, however complex factors likely play a role in determining these outcomes in counties with lower PCP per 100,000, which warrant further investigation.

Comparing secondary prevention for patients with coronary heart disease and stroke attending Australian general practices: a cross-sectional study using nationwide electronic database

OBJECTIVES

To compare secondary prevention care for patients with coronary heart disease (CHD) and stroke, exploring particularly the influences due to frequency and regularity of primary care visits.

SETTING

Secondary prevention for patients (≥18 years) in the National Prescription Service administrative electronic health record database collated from 458 Australian general practice sites across all states and territories.

DESIGN

Retrospective cross-sectional and panel study. Patient and care-level characteristics were compared for differing CHD/stroke diagnoses. Associations between the type of cardiovascular diagnosis and medication prescription as well as risk factor assessment were examined using multivariable logistic regression.

PARTICIPANTS

Patients with three or more general practice encounters within 2 years of their latest visit during 2016-2020.

OUTCOME MEASURES

Proportions and odds ratios (ORs) for (1) prescription of antihypertensives, antilipidaemics and antiplatelets and (2) assessment of blood pressure (BP) and low-density lipoprotein cholesterol (LDL-C) in patients with stroke only compared against those with CHD only and those with both conditions.

RESULTS

There were 111 892 patients with CHD only, 27 863 with stroke only and 9791 with both conditions. Relative to patients with CHD, patients with stroke were underprescribed antihypertensives (70.8% vs 82.8%), antilipidaemics (63.1% vs 78.7%) and antiplatelets (42.2% vs 45.7%). With sociodemographic factors, comorbidities and level of care considered as covariates, the odds of non-prescription of any recommended secondary prevention medications were higher in patients with stroke only (adjusted OR 1.37; 95% CI (1.31, 1.44)) compared with patients with CHD only. Patients with stroke only were also more likely to have neither BP nor LDL-C monitored (adjusted OR 1.26; 95% CI (1.18, 1.34)). Frequent and regular general practitioner encounters were independently associated with the prescription of secondary prevention medications (p<0.001).

CONCLUSIONS

Secondary prevention management is suboptimal in cardiovascular disease patients and worse post-stroke compared with post-CHD. More frequent and regular primary care encounters were associated with improved secondary prevention.

Process evaluation of a data-driven quality improvement program within a cluster randomised controlled trial to improve coronary heart disease management in Australian primary care

BACKGROUND

This study evaluates primary care practices' engagement with various features of a quality improvement (QI) intervention for patients with coronary heart disease (CHD) in four Australian states.

METHODS

Twenty-seven practices participated in the QI intervention from November 2019 -November 2020. A combination of surveys, semi-structured interviews and other materials within the QUality improvement in primary care to prevent hospitalisations and improve Effectiveness and efficiency of care for people Living with heart disease (QUEL) study were used in the process evaluation. Data were summarised using descriptive statistical and thematic analyses for 26 practices.

RESULTS

Sixty-four practice team members and Primary Health Networks staff provided feedback, and nine of the 63 participants participated in the interviews. Seventy-eight percent (40/54) were either general practitioners or practice managers. Although 69% of the practices self-reported improvement in their management of heart disease, engagement with the intervention varied. Forty-two percent (11/26) of the practices attended five or more learning workshops, 69% (18/26) used Plan-Do-Study-Act cycles, and the median (Interquartile intervals) visits per practice to the online SharePoint site were 170 (146-252) visits. Qualitative data identified learning workshops and monthly feedback reports as the key features of the intervention.

CONCLUSION

Practice engagement in a multi-featured data-driven QI intervention was common, with learning workshops and monthly feedback reports identified as the most useful features. A better understanding of these features will help influence future implementation of similar interventions.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12619001790134.

Greater temporal regularity of primary care visits was associated with reduced hospitalizations and mortality, even after controlling for continuity of care

BACKGROUND

Previous studies have shown that more temporally regular primary care visits are associated with improved patient outcomes.

OBJECTIVE

To examine the association of temporal regularity (TR) of primary care with hospitalizations and mortality in patients with chronic illnesses. Also, to identify threshold values for TR for predicting outcomes.

DESIGN

Retrospective cohort study.

PARTICIPANTS

We used data from the electronic health record of a health maintenance organization in Israel to study primary care visits of 70,095 patients age 40 + with one of three chronic conditions (diabetes mellitus, heart failure, chronic obstructive pulmonary disease).

