Which features of primary care affect unscheduled secondary care use? A systematic review

Relationship between patient-perceived quality of primary care and self-reported hospital utilisation in China: A cross-sectional study

BACKGROUND

Reducing avoidable hospital admissions is a global healthcare priority, with optimal primary care recognised as pivotal for achieving this objective. However, in developing systems like China, where primary care is evolving without compulsory gatekeeping, the relationship between patient-perceived primary care quality and hospital utilisation remains underexplored.

OBJECTIVES

This study aimed to explore the association between patient-perceived primary care quality and self-reported hospital utilisation in China.

METHODS

Data were collected from 16 primary care settings. Patient-perceived quality of primary care was measured using the Assessment Survey of Primary Care scale across six domains (first-contact care, continuity, comprehensiveness, accessibility, coordination, and patient-centredness). Hospital utilisation included patient self-reported outpatient visits, hospital admissions, and emergency department (ED) visits in the last six months. Logistic regression analyses were examined associations between self-reported hospital utilisation and perceived primary care quality adjusted for potential confounders.

RESULTS

Of 1,185 patients recruited, 398 (33.6%) reported hospital utilisation. Logistic regression analyses showed that higher total scores for patient-perceived quality of primary care were associated with decreased odds of hospital utilisation (adjusted odds ratio(AOR): 0.417, 95% confidence interval (CI): 0.308-0.565), outpatient visits (AOR: 0.394, 95% CI: 0.275-0.566) and hospital admissions (AOR: 0.496, 95% CI: 0.276-0.891). However, continuity of care was positively associated with ED visits (AOR: 2.252, 95% CI: 1.051-4.825).

CONCLUSION

Enhanced patient-perceived quality of primary care in China is associated with a reduction in self-reported overall hospital utilisation, including outpatient visits and hospital admissions. However, better continuity of care may be associated with increased ED visits. Further research is warranted for precise insights and validation of these findings.

Implementation and adaptation of a hub-based psychiatric and primary care program: A qualitative descriptive analysis of The Seamless Care Optimizing the Patient Experience (SCOPE) Mental Health program

BACKGROUND

The Seamless Care Optimizing the Patient Experience (SCOPE)-Mental Health program is a comprehensive case management and psychiatric care initiative that supports primary care physicians in independent medical practices. This program offers a range of services that aims to enhance primary care capacity for mental health and provide accessible clinical care for patients. With its flexible hub-based approach, this program allows participating sites to tailor their implementation based on their available resources and specific needs within their community.

OBJECTIVES

The aim of this quality improvement initiative was to investigate the evolution of this collaborative mental health model, focusing on specific site adaptations, local implementation challenges, and opportunities for ongoing development and sustainability across SCOPE sites in the Greater Toronto Area.

METHOD

This evaluation employed a qualitative descriptive design where semi-structured interviews, guided by the Reach Effectiveness Adoption, Implementation, and Maintenance framework were conducted with staff from all 8 SCOPE-Mental Health sites. Site representatives were interviewed virtually between March and July 2023 and data were analyzed using qualitative content analysis.

FINDINGS

The SCOPE-Mental Health model permits flexibility through specific local adaptations led by community need that leverage existing assets either at the site or within the individual community. Adoption by primary care physicians was crucial to program success and facilitated efficiency and interprofessional collaboration. Maintenance efforts included pathway refinement, and marketing and funding considerations. Challenges to program development included continuity of staff, physician compensation issues, and electronic health record interoperability. The SCOPE-Mental Health program fosters linkages among unaffiliated primary care offices, hospitals, and community-based resources to improve mental health care. Key recommendations include advocating for sustainable funding and facilitated mechanisms for psychiatric consultations.

CONCLUSIONS

This initiative offers valuable insights for healthcare organizations seeking to develop similar programs, emphasizing the need for tailored approaches and ongoing evaluation to ensure a lasting impact in underserved communities.

Coordination of oral anticoagulant care at hospital discharge (COACHeD): pilot randomised controlled trial

OBJECTIVES

To evaluate whether a focused, expert medication management intervention is feasible and potentially effective in preventing anticoagulation-related adverse events for patients transitioning from hospital to home.

DESIGN

Randomised, parallel design.

SETTING

Medical wards at six hospital sites in southern Ontario, Canada.

PARTICIPANTS

Adults 18 years of age or older being discharged to home on an oral anticoagulant (OAC) to be taken for at least 4 weeks.

INTERVENTIONS

Clinical pharmacologist-led intervention, including a detailed discharge medication management plan, a circle of care handover and early postdischarge virtual check-up visits to 1 month with 3-month follow-up. The control group received the usual care.

OUTCOMES MEASURES

Primary outcomes were study feasibility outcomes (recruitment, retention and cost per patient). Secondary outcomes included adverse anticoagulant safety events composite, quality of transitional care, quality of life, anticoagulant knowledge, satisfaction with care, problems with medications and health resource utilisation.

RESULTS

Extensive periods of restriction of recruitment plus difficulties accessing patients at the time of discharge negatively impacted feasibility, especially cost per patient recruited. Of 845 patients screened, 167 were eligible and 56 were randomised. The mean age (±SD) was 71.2±12.5 years, 42.9% females, with two lost to follow-up. Intervention patients were more likely to rate their ability to manage their OAC as improved (17/27 (63.0%) vs 7/22 (31.8%), OR 3.6 (95% CI 1.1 to 12.0)) and their continuity of care as improved (21/27 (77.8%) vs 2/22 (9.1%), OR 35.0 (95% CI 6.3 to 194.2)). Fewer intervention patients were taking one or more inappropriate medications (7 (22.5%) vs 15 (60%), OR 0.19 (95% CI 0.06 to 0.62)).

CONCLUSION

This pilot randomised controlled trial suggests that a transitional care intervention at hospital discharge for older adults taking OACs was well received and potentially effective for some surrogate outcomes, but overly costly to proceed to a definitive large trial.

TRIAL REGISTRATION NUMBER

NCT02777047.

