Modelling factors in primary care quality improvement: a cross-sectional study of premature CHD mortality

Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway

BACKGROUND

Continuity, usually considered a quality aspect of primary care, is under pressure in Norway, and elsewhere.

AIM

To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality.

DESIGN AND SETTING

Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs.

METHOD

Duration of RGP-patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP-patient relationship was categorised as 1, 2-3, 4-5, 6-10, 11-15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses.

RESULTS

Compared with a 1-year RGP-patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2-3 years' duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2-3 years' duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2-3 years' duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP-patient relationship of >15 years.

CONCLUSION

Length of RGP-patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose-response relationship between continuity and these outcomes indicates that the associations are causal.

Continuity of care, measurement and association with hospital admission and mortality: a registry-based longitudinal cohort study

OBJECTIVE

To assess whether continuity of care (COC) with a general practitioner (GP) is associated with mortality and hospital admissions for older patients We argue that the conventional continuity measure may overestimate these associations. To better reflect COC as a GP quality indicator, we present an alternative, service-based measure.

DESIGN

Registry-based, population-level longitudinal cohort study.

SETTING

Linked data from Norwegian administrative healthcare registries, including 3989 GPs.

PARTICIPANTS

757 873 patients aged 60-90 years with ≥2 contacts with a GP during 2016 and 2017.

MAIN OUTCOME MEASURE

All-cause emergency hospital admissions, emergency admissions for ambulatory care sensitive conditions, and mortality, in 2018.

RESULTS

We assessed COC using the conventional usual provider of care index (UPC^patient) and an alternative/supplementary index (UPC^{GP list}) based on the COC for all other patients enlisted with the same preferred GP.For both indices, the mean index score was 0.78. Our model controls for demographic and socioeconomic characteristics, prior healthcare use and municipality-fixed effects. Overall, UPC^{GP list} shows a much weaker association between COC and the outcomes. For both indices, there is a negative relationship between COC and hospital admissions. A 0.2-point increase in the index score would reduce admissions for ambulatory care sensitive conditions by 8.1% (CI 7.1% to 9.1%) versus merely 1.9% (0.2% to 3.5%) according to UPC^patient and UPC^{GP list}, respectively. Using UPC^{GP list}, we find that mortality is no longer associated with COC. There was greater evidence for an association between COC and all-cause admissions among patients with low education.

CONCLUSIONS

A continuity measure based on each patient's contacts with own preferred GP may overestimate the importance of COC as a feature of the GP practice. An alternative, service-based measure of continuity could be suitable as a quality measure in primary healthcare. Facilitating continuity should be considered a health policy measure to reduce inequalities in health.

Primary medical care continuity and patient mortality: a systematic review

BACKGROUND

A 2018 review into continuity of care with doctors in primary and secondary care concluded that mortality rates are lower with higher continuity of care.

AIM

This association was studied further to elucidate its strength and how causative mechanisms may work, specifically in the field of primary medical care.

DESIGN AND SETTING

Systematic review of studies published in English or French from database and source inception to July 2019.

METHOD

Original empirical quantitative studies of any design were included, from MEDLINE, Embase, PsycINFO, OpenGrey, and the library catalogue of the New York Academy of Medicine for unpublished studies. Selected studies included patients who were seen wholly or mostly in primary care settings, and quantifiable measures of continuity and mortality.

RESULTS

Thirteen quantitative studies were identified that included either cross-sectional or retrospective cohorts with variable periods of follow-up. Twelve of these measured the effect on all-cause mortality; a statistically significant protective effect of greater care continuity was found in nine, absent in two, and in one effects ranged from increased to decreased mortality depending on the continuity measure. The remaining study found a protective association for coronary heart disease mortality. Improved clinical responsibility, physician knowledge, and patient trust were suggested as causative mechanisms, although these were not investigated.

CONCLUSION

This review adds reduced mortality to the demonstrated benefits of there being better continuity in primary care for patients. Some patients may benefit more than others. Further studies should seek to elucidate mechanisms and those patients who are likely to benefit most. Despite mounting evidence of its broad benefit to patients, relationship continuity in primary care is in decline - decisive action is required from policymakers and practitioners to counter this.

Effect of family practice contract services on the quality of primary care in Guangzhou, China: a cross-sectional study using PCAT-AE

OBJECTIVE

Current healthcare reform in China has an overall goal of strengthening primary care and establishing a family practice system based on contract services. The objective of this study was to determine whether contracting a general practitioner (GP) could improve quality of primary care.

DESIGN

A cross-sectional study using two-stage sampling conducted from June to September 2014. Propensity score matching (PSM) was employed to control for confounding between patients with and without contracted GP.