MAIN MEASURES

We calculated TR for each patient during a two-year period (2016-2017), and divided patients into quintiles based on TR. Outcomes (hospitalization, death) were observed in 2018-2019. Covariates included the Bice-Boxerman continuity of care score, demographics, and comorbidities. We used multivariable logistic regression to examine TR's association with hospitalization and death, controlling for covariates.

KEY RESULTS

Compared to patients receiving the most regular care, patients receiving less regular care had increased odds of hospitalization and mortality, with a dose-response curve observed across quintiles (p for linear trend < 0.001). For example, patients with the least regular care had an adjusted odds ratio of 1.40 for all-cause mortality, compared to patients with the most regular care. Analyses stratified by age, sex, ethnic group, area-level SES, and certain comorbid conditions did not show strong differential associations of TR across groups.

CONCLUSIONS

We found an association between more temporally regular care in antecedent years and reduced hospitalization and mortality of patients with chronic illness in subsequent years, after controlling for covariates. There was no clear threshold value for temporal regularity; rather, more regular primary care appeared to be better across the entire range of the variable.

What quantifies good primary care in the United States? A review of algorithms and metrics using real-world data

Primary care physicians (PCPs) play an indispensable role in providing comprehensive care and referring patients for specialty care and other medical services. As the COVID-19 outbreak disrupts patient access to care, understanding the quality of primary care is critical at this unprecedented moment to support patients with complex medical needs in the primary care setting and inform policymakers to redesign our primary care system. The traditional way of collecting information from patient surveys is time-consuming and costly, and novel data collection and analysis methods are needed. In this review paper, we describe the existing algorithms and metrics that use the real-world data to qualify and quantify primary care, including the identification of an individual's likely PCP (identification of plurality provider and major provider), assessment of process quality (for example, appropriate-care-model composite measures), and continuity and regularity of care index (including the interval index, variance index and relative variance index), and highlight the strength and limitation of real world data from electronic health records (EHRs) and claims data in determining the quality of PCP care. The EHR audits facilitate assessing the quality of the workflow process and clinical appropriateness of primary care practices. With extensive and diverse records, administrative claims data can provide reliable information as it assesses primary care quality through coded information from different providers or networks. The use of EHRs and administrative claims data may be a cost-effective analytic strategy for evaluating the quality of primary care.

Patient-level predictors of temporal regularity of primary care visits

BACKGROUND

Patients with chronic diseases should meet with their primary care doctor regularly to facilitate proactive care. Little is known about what factors are associated with more regular follow-up.

METHODS

We studied 70,095 patients age 40 + with one of three chronic conditions (diabetes mellitus, heart failure, chronic obstructive pulmonary disease), cared for by Leumit Health Services, an Israeli health maintenance organization. Patients were divided into the quintile with the least temporally regular care (i.e., the most irregular intervals between visits) vs. the other four quintiles. We examined patient-level predictors of being in the least-temporally-regular quintile. We calculated the risk-adjusted regularity of care at 239 LHS clinics with at least 30 patients. For each clinic, compared the number of patients with the least temporally regular care with the number predicted to be in this group based on patient characteristics.

RESULTS

Compared to older patients, younger patients (age 40-49), were more likely to be in the least-temporally-regular group. For example, age 70-79 had an adjusted odds ratio (AOR) of 0.82 compared to age 40-49 (p < 0.001 for all findings discussed here). Males were more likely to be in the least-regular group (AOR 1.18). Patients with previous myocardial infarction (AOR 1.07), atrial fibrillation (AOR 1.08), and current smokers (AOR 1.12) were more likely to have an irregular pattern of care. In contrast, patients with diabetes (AOR 0.79) or osteoporosis (AOR 0.86) were less likely to have an irregular pattern of care. Clinic-level number of patients with irregular care, compared with the predicted number, ranged from 0.36 (fewer patients with temporally irregular care) to 1.71 (more patients).

CONCLUSIONS

Some patient characteristics are associated with more or less temporally regular patterns of primary care visits. Clinics vary widely on the number of patients with a temporally irregular pattern of care, after adjusting for patient characteristics. Health systems can use the patient-level model to identify patients at high risk for temporally irregular patterns of primary care. The next step is to examine which strategies are employed by clinics that achieve the most temporally regular care, since these strategies may be possible to emulate elsewhere.