Prevalence of Low-Acuity Pediatric Emergency Medical Services Transports to a Pediatric Emergency Department in an Urban Area

OBJECTIVES

Many patients transported by Emergency Medical Services (EMS) do not have emergent resource needs. Estimates for the proportion of pediatric EMS calls for low-acuity complaints, and thus potential candidates for alternative dispositions, vary widely and are often based on physician judgment. A more accurate reference standard should include patient assessments, interventions, and dispositions. The objective of this study was to describe the prevalence and characteristics of low-acuity pediatric EMS calls in an urban area.

METHODS

This is a prospective observational study of children transported by EMS to a tertiary care pediatric emergency department. Patient acuity was defined using a novel composite measure that included physiologic assessments, resources used, and disposition. Bivariable and multivariable logistic regression were conducted to assess for factors associated with low-acuity status.

RESULTS

A total of 996 patients were enrolled, of whom 32.9% (95% confidence interval, 30.0-36.0) were low acuity. Most of the sample was Black, non-Hispanic with a mean age of 7 years. When compared with adolescents, children younger than 1 year were more likely to be low acuity (adjusted odds ratio, 3.1 [1.9-5.1]). Patients in a motor vehicle crash were also more likely to be low acuity (adjusted odds ratio, 2.4 [1.2-4.6]). All other variables, including race, insurance status, chief complaint, and dispatch time, were not associated with low-acuity status.

CONCLUSIONS

One third of pediatric patients transported to the pediatric emergency department by EMS in this urban area are for low-acuity complaints. Further research is needed to determine low-acuity rates in other jurisdictions and whether EMS providers can accurately identify low-acuity patients to develop alternative EMS disposition programs for children.

Two-year follow-up of a clustered randomised controlled trial of a multicomponent general practice intervention for people at risk of poor health outcomes

BACKGROUND

This study was a two-year follow-up evaluation of health service use and the cost-effectiveness of a multicomponent general practice intervention targeted at people at high risk of poor health outcomes.

METHODS

A two-year follow-up study of a clustered randomised controlled trial was conducted in South Australia during 2018-19, recruiting 1044 patients from three cohorts: children; adults (aged 18-64 years with two or more chronic diseases); and older adults (aged ≥ 65 years). Intervention group practices (n = 10) provided a multicomponent general practice intervention for 12 months. The intervention comprised patient enrolment to a preferred general practitioner (GP), access to longer GP appointments and timely general practice follow-up after episodes of hospital care. Health service outcomes included hospital use, specialist services and pharmaceuticals. The economic evaluation was based on quality-adjusted life years (QALYs) calculated from EuroQoL 5 dimensions, 5 level utility scores and used an A$50,000 per QALY gained threshold for determining cost-effectiveness.

RESULTS

Over the two years, there were no statistically significant intervention effects for health service use. In the total sample, the mean total cost per patient was greater for the intervention than control group, but the number of QALYs gained in the intervention group was higher. The estimated incremental cost-effectiveness ratio (ICER) was A$18,211 per QALY gained, which is lower than the A$50,000 per QALY gained threshold used in Australia. However, the intervention's cost-effectiveness was shown to differ by cohort. For the adult cohort, the intervention was associated with higher costs and lower QALYs gained (vs the total cohort) and was not cost-effective. For the older adults cohort, the intervention was associated with lower costs (A$540 per patient), due primarily to lower hospital costs, and was more effective than usual care.

CONCLUSIONS

The positive cost-effectiveness results from the 24-month follow-up warrant replication in a study appropriately powered for outcomes such as hospital use, with an intervention period of at least two years, and targeted to older people at high risk of poor health outcomes.

A paradox of problems in accessing general practice: a qualitative participatory case study

BACKGROUND

Despite longstanding problems of access to general practice, attempts to understand and address the issues do not adequately include perspectives of the people providing or using care, nor do they use established theories of access to understand complexity.

AIM

To understand problems of access to general practice from the multiple perspectives of service users and staff using an applied theory of access.

DESIGN AND SETTING

A qualitative participatory case study in an area of northwest England.

METHOD

A community-based participatory approach was used with qualitative interviews, focus groups, and observation to understand perspectives about accessing general practice. Data were collected between October 2015 and October 2016. Inductive and abductive analysis, informed by Levesque et al's theory of access, allowed the team to identify complexities and relationships between interrelated problems.

RESULTS

This study presents a paradox of problems in accessing general practice, in which the demand on general practice both creates and hides unmet need in the population. Data show how reactive rules to control demand have undermined important aspects of care, such as continuity. The layers of rules and decreased continuity create extra work for practice staff, clinicians, and patients. Complicated rules, combined with a lack of capacity to reach out or be flexible, leave many patients, including those with complex and/or unrecognised health needs, unable to navigate the system to access care. This relationship between demand and unmet need exacerbates existing health inequities.

CONCLUSION

Understanding the paradox of access problems allows for different targets for change and different solutions to free up capacity in general practice to address the unmet need in the population.

General practice staff and patient experiences of a multicomponent intervention for people at high risk of poor health outcomes: a qualitative study

BACKGROUND

This study reports the experiences of general practice staff and patients at high risk of poor health outcomes who took part in a clustered randomised controlled trial of a multicomponent general practice intervention. The intervention comprised patient enrolment to a preferred General Practitioner (GP) to promote continuity of care, access to longer GP appointments, and timely general practice follow-up after hospital care episodes. The aims of the study were to better understand participant's (practice staff and patients) perspectives of the intervention, their views on whether the intervention had improved general practice services, reduced hospital admissions and finally whether they believed the intervention would be sustainable after the trial had completed.

METHODS

A qualitative study design with semi-structured interviews was employed. The practice staff sample was drawn from both the control and intervention groups. The patient sample was drawn from those who had expressed an interest in taking part in an interview during the trial and who had also experienced a recent hospital care episode.

RESULTS

Interviews were conducted with 41 practice staff and 45 patients. Practice staff and patients expressed support for the value of appointments with a regular GP and having sufficient time in appointments for the provision of comprehensive care. There were mixed views with respect to the extent to which the intervention had improved services. The positive changes reported were related to services being provided in a more proactive, thorough, and systematic manner with a greater emphasis on team based care involving the Practice Nurse. Patients nominated after hours care and financial considerations as the key reasons for seeking hospital care. Practice staff noted that the intervention would be difficult to sustain financially in the absence of additional funding.