SETTING

Three community health centres in Guangzhou, China.

PARTICIPANTS

698 patients aged 18-89 years.

MAIN OUTCOME MEASURES

The quality of primary care was measured using a validated Chinese version of primary care assessment tool (PCAT). Eight domains are included (first contact utilisation, accessibility, continuity, comprehensiveness, coordination, family-centredness, community orientation and cultural competence from patient's perceptions).

RESULTS

A total of 692 effective samples were included for data analysis. After PSM, 94 pairs of patients were matched between the patients with and without contracted GPs. The total PCAT score, continuity (3.12 vs 2.68, p<0.01), comprehensiveness (2.31 vs 2.04, p<0.01) and family-centredness (2.11 vs 1.79, p<0.01) were higher in patients who contracted GPs than those did not. However, the domains of first contact utilisation (2.74 vs 2.87, p=0.14) and coordination (1.76 vs 1.93, p<0.05) were lower among patients contracted with GPs than in those who did not.

CONCLUSION

Our findings demonstrated that patients who had a contracted GP tend to experience higher quality of primary care. Our study provided evidence for health policies aiming to promote the implementation of family practice contract services. Our results also highlight further emphases on the features of primary care, first contact services and coordination services in particular.

Association between the General Practitioner Workforce Crisis and Premature Mortality in Hungary: Cross-Sectional Evaluation of Health Insurance Data from 2006 to 2014

The workforce crisis of primary care is reflected in the increasing number of general medical practices (GMP) with vacant general practitioner (GP) positions, and the GPs’ ageing. Our study aimed to describe the association between this crisis and premature mortality. Age-sex-standardized mortality for 18–64 years old adults was calculated for all Hungarian GMPs annually in the period from 2006 to 2014. The relationship of premature mortality with GPs’ age and vacant GP positions was evaluated by standardized linear regression controlled for list size, urbanization, geographical location, clients’ education, and type of the GMP. The clients’ education was the strongest protective factor (beta = −0175; p < 0.001), followed by urban residence (beta = −0.149; p < 0.001), and bigger list size (beta_1601–2000 = −0.054; p < 0.001; beta_2001−X = −0.096; p < 0.001). The geographical localization also significantly influenced the risk. Although GMPs with a GP aged older than 65 years (beta = 0; p = 0.995) did not affect the risk, GP vacancy was associated with higher risk (beta = 0.010; p = 0.033), although the corresponding number of attributable cases was 23.54 over 9 years. The vacant GP position is associated with a significant but hardly detectable increased risk of premature mortality without considerable public health importance. Nevertheless, employment of GPs aged more than 65 does not impose premature mortality risk elevation.

Continuity of care with doctors-a matter of life and death? A systematic review of continuity of care and mortality

OBJECTIVE

Continuity of care is a long-standing feature of healthcare, especially of general practice. It is associated with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. This review aims to examine whether there is a relationship between the receipt of continuity of doctor care and mortality.

DESIGN

Systematic review without meta-analysis.

DATA SOURCES

MEDLINE, Embase and the Web of Science, from 1996 to 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Peer-reviewed primary research articles, published in English which reported measured continuity of care received by patients from any kind of doctor, in any setting, in any country, related to measured mortality of those patients.

RESULTS

Of the 726 articles identified in searches, 22 fulfilled the eligibility criteria. The studies were all cohort or cross-sectional and most adjusted for multiple potential confounding factors. These studies came from nine countries with very different cultures and health systems. We found such heterogeneity of continuity and mortality measurement methods and time frames that it was not possible to combine the results of studies. However, 18 (81.8%) high-quality studies reported statistically significant reductions in mortality, with increased continuity of care. 16 of these were with all-cause mortality. Three others showed no association and one demonstrated mixed results. These significant protective effects occurred with both generalist and specialist doctors.

CONCLUSIONS

This first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates. Although all the evidence is observational, patients across cultural boundaries appear to benefit from continuity of care with both generalist and specialist doctors. Many of these articles called for continuity to be given a higher priority in healthcare planning. Despite substantial, successive, technical advances in medicine, interpersonal factors remain important.

PROSPERO REGISTRATION NUMBER

CRD42016042091.

Population characteristics, mechanisms of primary care and premature mortality in England: a cross-sectional study

OBJECTIVES

Health systems with strong primary care tend to have better population outcomes, but in many countries demand for care is growing. We sought to identify mechanisms of primary care that influence premature mortality.