Data-driven quality improvement program to prevent hospitalisation and improve care of people living with coronary heart disease: Protocol for a process evaluation

BACKGROUND

Practice-level quality improvement initiatives using rapidly advancing technology offers a multidimensional approach to reduce cardiovascular disease burden. For the "QUality improvement in primary care to prevent hospitalisations and improve Effectiveness and efficiency of care for people Living with heart disease" (QUEL) cluster randomised controlled trial, a 12-month quality improvement intervention was designed for primary care practices to use data and implement progressive changes using "Plan, Do, Study, Act" cycles within their practices with training in a series of interactive workshops. This protocol aims to describe the systematic methods to conduct a process evaluation of the data-driven intervention within the QUEL study.

METHODS

A mixed-method approach will be used to conduct the evaluation. Quantitative data collected throughout the intervention period, via surveys and intervention materials, will be used to (1) identify the key elements of the intervention and how, for whom and in what context it was effective; (2) determine if the intervention is delivered as intended; and (3) describe practice engagement, commitment and capacity associated with various intervention components. Qualitative data, collected via semi-structured interviews and open-ended questions, will be used to gather in-depth understanding of the (1) satisfaction, utility, barriers and enablers; (2) acceptability, uptake and feasibility, and (3) effect of the COVID-19 pandemic on the implementation of the intervention.

CONCLUSION

Findings from the evaluation will provide new knowledge on the implementation of a complex, multi-component intervention at practice-level using their own electronic patient data to enhance secondary prevention of cardiovascular disease.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) number ACTRN12619001790134.

Optimal measures for primary care physician encounters after stroke and association with survival: a data linkage study

BACKGROUND AND PURPOSE

Primary care physicians provide ongoing management after stroke. However, little is known about how best to measure physician encounters with reference to longer term outcomes. We aimed to compare methods for measuring regularity and continuity of primary care physician encounters, based on survival following stroke using linked healthcare data.

METHODS

Data from the Australian Stroke Clinical Registry (2010-2014) were linked with Australian Medicare claims from 2009 2016. Physician encounters were ascertained within 18 months of discharge for stroke. We calculated three separate measures of continuity of encounters (consistency of visits with primary physician) and three for regularity of encounters (distribution of service utilization over time). Indices were compared based on 1-year survival using multivariable Cox regression models. The best performing measures of regularity and continuity, based on model fit, were combined into a composite 'optimal care' variable.

RESULTS

Among 10,728 registrants (43% female, 69% aged ≥65 years), the median number of encounters was 17. The measures most associated with survival (hazard ratio [95% confidence interval], Akaike information criterion [AIC], Bayesian information criterion [BIC]) were the: Continuity of Care Index (COCI, as a measure of continuity; 0.88 [0.76 1.02], p=0.099, AIC=13746, BIC=13855) and our persistence measure of regularity (encounter at least every 6 months; 0.80 [0.67 0.95], p=0.011, AIC=13742, BIC=13852). Our composite measure, persistent plus COCI ≥80% (24% of registrants; 0.80 [0.68 0.94], p=0.008, AIC=13742, BIC=13851), performed marginally better than our persistence measure alone.

CONCLUSIONS

Our persistence measure of regularity or composite measure may be useful when measuring physician encounters following stroke.

The association between general practitioner regularity of care and 'high use' hospitalisation

Background

In Australia, as in many high income countries, there has been a movement to improve out-of-hospital care. If primary care improvements can yield appropriately lower hospital use, this would improve productive efficiency. This is especially important among ‘high cost users’, a small group of patients accounting for disproportionately high hospitalisation costs. This study aimed to assess the association between regularity of general practitioner (GP) care and ‘high use’ hospitalisation.

Methods

This retrospective, cohort study used linked administrative and survey data from the 45 and Up Study, conducted in New South Wales, Australia. The exposure was regularity of GP care between 1 July 2005 and 30 June 2009, categorised by quintile (lowest to highest). Outcomes were ‘high use’ of hospitalisation (defined as ≥3 and ≥ 5 admissions within 12 months), extended length of stay (LOS, ≥30 days), a combined metric (≥3 hospitalisations in a 12 month period where ≥1 hospitalisation was ≥30 days) and 30-day readmission between 1 July 2009 and 31 December 2017. Associations were assessed using multivariable logistic regression. Potential for outcome prevention in a hypothetical scenario where all individuals attain the highest GP regularity was estimated via the population attributable fraction (PAF).