CONCLUSIONS

The multicomponent intervention was supported by practice staff and patients and some patients perceived that it had led to improvements in care.

GP assessment of unmet need in a complex multimorbid population using a data-driven and clinical triage system: a prospective cohort study

BACKGROUND

Patients with unmet healthcare needs are more likely to access unscheduled care. Identifying these patients through data-driven and clinical risk stratification for active case management in primary care can help address patient need and reduce demand on acute services.

AIM

To determine how a proactive digital healthcare system can be used to undertake comprehensive needs analysis of patients at risk of unplanned admission and mortality.

DESIGN & SETTING

Prospective cohort study of six general practices in a deprived UK city.

METHOD

To identify those with unmet needs, the study's population underwent digitally-driven risk stratification into Escalated and Non-escalated groups using seven risk factors. The Escalated group underwent further stratification using GP clinical assessment into Concern and No concern groups. The Concern group underwent Unmet Needs Analysis (UNA).

RESULTS

From 24 746 patients, 516 (2.1%) were triaged into the Concern group and 164 (0.7%) underwent UNA. These patients were more likely to be older (t = 4.69, P<0.001), female (X2 = 4.46, P<0.05), have a Patients At Risk of Re-hospitalisation (PARR) score ≥80 (X2 = 4.31, P<0.05), be a nursing home resident (X2 = 6.75, P<0.01), or on an end-of-life (EOL) register (X2 = 14.55, P<0.001). Following UNA, 143 (87.2%) patients had further review planned or were referred for further input. The majority of patients had four domains of need. In those who GPs would not be surprised if they died within the next few months, n = 69 (42.1%) were not on an EOL register.

CONCLUSION

This study showed how an integrated, patient-centred, digital care system working with GPs can highlight and implement resources to address the escalating care needs of complex individuals.

Predictors, Prevalence, and Clinical Outcomes of Out-of-Hospital Cardiac Arrests in Croatia: A Nationwide Study

BACKGROUND

Out-of-hospital cardiac arrest (OHCA) remains a pivotal health challenge globally. In Croatia, there has been a knowledge gap regarding the prevalence, predictors, and outcomes of OHCA patients. This study aims to determine the prevalence, prediction, and outcomes of OHCA patients in Croatia.

METHODS

An extensive one-year analysis was performed on all OHCA treated by the Emergency Medical Service in Croatia, based on the Utstein recommendations. Data were extracted from Croatian Institute of Emergency Medicine databases, focusing on adult individuals who experienced sudden cardiac arrest in out-of-hospital settings in Croatia.

RESULTS

From 7773 OHCA cases, 9.5% achieved spontaneous circulation pre-hospital. Optimal outcomes corresponded to EMS intervention within ≤13 min post-arrest onset AUC = 0.577 (95% CI: 0.56-0.59; p < 0.001) and female gender OR = 1.81 (95% CI: 1.49-2.19; p < 0.001). Northern Croatia witnessed lower success rates relative to the capital city Zagreb OR = 0.68 (95% CI: 0.50-0.93; p = 0.015).

CONCLUSIONS

Early intervention by EMS, specifically within a 13-min period following the onset of a cardiac arrest, significantly enhances the probability of achieving successful OHCA outcomes. Gender differences and specific initial heart rhythms further influenced the likelihood of successful outcomes. Regional disparities, with reduced success rates in northern Croatia compared to the City of Zagreb, were evident.

Predictors of intent to utilize the emergency department among a free clinic's patients

OBJECTIVE

Primary care use helps reduce utilization of more expensive modes of care, such as the emergency department (ED). Although most studies have investigated this association among patients with insurance, few have done so for patients without insurance. We used data from a free clinic network to assess the association between free clinic use and intent to use the ED.

METHODS

Data were collected from a free clinic network's electronic health records on adult patients from January 2015 to February 2020. Our outcome was whether patients reported themselves as 'very likely' to visit the ED if the free clinics were unavailable. The independent variable was frequency of free clinic use. Using a multivariable logistic regression model, we controlled for other factors, such as patient demographic factors, social determinants of health, health status, and year effect.

RESULTS

Our sample included 5008 visits. When controlling for other factors, higher odds of expressing ED interest were observed for patients who are non-Hispanic Black, older, not married, lived with others, had lower education, were homeless, had personal transportation, lived in rural areas, and had a higher comorbidity burden. In sensitivity analyses, higher odds were observed for dental, gastrointestinal, genitourinary, musculoskeletal, or respiratory conditions.

CONCLUSIONS

In the free clinic space, several patient demographic, social determinants of health and medical conditions were independently associated with greater odds of reporting intent on visiting the ED. Additional interventions that improve access and use of free clinics (e.g., dental) may keep patients without insurance from the ED.

The incidence rate of planned and emergency physical health hospital admissions in people diagnosed with severe mental illness: a cohort study

BACKGROUND

People with severe mental illness (SMI) have more physical health conditions than the general population, resulting in higher rates of hospitalisations and mortality. In this study, we aimed to determine the rate of emergency and planned physical health hospitalisations in those with SMI, compared to matched comparators, and to investigate how these rates differ by SMI diagnosis.

METHODS

We used Clinical Practice Research DataLink Gold and Aurum databases to identify 20,668 patients in England diagnosed with SMI between January 2000 and March 2016, with linked hospital records in Hospital Episode Statistics. Patients were matched with up to four patients without SMI. Primary outcomes were emergency and planned physical health admissions. Avoidable (ambulatory care sensitive) admissions and emergency admissions for accidents, injuries and substance misuse were secondary outcomes. We performed negative binomial regression, adjusted for clinical and demographic variables, stratified by SMI diagnosis.