DESIGN

We developed a conceptual model of the mechanisms by which primary care influences premature mortality, and undertook a cross-sectional study in which population and primary care variables reflecting the model were used to explain variations in mortality of those aged under 75 years. The premature standardised mortality ratios (SMRs) for each practice, available from the Department of Health, had been calculated from numbers of deaths in the 5 years from 2006 to 2010. A regression model was undertaken with explanatory variables for the year 2009/2010, and repeated to check stability using data for 2008/2009 and 2010/2011.

SETTING

All general practices in England were eligible for inclusion and, of the total of 8290, complete data were available for 7858.

RESULTS

Population variables, particularly deprivation, were the most powerful predictors of premature mortality, but the mechanisms of primary care depicted in our model also affected mortality. The number of GPs/1000 population and detection of hypertension were negatively associated with mortality. In less deprived practices, continuity of care was also negatively associated with mortality.

CONCLUSIONS

Greater supply of primary care is associated with lower premature mortality even in a health system that has strong primary care (England). Health systems need to sustain the capacity of primary care to deliver effective care, and should assist primary care providers in identifying and meeting the needs of socioeconomically deprived groups.

Impact of continuity of care on mortality and health care costs: a nationwide cohort study in Korea

PURPOSE

Continuity of care is considered a core element of high-quality primary care, but its impact on mortality and health care costs is unclear. We aimed to determine the impact of continuity of care on mortality, costs, and health outcomes in patients with newly diagnosed cardiovascular risk factors.

METHODS

We conducted a cohort study of a 3% nationwide random sample of Korean National Health Insurance enrollees. A total of 47,433 patients who had received new diagnoses of hypertension, diabetes, hypercholesterolemia, or their complications in 2003 or 2004 were included. We determined standard indices of continuity of care-most frequent provider continuity (MFPC), modified, modified continuity index (MMCI), and continuity of care index (COC)-and evaluated their association with study outcomes over 5 years of follow-up. Outcome measures included overall mortality, cardiovascular mortality, incident cardiovascular events, and health care costs.

RESULTS

The multivariable-adjusted hazard ratios (HRs) for all-cause mortality, cardiovascular mortality, incident myocardial infarction, and incident ischemic stroke comparing participants with COC index below the median to those above the median were HR = 1.12 (95% CI, 1.04-1.21), 1.30 (1.13-1.50), 1.57 (1.28-1.95), and 1.44 (1.27-1.63), respectively. Similar findings were obtained for other indices of continuity of care. Lower continuity of care was also associated with increased inpatient and outpatient days and costs.

CONCLUSIONS

Lower indices of continuity of care in patients with newly diagnosed hypertension, diabetes, and hypercholesterolemia were associated with higher all-cause and cardiovascular mortality, cardiovascular events, and health care costs. Health care systems should be designed to support long-term trusting relationships between patients and physicians.

Estimating smoking prevalence in general practice using data from the Quality and Outcomes Framework (QOF)

OBJECTIVES

To determine to what extent underlying data published as part of Quality and Outcomes Framework (QOF) can be used to estimate smoking prevalence within practice populations and local areas and to explore the usefulness of these estimates.

DESIGN

Cross-sectional, observational study of QOF smoking data. Smoking prevalence in general practice populations and among patients with chronic conditions was estimated by simple manipulation of QOF indicator data. Agreement between estimates from the integrated household survey (IHS) and aggregated QOF-based estimates was calculated. The impact of including smoking estimates in negative binomial regression models of counts of premature coronary heart disease (CHD) deaths was assessed.

SETTING

Primary care in the East Midlands.

PARTICIPANTS

All general practices in the area of study were eligible for inclusion (230). 14 practices were excluded due to incomplete QOF data for the period of study (2006/2007-2012/2013). One practice was excluded as it served a restricted practice list.

MEASUREMENTS

Estimates of smoking prevalence in general practice populations and among patients with chronic conditions.

RESULTS

Median smoking prevalence in the practice populations for 2012/2013 was 19.2% (range 5.8-43.0%). There was good agreement (mean difference: 0.39%; 95% limits of agreement (-3.77, 4.55)) between IHS estimates for local authority districts and aggregated QOF register estimates. Smoking prevalence estimates in those with chronic conditions were lower than for the general population (mean difference -3.05%), but strongly correlated (Rp=0.74, p<0.0001). An important positive association between premature CHD mortality and smoking prevalence was shown when smoking prevalence was added to other population and service characteristics.

CONCLUSIONS

Published QOF data allow useful estimation of smoking prevalence within practice populations and in those with chronic conditions; the latter estimates may sometimes be useful in place of the former. It may also provide useful estimates of smoking prevalence in local areas by aggregating practice based data.