Results

Of 253,500 eligible participants, 15% had ≥3 and 7% had ≥5 hospitalisations in a 12-month period. Five percent of the cohort had a hospitalisation lasting ≥30 days and 25% had a readmission within 30 days. Compared with lowest regularity, highest regularity was associated with between 6% (p < 0.001) and 11% (p = 0.027) lower odds of ‘high use’. There was a 7–8% reduction in odds for all regularity levels above ‘low’ regularity for LOS ≥30 days. Otherwise, there was no clear sequential reduction in ‘high use’ with increasing regularity. The PAF associated with a move to highest regularity ranged from 0.05 to 0.13. The number of individuals who could have had an outcome prevented was estimated to be between 269 and 2784, depending on outcome.

Conclusions

High GP regularity is associated with a decreased likelihood of ‘high use’ hospitalisation, though for most outcomes there was not an apparent linear association with regularity.

Frequent general practitioner visits are protective against statin discontinuation after a Pharmaceutical Benefits Scheme copayment increase

Objective This study assessed the effect of the frequency of general practitioner (GP) visitation in the 12 months before a 21% consumer copayment increase in the Pharmaceutical Benefits Scheme (PBS; January 2005) on the reduction or discontinuation of statin dispensing for tertiary prevention. Methods The study used routinely collected, whole-population linked PBS, Medicare, mortality and hospital data from Western Australia. From 2004 to 2005, individuals were classified as having discontinued, reduced or continued their use of statins in the first six months of 2005 following the 21% consumer copayment increase on 1 January 2005. The frequency of GP visits was calculated in 2004 from Medicare data. Multivariate logistic regression models were used to determine the association between GP visits and statin use following the copayment increase. Results In December 2004, there were 22495 stable statin users for tertiary prevention of prior coronary heart disease, prior stroke or prior coronary artery revascularisation procedure. Following the copayment increase, patients either discontinued (3%), reduced (12%) or continued (85%) their statins. Individuals who visited a GP three or more times in 2004 were 47% less likely to discontinue their statins in 2005 than people attending only once. Subgroup analysis showed the effect was apparent in men, and long-term or new statin users. The frequency of GP visits did not affect the proportion of patients reducing their statin therapy. Conclusions Patients who visited their GP at least three times per year had a lower risk of ceasing their statins in the year following the copayment increase. GPs can help patients maintain treatment following rises in medicines costs. What is known about the topic? Following the 21% increase in medication copayment in 2005, individuals discontinued or reduced their statin usage, including for tertiary prevention. What does this paper add? Patients who visited their GP at least three times per year were less likely to discontinue their statin therapy for tertiary prevention following a large copayment increase. What are the implications for practitioners? This paper identifies the important role that GPs have in maintaining the continued use of important medications following rises in medicines costs.

Effect Modification of Multimorbidity on the Association Between Regularity of General Practitioner Contacts and Potentially Avoidable Hospitalisations

BACKGROUND

Scheduled regular contact with the general practitioner (GP) may lower the risk of potentially avoidable hospitalisations (PAHs). Despite the high prevalence of multimorbidity, little is known about its effect on the relationship between regularity of GP contact and PAHs.

OBJECTIVE

To investigate potential effect modification of multimorbidity on the relationship between regularity of GP contact and probability of PAHs.

DESIGN

A retrospective, cross-sectional study.

PARTICIPANTS

229,964 individuals aged 45 years and older from the 45 and Up Study in New South Wales, Australia, from 2009 to 2015.

MAIN MEASURES

The main exposure was regularity of GP contact (capturing dispersion of GP contacts); the outcomes were PAHs evaluated by unplanned hospitalisations, chronic ambulatory care sensitive condition (ACSC) hospitalisations and unplanned chronic ACSC hospitalisations. Multivariable logistic regression models and population attributable fractions (PAF) were conducted to identify effect modification of multimorbidity, assessed by Rx-Risk comorbidity score.