RESULTS

Emergency physical health (aIRR:2.33; 95% CI 2.22-2.46) and avoidable (aIRR:2.88; 95% CI 2.60-3.19) admissions were higher in patients with SMI than comparators. Emergency admission rates did not differ by SMI diagnosis. Planned physical health admissions were lower in schizophrenia (aIRR:0.80; 95% CI 0.72-0.90) and higher in bipolar disorder (aIRR:1.33; 95% CI 1.24-1.43). Accident, injury and substance misuse emergency admissions were particularly high in the year after SMI diagnosis (aIRR: 6.18; 95% CI 5.46-6.98).

CONCLUSION

We found twice the incidence of emergency physical health admissions in patients with SMI compared to those without SMI. Avoidable admissions were particularly elevated, suggesting interventions in community settings could reduce hospitalisations. Importantly, we found underutilisation of planned inpatient care in patients with schizophrenia. Interventions are required to ensure appropriate healthcare use, and optimal diagnosis and treatment of physical health conditions in people with SMI, to reduce the mortality gap due to physical illness.

Trustful conversations: a qualitative interview study on older patients' experiences of the intervention Proactive healthcare in a Swedish primary care setting

AIM

To explore older patients' experiences of the intervention Proactive healthcare for frail elderly persons.

BACKGROUND

Previous research has indicated that continuity and good access to primary care can improve satisfaction in older people seeking care. However, little is known about the older patients' experiences in taking part of interventions aiming to enhance the care.

METHODS

Individual interviews were conducted with 24 older patients who participated in the intervention Proactive healthcare for frail elderly persons, selected from nine Swedish primary care centres. Interviews were analysed using qualitative content analysis.

FINDINGS

Older patients' experiences of the intervention involved five manifest categories: Ways of naming the elder care team, covering the older patients' lack of understanding regarding their connection to the team, and the need for clarity on this and on how the specialised care provided differed from conventional care; Availability, indicating how older patients associated easy access and a direct telephone number with a team nurse available at certain times with a sense of security; The importance of relations, covering how patients appreciated continuity in their personal and professional conversations with staff; A feeling of safety and trust, stressing the value of older persons attach to being given enough time, to be listened to and being recognised as people; and Finiteness of life, which refers to the difficulty of having end-of-life conversations and the need for experienced staff with personal knowledge of the patients. The latent theme Trustful conversations was created to give a deeper meaning to the content of the categories.Trustful conversations, created through good personal knowledge of patients and continuity of contact, engender a feeling of safety in older patients. Using elder care teams could result in a better quality of care, with increased satisfaction and feelings of security among patients, and a reduction in healthcare needs.

General practitioners ending their practice and impact on patients' health, healthcare use and mortality: a protocol for national registry cohort studies in Norway, 2008 to 2021

INTRODUCTION

Continuous general practitioner (GP) and patient relations associate with positive health outcomes. Termination of GP practice is unavoidable, while consequences of final breaks in relations are less explored. We will study how an ended GP relation affects patient's healthcare utilisation and mortality compared with patients with a continuous GP relation.

METHODS AND ANALYSIS

We link national registries data on individual GP affiliation, sociodemographic characteristics, healthcare use and mortality. From 2008 to 2021, we identify patients whose GP stopped practicing and will compare acute and elective, primary and specialist healthcare use and mortality, with patients whose GP did not stop practicing. We match GP-patient pairs on age and sex (both), immigrant status and education (patients), and number of patients and practice period (GPs). We analyse the outcomes before and after an ended GP-patient relation, using Poisson regression with high-dimensional fixed effects.

ETHICS AND DISSEMINATION

This study protocol is part of the approved project Improved Decisions with Causal Inference in Health Services Research, 2016/2159/REK Midt (the Regional Committees for Medical and Health Research Ethics) and does not require consent. HUNT Cloud provides secure data storage and computing. We will report using the STROBE guideline for observational case-control studies and publish in peer-reviewed journals, accessible in NTNU Open and present at scientific conferences. To reach a broader audience, we will summarise articles in the project's web page, regular and social media, and disseminate to relevant stakeholders.

The role of contextual factors in decision-making by General Practitioners on paediatric referral to the Emergency Department: A Discrete Choice Experiment

A General Practitioner's (GP) decision to refer a patient to the emergency department (ED) requires consideration of a multitude of factors, and significant variation in GP referral patterns to secondary care has been recorded. This study examines the contextual factors that influence GPs when referring a paediatric patient with potentially self-limiting clinical symptoms to the ED. Utilizing a discrete choice experiment, survey data was collected from GPs in Ireland (n = 142) to elicit factors influencing this decision across five attributes: time/day of visit, repeat presentation, parents' capacity to cope, parent requesting a referral, and access to a paediatric outpatient clinic/day unit. Using mixed logit models, all attributes were statistically significant, with repeat presentation and parents lacking the capacity to cope identified as the strongest contextual factors leading to the decision to refer to the ED. There has been limited exploration of this decision-making process and this study uses a robust design to identify and rank contextual attributes. Enhanced awareness of contextual factors on referral decision-making is crucial to understanding patterns of paediatric unscheduled healthcare and to planning services that respond to parent's and children's needs, whilst allowing GPs to make decisions in the best interest of the child.

Primary health care utilization and hospital readmission in children with asthma: a multi-site linked data cohort study

OBJECTIVES

To (1) describe primary health care utilization and (2) estimate the effect of primary care early follow-up, continuity, regularity, frequency, and long consultations on asthma hospital readmission, including secondary outcomes of emergency (ED) presentations, asthma preventer adherence, and use of rescue oral corticosteroids within 12 months.

METHODS

An Australian multi-site cohort study of 767 children aged 3-18 years admitted with asthma between 2017 and 2018, followed up for at least 12 months with outcome and primary care exposure data obtained through linked administrative datasets. We estimated the effect of primary care utilization through a modified Poisson regression adjusting for child age, asthma severity, socioeconomic status and self-reported GP characteristics.

RESULTS

The median number of general practitioner (GP) consultations, unique GPs and clinics visited was 9, 5, and 4, respectively. GP care was irregular and lacked continuity, only 152 (19.8%) children visited their usual GP on more than 60% of occasions. After adjusting for confounders, there was overall weak indication of effects due to any of the exposures. Increased frequency of GP visits was associated with reduced readmissions (4-14 visits associated with risk ratio of 0.71, 95% CI 0.50-1.00, p = 0.05) and ED presentations (>14 visits associated risk ratio 0.62, 95% CI 0.42-0.91, p = 0.02).