KEY RESULTS

Compared with the lowest quintile of regularity, the highest quintile had significantly lower predicted probability of unplanned admission (- 79.9 per 1000 people at risk, 95% confidence interval (CI) - 85.6; - 74.2), chronic ACSC (- 6.07 per 1000 people at risk, 95%CI - 8.07; - 4.08) and unplanned chronic ACSC hospitalisation (- 4.68 per 1000 people at risk, 95%CI - 6.11; - 3.26). Effect modification of multimorbidity was observed. Specifically, the PAF among people with no multimorbidity indicated that 31.7% (95%CI 28.7-34.4%) of unplanned, 36.4% (95%CI 25.1-45.9%) of chronic ACSC and 48.9% (95%CI 32.9-61.1%) of unplanned chronic ACSC hospitalisation would be reduced by a shift to the highest quintile of regularity. However, among people with 10+ morbidities, the proportional reduction was only 5.2% (95%CI 3.8-6.5%), 9.0% (95%CI 0.5-16.8%) and 17.8% (95%CI 5.4-28.5%), respectively.

CONCLUSIONS

Weakening of the association between regularity and PAHs with increasing levels of multimorbidity suggests a need to improve primary care support to prevent PAHs for patients with multimorbidity.

Time protective effect of contact with a general practitioner and its association with diabetes-related hospitalisations: a cohort study using the 45 and Up Study data in Australia

OBJECTIVES

To evaluate the relationship between the proportion of time under the potentially protective effect of a general practitioner (GP) captured using the Cover Index and diabetes-related hospitalisation and length of stay (LOS).

DESIGN

An observational cohort study over two 3-year time periods (2009/2010-2011/2012 as the baseline and 2012/2013-2014/2015 as the follow-up).

SETTING

Linked self-report and administrative health service data at individual level from the 45 and Up Study in New South Wales, Australia.

PARTICIPANTS

A total of 21 965 individuals aged 45 years and older identified with diabetes before July 2009 were included in this study.

MAIN OUTCOME MEASURES

Diabetes-related hospitalisation, unplanned diabetes-related hospitalisation and LOS of diabetes-related hospitalisation and unplanned diabetes-related hospitalisation.

METHODS

The average annual GP cover index over a 3-year period was calculated using information obtained from Australian Medicare and hospitalisation. The effect of exposure to different levels of the cover on the main outcomes was estimated using negative binomial models weighted for inverse probability of treatment weight to control for observed covariate imbalance at the baseline period.

RESULTS

Perfect GP cover was observed among 53% of people with diabetes in the study cohort. Compared with perfect level of GP cover, having lower levels of GP cover including high (incidence rate ratio (IRR) 2.8, 95% CI 2.6 to 3.0), medium (IRR 3.2, 95% CI 2.7 to 3.8) and low (IRR 3.1, 95% CI 2.0 to 4.9) were significantly associated with higher number of diabetes-related hospitalisation. Similar association was observed between the different levels of GP cover and other outcomes including LOS for diabetes-related hospitalisation, unplanned diabetes-related hospitalisation and LOS for unplanned diabetes-related hospitalisation.

CONCLUSIONS

Measuring longitudinal continuity in terms of time under cover of GP care may offer opportunities to optimise the performance of primary healthcare and reduce secondary care costs in the management of diabetes.

Transition of care to prevent recurrence after acute coronary syndrome: the critical role of the primary care provider and pharmacist

Despite therapeutic advances, patients with acute coronary syndrome (ACS) are at an increased long-term risk of recurrent cardiovascular events. This risk continues to rise as the number of associated comorbidities, often observed in patients presenting with ACS, increases. Such a level of clinical complexity can lead to gaps in care and subsequently worse outcomes. Guidelines recommend providing an evidence-based post-discharge plan to prevent readmission and recurrent ACS, including cardiac rehabilitation, medication, patient/caregiver education, and ongoing follow-up. A patient-centric multidisciplinary approach is critical for the effective management of the transition of care from acute care in the hospital setting to the outpatient care setting in patients with ACS. Ongoing communication between in-hospital and outpatient healthcare providers ensures that the transition is smooth. Primary care providers and pharmacists have a pivotal role to play in the effective management of transitions of care in patients with ACS. Guideline recommendations regarding the post-discharge care of patients with ACS and the role of the primary care provider and the pharmacist in the management of transitions of care will be reviewed.

Regularity of contact with GPs: Measurement approaches to improve valid associations with hospitalization

BACKGROUND

Studies examine longitudinal continuity of GP contact though few consider 'regularity of GP contact', i.e., the dispersion of contacts over time. Increased regularity may indicate planned ongoing care. Current measures of regularity may be correlated with the number of contacts and may not isolate the phenomenon of interest.

OBJECTIVES

To compare two published and one newly developed regularity index in terms of their ability to measure regularity of GP contacts independently of the number of contacts and the impact on their association with hospitalization.

METHODS

A cohort at risk of diabetes-related hospitalization in Western Australia from 1990 to 2004 was identified using linked administrative data. For each regularity index, relationships with number of GP contacts were assessed. Hospitalization was then regressed on each index with and without number of contacts as a covariate.

RESULTS

Among 153,414 patients the new regularity index showed a reduced association with number of contacts compared with existing indices. Associations with hospitalization differed between measures; for previously published indices, there were no significant associations between regularity and hospitalization, whereas on the new index, most regular GP contact was associated with reduced hospitalization (IRR = 0.90, 95% CI = 0.88-0.93). When number of contacts was added as a covariate, point estimates for this index showed little change, whereas for existing measures this addition changed point estimates.

CONCLUSION

A new measure of regularity of GP contact was less correlated with the number of contacts than previously published measures and better suited to estimating unconfounded relationships of regularity with hospitalization.

Association between continuity of provider-adjusted regularity of general practitioner contact and unplanned diabetes-related hospitalisation: a data linkage study in New South Wales, Australia, using the 45 and Up Study cohort

OBJECTIVE

To assess the association between continuity of provider-adjusted regularity of general practitioner (GP) contact and unplanned diabetes-related hospitalisation or emergency department (ED) presentation.

DESIGN

Cross-sectional study.

SETTING

Individual-level linked self-report and administrative health service data from New South Wales, Australia.

PARTICIPANTS

27 409 survey respondents aged ≥45 years with a prior history of diabetes and at least three GP contacts between 1 July 2009 and 30 June 2015.

MAIN OUTCOME MEASURES

Unplanned diabetes-related hospitalisations or ED presentations, associated costs and bed days.

RESULTS

Twenty-one per cent of respondents had an unplanned diabetes-related hospitalisation or ED presentation. Increasing regularity of GP contact was associated with a lower probability of hospitalisation or ED presentation (19.9% for highest quintile, 23.5% for the lowest quintile). Conditional on having an event, there was a small decrease in the number of hospitalisations or ED presentations for the low (-6%) and moderate regularity quintiles (-8%), a reduction in bed days (ranging from -30 to -44%) and a reduction in average cost of between -23% and -41%, all relative to the lowest quintile. When probability of diabetes-related hospitalisation or ED presentation was included, only the inverse association with cost remained significant (mean of $A3798 to $A6350 less per individual, compared with the lowest regularity quintile). Importantly, continuity of provider did not significantly modify the effect of GP regularity for any outcome.

CONCLUSIONS

Higher regularity of GP contact-that is more evenly dispersed, not necessarily more frequent care-has the potential to reduce secondary healthcare costs and, conditional on having an event, the time spent in hospital, irrespective of continuity of provider. These findings argue for the advocacy of regular care, as distinct from solely continuity of provider, when designing policy and financial incentives for GP-led primary care.

A time-duration measure of continuity of care to optimise utilisation of primary health care: a threshold effects approach among people with diabetes

BACKGROUND

Literature highlighted the importance of timely access and ongoing care provided at primary care settings in reducing hospitalisation and health care resource uses. However, the effect of timely access to primary care has not been fully captured in most of the current continuity of care indices. This study aimed to develop a time-duration measure of continuity of primary care ("cover index") capturing the proportion of time an individual is under the potentially protective effect of primary health care contacts.

METHODS

An observational study was conducted on 36,667 individuals aged 45 years or older with diabetes mellitus extracted from Western Australian linked administrative data. Threshold effect models were used to determine the maximum time interval between general practitioner (GP) visits that afforded a protective effect against avoidable hospitalisation across complication cohorts. The optimal maximum time interval was used to compute a cover index for each individual. The cover was evaluated using descriptive statistics stratified by population socio-demographic characteristics.

RESULTS

The optimal maximum time between GP visits was 9-13 months for people with diabetes with no complication, 5-11 months for people with diabetes with 1-2 complications, and 4-9 months for people with diabetes with 3+ complications. The cover index was lowest among those aged 75+ years, males, Indigenous people, socio-economically disadvantaged and those in very remote areas.

CONCLUSIONS

This study developed a new measure of continuity of primary care that adds a time parameter to capturing longitudinal continuity. Cover has the potential to better capture underuse of primary care and will significantly contribute to the sparsely available methods for analysis of linked administrative data in evaluating continuity of care for people with chronic conditions.