CONCLUSIONS

Our study demonstrates that primary care use by children with asthma is often irregular and lacking in continuity. This highlights the importance of improving accessibility, consistency in care, and streamlining discharge communication from acute health services.

The Influence of Provider Connectedness on Continuity of Care and Hospital Readmissions in Patients With COPD: A Claims Data Based Social Network Study

Background

Hospital readmission rates are very high in patients with chronic obstructive pulmonary disease (COPD). Continuity of care (CoC) with general practitioners (GPs) and ambulatory specialists can impact readmission rates. This study aimed to identify shared patient networks of ambulatory care physicians and to examine the effect of provider connectedness on CoC and hospital readmissions.

Methods

A retrospective observational study was conducted in claims data from the years 2016 to 2018 in patients with COPD (aged 40 years or older; hospital stay in 2017). Linkages between GPs, pneumologists, and cardiologists were determined on the basis of shared patients. Multilevel regression models were used to analyze the impact of provider connectedness, operationalized by several social network characteristics, on continuity of care (sequential continuity [SECON] index) and hospital readmission rates.

Results

A total of 7294 patients linked to 3673 GPs were available for analysis. Closeness centrality (β=- 0.029) and the external-internal (EI)-index (β =0.037) impacted on the SECON index. The EI-index (odds ratio [OR]=1.25) and degree centrality (OR=1.257) impacted 30-day readmission. Network density (OR=0.811) and the SECON index (OR=1.121) affected the likelihood of a 90-day readmission. None of the predictors had a significant impact on 180-day and 365-day readmissions.

Conclusions

Ambulatory care providers' connectedness showed some effects on hospital readmissions and CoC in patients with COPD up to 90 days after hospital discharge, but the additional predictive power is limited.

Association between coeliac disease and cardiovascular disease: prospective analysis of UK Biobank data

Objectives

To investigate whether people with coeliac disease are at increased risk of cardiovascular disease, including ischaemic heart disease, myocardial infarction, and stroke.

Design

Prospective analysis of a large cohort study.

Setting

UK Biobank database.

Participants

469 095 adults, of which 2083 had coeliac disease, aged 40-69 years from England, Scotland, and Wales between 2006 and 2010 without cardiovascular disease at baseline.

Main outcome measure

A composite primary outcome was relative risk of cardiovascular disease, ischaemic heart disease, myocardial infarction, and stroke in people with coeliac disease compared with people who do not have coeliac disease, assessed using Cox proportional hazard models.

Results

40 687 incident cardiovascular disease events occurred over a median follow-up of 12.4 years (interquartile range 11.5-13.1), with 218 events among people with coeliac disease. Participants with coeliac disease were more likely to have a lower body mass index and systolic blood pressure, less likely to smoke, and more likely to have an ideal cardiovascular risk score than people who do not have coeliac disease. Despite this, participants with coeliac disease had an incidence rate of 9.0 cardiovascular disease cases per 1000 person years (95% confidence interval 7.9 to 10.3) compared with 7.4 per 1000 person years (7.3 to 7.4) in people with no coeliac disease. Coeliac disease was associated with an increased risk of cardiovascular disease (hazard ratio 1.27 (95% confidence interval 1.11 to 1.45)), which was not influenced by adjusting for lifestyle factors (1.27 (1.11 to 1.45)), but was strengthened by further adjusting for other cardiovascular risk factors (1.44 (1.26 to 1.65)). Similar associations were identified for ischaemic heart disease and myocardial infarction but fewer stroke events were reported and no evidence of an association between coeliac disease and risk of stroke.

Conclusions

Individuals with coeliac disease had a lower prevalence of traditional cardiovascular risk factors but had a higher risk of developing cardiovascular disease than did people with no coeliac disease. Cardiovascular risk scores used in clinical practice might therefore not adequately capture the excess risk of cardiovascular disease in people with coeliac disease, and clinicians should be aware of the need to optimise cardiovascular health in this population.

Exploring gaps and opportunities in primary care following an asthma hospital admission: a multisite mixed-methods study of three data sources

OBJECTIVE

Explore gaps and opportunities in primary care for children following a hospital admission for asthma.

DESIGN

Exploratory mixed-methods, using linked hospital and primary care administration data.

SETTING

Eligible children, aged 3-18 years, admitted to one of three hospitals in Victoria, Australia between 2017 and 2018 with a clinical diagnosis of asthma.

RESULTS

767 caregivers of eligible children participated, 39 caregivers completed a semistructured interview and 277 general practitioners (GPs) caring for 360 children completed a survey. Over 90% (n=706) of caregivers reported their child had a regular GP. However, few (14.1%, n=108) attended a GP in the 24 hours prior to index admission or in the 7 days after (35.8%, n=275). Children readmitted for asthma (34.2%, n=263), compared with those not readmitted (65.8%, n=504), were less likely to have visited a GP in the non-acute phase of their asthma in the 12 months after index admission (22.1% vs 42.1%, respectively), and their GP was more likely to report not knowing the child had an asthma admission (52.8% vs 39.2%, respectively). Fewer GPs reported being extremely confident managing children with poorly controlled asthma (11.9%, n=43) or post-discharge (16.7%, n=60), compared with children with well-controlled asthma (36.4%, n=131), with no difference by child readmission status.

CONCLUSIONS

Given the exploratory design and descriptive approach, it is unknown if the differences by child readmission status have any causal relationship with readmission. Nonetheless, improving preventative patterns of primary care visits, timely communication between hospitals and primary care providers, and guideline concordant care by GPs are needed.

Hospitalizations for Ambulatory Care Sensitive Conditions in a Large City of Japan: a Descriptive Analysis Using Claims Data

BACKGROUND

Hospitalization for ambulatory care sensitive conditions (ACSCs) is an indicator of the quality of primary care in different health systems. In Japan, where patients can choose any healthcare facility with universal health coverage (UHC), data on these admissions are unknown.