Impact of consumer copayments for subsidised medicines on health services use and outcomes: a protocol using linked administrative data from Western Australia

INTRODUCTION

Across the world, health systems are adopting approaches to manage rising healthcare costs. One common strategy is a medication copayments scheme where consumers make a contribution (copayment) towards the cost of their dispensed medicines, with remaining costs subsidised by the health insurance service, which in Australia is the Federal Government.In Australia, copayments have tended to increase in proportion to inflation, but in January 2005, the copayment increased substantially more than inflation. Results from aggregated dispensing data showed that this increase led to a significant decrease in the use of several medicines. The aim of this study is to determine the demographic and clinical characteristics of individuals ceasing or reducing statin medication use following the January 2005 Pharmaceutical Benefit Scheme (PBS) copayment increase and the effects on their health outcomes.

METHODS AND ANALYSIS

This whole-of-population study comprises a series of retrospective, observational investigations using linked administrative health data on a cohort of West Australians (WA) who had at least one statin dispensed between 1 May 2002 and 30 June 2010. Individual-level data on the use of pharmaceuticals, general practitioner (GP) visits, hospitalisations and death are used.This study will identify patients who were stable users of statin medication in 2004 with follow-up commencing from 2005 onwards. Subgroups determined by change in adherence levels of statin medication from 2004 to 2005 will be classified as continuation, reduction or cessation of statin therapy and explored for differences in health outcomes and health service utilisation after the 2005 copayment change.

ETHICS AND DISSEMINATION

Ethics approvals have been obtained from the Western Australian Department of Health (#2007/33), University of Western Australia (RA/4/1/1775) and University of Notre Dame (0 14 167F). Outputs from the findings will be published in peer reviewed journals designed for a policy audience and presented at state, national and international conferences.

Improving cardiovascular outcomes among Aboriginal Australians: Lessons from research for primary care

BACKGROUND

The Aboriginal people of Australia have much poorer health and social indicators and a substantial life expectancy gap compared to other Australians, with premature cardiovascular disease a major contributor to poorer health. This article draws on research undertaken to examine cardiovascular disparities and focuses on ways in which primary care practitioners can contribute to reducing cardiovascular disparities and improving Aboriginal health.

METHODS

The overall research utilised mixed methods and included data analysis, interviews and group processes which included Aboriginal people, service providers and policymakers. Workshop discussions to identify barriers and what works were recorded by notes and on whiteboards, then distilled and circulated to participants and other stakeholders to refine and validate information. Additional engagement occurred through circulation of draft material and further discussions. This report distils the lessons for primary care practitioners to improve outcomes through management that is attentive to the needs of Aboriginal people.

RESULTS

Aspects of primordial, primary and secondary prevention are identified, with practical strategies for intervention summarised. The premature onset and high incidence of Aboriginal cardiovascular disease make prevention imperative and require that primary care practitioners understand and work to address the social underpinnings of poor health. Doctors are well placed to reinforce the importance of healthy lifestyle at all visits to involve the family and to reduce barriers which impede early care seeking. Ensuring better information for Aboriginal patients and better integrated care for patients who frequently have complex needs and multi-morbidities will also improve care outcomes.

CONCLUSION

Primary care practitioners have an important role in improving Aboriginal cardiovascular care outcomes. It is essential that they recognise the special needs of their Aboriginal patients and work at multiple levels both outside and inside the clinic for prevention and management of disease. A toolkit of proactive and holistic opportunities for interventions is proposed.

Findings from a clinical audit in regional general practice of management of patients following acute coronary syndrome

Patients with acute coronary syndrome (ACS) require ongoing treatment and support from their primary care provider to modify cardiovascular risk factors (including diet, exercise and mood), to receive evidence-based pharmacotherapies and be properly monitored and to ensure their take-up and completion of cardiac rehabilitation (CR). This study assesses adherence to National Heart Foundation guidelines for ACS in primary care in a regional centre in Western Australia. Patients discharged from hospital after a coronary event (unstable angina or myocardial infarction) or a coronary procedure (stent or coronary artery bypass graft) were identified through general practice electronic medical records. Patient data was extracted using a data form based on National Heart Foundation guidelines. Summary statistics were calculated and reported. Our study included 22 GPs and 44 patients in a regional centre. In total, 90% (n=39) of discharge summaries recorded medications. Assessment of pharmacological management showed that 53% (n=23) of patients received four or more classes of pharmacotherapy and that GPs often augmented medication beyond that prescribed at discharge. Of 15 smokers, 13 (87%) had advice to quit documented. Minimal advice for other risk-factor modification was documented in care plans. Patients with type 2 diabetes (n=20) were 70% more likely to receive allied health referral (P=0.02) and 60% more likely to receive advice regarding diet and exercise (P=0.007). However, overall, only 30% (n=13) of those eligible were referred to a dietician, and only 25% were referred to CR (n=10) with six completing CR. Although most GPs did not use standardised tools for mood assessment, 18 (41%) patients were diagnosed as depressed, of which 88% (n=16) were started on antidepressants and 28% (n=6) were referred to a psychologist. Although pharmacotherapy, mood management and smoking cessation management generally followed recommended guidelines, risk factor management relating to diet and exercise by GPs require improvement. Detailed care plans and referral to CR and allied health staff for patient support is recommended.