OBJECTIVE

To describe the current situation of ACSC admissions in a city of Japan.

DESIGN

Retrospective observational study using claims data.

PARTICIPANTS

Beneficiaries aged 0-74 years of the National Health Insurance (NHI) program in a large city in the Greater Tokyo Area. We extracted ACSC admissions from all inpatient claims between April 2013 and March 2017.

MAIN MEASURES

We calculated age- and sex-specific annual ACSC admission rates for three categories: acute, chronic, and vaccine-preventable. We estimated the age-adjusted admission rates by ACSC category according to administrative districts and rate ratios using Poisson regression models. We also estimated medical expenditures and lengths of stay for ACSC admissions.

KEY RESULTS

Of 91,350 hospitalization episodes, we identified 7666 (8.4%) that were ACSC admissions. Males had higher annual ACSC admission rates than females (p < 0.001), especially for chronic ACSCs. Admission rates were lowest in those aged 15-39 years and higher in the youngest (0-4 years) and oldest (70-74 years) age groups. Age-adjusted chronic ACSC admission rates were lower in a newly developed area (rate ratio [RR]: 0.79, 95% confidence interval [CI]: 0.71-0.87) and higher in a residential area (RR: 1.14, 95% CI: 1.04-1.24) than in the center of the city. Total medical expenditures for all ACSC admissions accounted for 5.8% of the total inpatient expenditures of NHI in the city.

CONCLUSIONS

ACSC admission rates in Japan were higher for males than for females and showed a U-shaped trend in terms of age, as in other countries with UHC, and deferred by region. This study provided possible factors to reduce ACSC admissions.

Prediction models for the prediction of unplanned hospital admissions in community-dwelling older adults: A systematic review

Background

Identification of community-dwelling older adults at risk of unplanned hospitalizations is of importance to facilitate preventive interventions. Our objective was to review and appraise the methodological quality and predictive performance of prediction models for predicting unplanned hospitalizations in community-dwelling older adults

Methods and findings

We searched MEDLINE, EMBASE and CINAHL from August 2013 to January 2021. Additionally, we checked references of the identified articles for the inclusion of relevant publications and added studies from two previous reviews that fulfilled the eligibility criteria. We included prospective and retrospective studies with any follow-up period that recruited adults aged 65 and over and developed a prediction model predicting unplanned hospitalizations. We included models with at least one (internal or external) validation cohort. The models had to be intended to be used in a primary care setting. Two authors independently assessed studies for inclusion and undertook data extraction following recommendations of the CHARMS checklist, while quality assessment was performed using the PROBAST tool. A total of 19 studies met the inclusion criteria. Prediction horizon ranged from 4.5 months to 4 years. Most frequently included variables were specific medical diagnoses (n = 11), previous hospital admission (n = 11), age (n = 11), and sex or gender (n = 8). Predictive performance in terms of area under the curve ranged from 0.61 to 0.78. Models developed to predict potentially preventable hospitalizations tended to have better predictive performance than models predicting hospitalizations in general. Overall, risk of bias was high, predominantly in the analysis domain.

Conclusions

Models developed to predict preventable hospitalizations tended to have better predictive performance than models to predict all-cause hospitalizations. There is however substantial room for improvement on the reporting and analysis of studies. We recommend better adherence to the TRIPOD guidelines.

Variation in general practice referral rate to acute medicine services and association with hospital admission. A retrospective observational study

BACKGROUND

Variation in general practice (GP) referral rates to outpatient services is well described however variance in rates of referral to acute medical units is lacking.

OBJECTIVE

To investigate variance in GP referral rate for acute medical assessment and subsequent need for hospital admission.

METHODS

A retrospective cohort study of acute medical referrals from 88 GPs in Lothian, Scotland between 2017 and 2020 was performed using practice population size, age, deprivation, care home residence, and distance from hospital as explanatory variables. Patient-level analysis of demography, deprivation, comorbidity, and acuity markers was subsequently performed on referred and clinically assessed acute medical patients (n = 42,424) to examine how practice referral behaviour reflects clinical need for inpatient hospital care.

RESULTS

Variance in GP referral rates for acute medical assessment was high (2.53-fold variation 1st vs. 4th quartile) and incompletely explained by increasing age and deprivation (adjusted R2 0.67, P < 0.001) such that significant variance remained after correction for confounders (2.15-fold). Patients from the highest referring quartile were significantly less likely to require hospital admission than those from the third, second, or lowest referring quartiles (adjusted odds ratio 1.28 [1.21-1.36, P < 0.001]; 1.30 [1.23-1.37, P < 0.001]; 1.53 [1.42-1.65, P < 0.001]).

CONCLUSIONS

High variation in GP practice referral rate for acute medical assessment is incompletely explained by practice population socioeconomic factors and negatively associates with need for urgent inpatient care. Identifying modifiable factors influencing referral rate may provide opportunities to facilitate community-based care and reduce congestion on acute unscheduled care pathways.

Expansion of primary healthcare and emergency hospital admissions among the urban poor in Rio de Janeiro Brazil: A cohort analysis

Background

Robust evidence on the relationship between primary care and emergency admissions is lacking in low- and middle-income countries. This study evaluates how the phased roll out of the family health strategy (FHS) to the urban poor in Rio de Janeiro Brazil affected emergency hospital admissions and readmissions from ambulatory-care sensitives conditions (ACSCs).

Methods

A cohort of 1.2 million adults in Rio de Janeiro city were followed for five years (Jan 2012 to Dec 2016). The association between FHS use and the likelihood of emergency hospital admissions and 30-day readmissions were evaluated using multi-level Poisson regression models with inverse probability treatment weighting and regression adjustment (IPTW-RA) for socioeconomic and household characteristics. Inequalities in associations were examined across groups of causes and by key socioeconomic groups.

Results

Records from 2,551,934 primary care consultations and 15,627 admissions were analysed. In IPTW-RA analyses, each additional FHS consultation was associated with a 3% lower rate of ACSC admission (RR: 0.97; 95%CI: 0.95, 0.98), a 63% lower rate of 30-day readmissions from any non-birth cause (RR: 0.37; 95%CI: 0.30, 0.46), and an 57% lower rate of 30-day readmissions from ACSCs (RR: 0.43; 95%CI: 0.33, 0.55). Individuals who were older, had the lowest educational attainment, were unemployed, and had higher incomes had larger reductions in ACSC admissions associated with FHS use.

Interpretation

Investment in primary care is important for reducing emergency hospital admissions and their associated costs in LMICs.

Funding

DFID/MRC/Wellcome Trust/ESRC.

The impact of comorbid severe mental illness and common chronic physical health conditions on hospitalisation: A systematic review and meta-analysis

Background

People with severe mental illness (SMI) are at higher risk of physical health conditions compared to the general population, however, the impact of specific underlying health conditions on the use of secondary care by people with SMI is unknown. We investigated hospital use in people managed in the community with SMI and five common physical long-term conditions: cardiovascular diseases, COPD, cancers, diabetes and liver disease.

Methods

We performed a systematic review and meta-analysis (Prospero: CRD42020176251) using terms for SMI, physical health conditions and hospitalisation. We included observational studies in adults under the age of 75 with a diagnosis of SMI who were managed in the community and had one of the physical conditions of interest. The primary outcomes were hospital use for all causes, physical health causes and related to the physical condition under study. We performed random-effects meta-analyses, stratified by physical condition.

Results

We identified 5,129 studies, of which 50 were included: focusing on diabetes (n = 21), cardiovascular disease (n = 19), COPD (n = 4), cancer (n = 3), liver disease (n = 1), and multiple physical health conditions (n = 2). The pooled odds ratio (pOR) of any hospital use in patients with diabetes and SMI was 1.28 (95%CI:1.15–1.44) compared to patients with diabetes alone and pooled hazard ratio was 1.19 (95%CI:1.08–1.31). The risk of 30-day readmissions was raised in patients with SMI and diabetes (pOR: 1.18, 95%CI:1.08–1.29), SMI and cardiovascular disease (pOR: 1.27, 95%CI:1.06–1.53) and SMI and COPD (pOR:1.18, 95%CI: 1.14–1.22) compared to patients with those conditions but no SMI.

Conclusion

People with SMI and five physical conditions are at higher risk of hospitalisation compared to people with that physical condition alone. Further research is warranted into the combined effects of SMI and physical conditions on longer-term hospital use to better target interventions aimed at reducing inappropriate hospital use and improving disease management and outcomes.

Fragmentation of ambulatory care among older adults: an exhaustive database study in an ageing city in Japan

OBJECTIVES

Continuity of care is a core dimension of primary care, and better continuity is associated with better patient outcomes. Therefore, care fragmentation can be an indicator to assess the quality of primary care, especially in countries without formal gatekeeping system, such as Japan. Thus, this study aimed to describe care fragmentation among older adults in an ageing city in Japan.

DESIGN

Cross-sectional study.

SETTING

The most populated basic municipality in Japan.

PARTICIPANTS

Older adults aged 75 years and older.

INTERVENTIONS

This study used a health claims database, including older adults who visited medical facilities at least four times a year in an urban city in Japan. The Fragmentation of Care Index (FCI) was used as an indicator of fragmentation. The FCI was developed from the Continuity of Care Index and is based on the total number of visits, different institutions visited and proportion of visits to each institution. We employed Tobit regression analysis to examine the association between the FCI and age, sex, type of insurance and most frequently visited facility.

RESULTS

The total number of participants was 413 600. The median age of the study population was 81 years, and 41.6% were men. The study population visited an average of 3.42 clinics/hospitals, and the maximum number of visited institutions was 20. The proportion of patients with FCI >0 was 85.0%, with a mean of 0.583. Multivariable analysis showed that patients receiving public assistance had a lower FCI compared with patients not receiving public assistance, with a coefficient of 0.137.

CONCLUSIONS

To our knowledge, this is the first study to demonstrate care fragmentation in Japan. Over 80% of the participants visited two or more medical facilities, and their mean FCI was 0.583. The FCI could be a basic indicator for assessing the quality of primary care.

Coordination of Oral Anticoagulant Care at Hospital Discharge (COACHeD): protocol for a pilot randomised controlled trial

Background

Oral anticoagulants (OACs) are commonly prescribed, have well-documented benefits for important clinical outcomes but have serious harms as well. Rates of OAC-related adverse events including thromboembolic and hemorrhagic events are especially high shortly after hospital discharge. Expert OAC management involving virtual care is a research priority given its potential to reach remote communities in a more feasible, timely, and less costly way than in-person care. Our objective is to test whether a focused, expert medication management intervention using a mix of in-person consultation and virtual care follow-up, is feasible and effective in preventing anticoagulation-related adverse events, for patients transitioning from hospital to home.

Methods and analysis

A randomized, parallel, multicenter design enrolling consenting adult patients or the caregivers of cognitively impaired patients about to be discharged from medical wards with a discharge prescription for an OAC. The interdisciplinary multimodal intervention is led by a clinical pharmacologist and includes a detailed discharge medication reconciliation and management plan focused on oral anticoagulants at hospital discharge; a circle of care handover and coordination with patient, hospital team and community providers; and early post-discharge follow-up virtual medication check-up visits at 24 h, 1 week, and 1 month. The control group will receive usual care plus encouragement to use the Thrombosis Canada website.

The primary feasibility outcomes include recruitment rate, participant retention rates, trial resources management, and the secondary clinical outcomes include adverse anticoagulant safety events composite (AASE), coordination and continuity of care, medication-related problems, quality of life, and healthcare resource utilization. Follow-up is 3 months.

Discussion

This pilot RCT tests whether there is sufficient feasibility and merit in coordinating oral anticoagulant care early post-hospital discharge to warrant a full sized RCT.

Trial registration

NCT02777047.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40814-022-01130-z.

Effects of GP characteristics on unplanned hospital admissions and patient safety. A 9-year follow-up of all Norwegian out-of-hours contacts

BACKGROUND

There are substantial differences in hospital referrals between general practitioners (GPs); however, there is little research on the consequences for patient safety and further healthcare use.