Disparities in equity and access for hospitalised atherothrombotic disease

OBJECTIVE

This study of equity and access characterises admissions for coronary, cerebrovascular and peripheral arterial disease by hospital type (rural, tertiary and non-tertiary metropolitan) in a representative Australian population.

METHODS

We conducted a descriptive analysis using data linkage of all residents aged 35-84 years hospitalised in Western Australia with a primary diagnosis for an atherothrombotic event in 2007. We compared sociodemographic and clinical features by atherothrombotic territory and hospital type.

RESULTS

There were 11670 index admissions for atherothrombotic disease in 2007 of which 46% were in tertiary hospitals, 41% were in non-tertiary metropolitan hospitals and 13% were in rural hospitals. Coronary heart disease comprised 72% of admissions, followed by cerebrovascular disease (19%) and peripheral arterial disease (9%). Comparisons of socioeconomic disadvantage reveal that for those admitted to rural hospitals, more than one-third were in the most disadvantaged quintile, compared with one-fifth to any metropolitan hospital.

CONCLUSIONS

Significant differences in demographic characteristics were evident between Western Australian tertiary and non-tertiary hospitals for patients hospitalised for atherothrombotic disease. Notably, the differences among tertiary, non-tertiary metropolitan and rural hospitals were related to socioeconomic disadvantage. This has implications for atherothrombotic healthcare provision and the generalisation of research findings from studies conducted exclusively in the tertiary metropolitan hospitals.

Association of physician care with mortality in Kidney Early Evaluation Program (KEEP) participants

BACKGROUND

People with or at high risk of chronic kidney disease (CKD) are at increased risk of premature morbidity and mortality. We sought to examine the effect of care provided by a primary care physician (PCP) on survival for all participants in the National Kidney Foundation's Kidney Early Evaluation Program (KEEP) and the effect of care provided by a nephrologist on survival for KEEP participants with estimated glomerular filtration rate (eGFR) <60 mL/min/1.73 m(2).

METHODS

Provision of care by a PCP (n = 138,331) or nephrologist (n = 10,797) was defined using self-report of seeing that provider within the past year. Survival was ascertained by linking KEEP data to the Social Security Administration Death Master File. Multivariable Cox proportional hazards models examining the relationship between primary care and nephrologist provider status adjusted for age, sex, race, smoking status, education, health insurance, diabetes, cardiovascular disease, hypertension, cancer, albuminuria, body mass index, baseline eGFR, and hemoglobin level, with nephrology models further adjusting for calcium, phosphorus, and parathyroid hormone levels.

RESULTS

Of all participants, 70.9% (98,050 of 138,331) reported receiving PCP care; older age and female sex were associated with this care. During a median follow-up of 4.2 years, 4,836 deaths occurred. After multivariable adjustment, receiving PCP care and mortality were not associated (HR, 0.94; 95% CI, 0.86-1.03; P = 0.2). Of participants with eGFR <60 mL/min/1.73 m(2), 10.1% (1,095 of 10,797) reported receiving nephrology care; younger age and male sex were associated with receipt of nephrology care. During a mean follow-up of 2.2 years, 558 deaths occurred. After multivariable adjustment, nephrologist care was not associated with mortality (HR, 1.01; 95% CI, 0.75-1.36; P = 0.9). These associations were not modified by other specialist care (endocrinologist or cardiologist).

CONCLUSIONS

For all KEEP participants, neither PCP nor nephrology care was associated with improved survival. These results highlight the need to explore the connection between access to health care and outcomes in persons at high risk of or with CKD.