OBJECTIVE

To investigate associations between out-of-hours GP characteristics, unplanned hospital admissions, and patient safety.

METHODS

This cohort study included all Norwegian out-of-hours services contacts from 2008 to 2016, linked to registry data on patient characteristics, healthcare use and death, and GP age, sex, specialist status, out-of-hours service experience, and prior admission proportion. We estimated the impact from GP characteristics on (i) immediate unplanned hospital admissions for "all conditions," (ii) immediate unplanned hospital admissions for "critical conditions," (iii) 30-day unplanned hospital admissions, (iv) 30-day hospital costs, and (v) 30-day risk of death. To limit confounding, we matched patients in groups by age, time, and location, with an assumption of random assignment of GPs to patients with this design.

RESULTS

Patients under the care of older and male GPs had fewer immediate unplanned hospital admissions, but the effects on cumulative 30-day unplanned hospital admissions and costs were small. The GPs' prior admission proportion was strongly associated with both immediate and 30-day unplanned hospital admissions. Higher prior admission proportion was also associated with admitting more patients with critical conditions. There was little evidence of any associations between GP characteristics and 30-day risk of death.

CONCLUSIONS

GPs' prior admission proportion was strongly associated with unplanned hospital admissions. We found little effects on 30-day mortality, but more restrictive referral practices may threaten patient safety through missing out on critical cases.

A general practice intervention for people at risk of poor health outcomes: the Flinders QUEST cluster randomised controlled trial and economic evaluation

Objective

To determine whether a multicomponent general practice intervention cost‐effectively improves health outcomes and reduces health service use for patients at high risk of poor health outcomes.

Design, setting

Clustered randomised controlled trial in general practices in metropolitan Adelaide.

Participants

Three age‐based groups of patients identified by their general practitioners as being at high risk of poor health outcomes: children and young people (under 18 years), adults (18–64 years) with two or more chronic diseases, and older people (65 years or more).

Intervention

Enrolment of patients with a preferred GP, longer general practice appointments, and general practice follow‐up within seven days of emergency department and hospital care episodes. Intervention practices received payment of $1000 per enrolled participant.

Main outcome measures

Primary outcome: change in self‐rated health between baseline and 12‐month follow‐up for control (usual care) and intervention groups. Secondary outcomes: numbers of emergency department presentations and hospital admissions, Medicare specialist claims and Pharmaceutical Benefits Scheme (PBS) items supplied, Health Literacy Questionnaire scores, and cost‐effectiveness of the intervention (based on the number of quality‐adjusted life‐years [QALYs] gained over 12 months, derived from EQ‐5D‐5L utility scores for the two adult groups).

Results

Twenty practices with a total of 92 GPs were recruited, and 1044 eligible patients participated. The intervention did not improve self‐rated health (coefficient, –0.29; 95% CI, –2.32 to 1.73), nor did it have significant effects on the numbers of emergency department presentations (incidence rate ratio [IRR], 0.90; 95% CI, 0.69–1.17), hospital admissions (IRR, 0.90; 95% CI, 0.66–1.22), Medicare specialist claims (IRR, 1.00; 95% CI, 0.91–1.09), or PBS items supplied (IRR, 0.99; 95% CI, 0.96–1.03), nor on Health Literacy Questionnaire scores. The intervention was effective in terms of QALYs gained (v usual care: difference, 0.032 QALYs; 95% CI, 0.001–0.063), but the incremental cost‐effectiveness ratio was $69 585 (95% CI, $22 968–$116 201) per QALY gained, beyond the willingness‐to‐pay threshold.

Conclusions

Our multicomponent intervention did not improve self‐rated health, health service use, or health literacy. It achieved greater improvement in quality of life than usual care, but not cost‐effectively.

Trial registration

Australian New Zealand Clinical Trials Registry, ACTRN12617001589370 (prospective).

Age-varying effects of repeated emergency department presentations for children in Canada

Objectives

Repeated presentations to emergency departments (EDs) may indicate a lack of access to other health care resources. Age is an important predictor of frequent ED use; however, age-varying effects are not generally investigated. This study examines the age-specific effects of predictors on ED presentation frequency for children in Alberta and Ontario, Canada.

Methods

This retrospective study used population-based data during April 2010 to March 2017. Data were extracted from the National Ambulatory Care Reporting System for children aged <18 who were members of the top 10% of ED users in any one of the fiscal years 2011/2012 to 2015/2016 along with a comparison sample from the bottom 90%. A marginal regression model studied the age-varying associations on the frequency of ED presentations with province, sex, access to primary health care provider (for Ontario only), area of residence and lowest neighbourhood income quintile.

Results

There were 2,481,172 patients who made 9,229,156 ED presentations. The effects of sex, lowest income quintile, rural residence, access to primary health care provider and province on the frequency of presentations varied by age. Notably, boys go from having more frequent presentations than girls when aged ≤5 (i.e. adjusted intensity ratio [IR]=1.04 at age 5, 95% confidence interval [CI] = 1.03,1.06) to less frequent for ages 8–11 years and beyond 14 (i.e. IR = 0.80 at age 15, 95% CI = 0.78,0.81). Adolescents aged ≥15 without access to a primary care provider had more frequent presentations compared to those with a primary care provider.

Conclusions

When examining the frequency of ED presentations in children, age-varying effects of predictors should be considered. Our more nuanced examination of age provides insights into how health services might better target programmes for different ages to potentially reduce unnecessary ED use by providing other health care alternatives.

How do clinical quality and patient satisfaction vary with provider size in primary care? Evidence from English general practice panel data

We examine the relationship between general practice list size and measures of clinical quality and patient satisfaction. Using data on all English practices from 2005/6 to 2016/17, we estimate practice level models with rich data on patient demographics, deprivation, and morbidity. We use lagged list size to allow for potential simultaneity bias from the effect of quality on list size. We compare results from three different estimation methods: pooled ordinary least squares, random practice effects, fixed practice effects. With all three estimation methods increased list size is associated with reductions in all four measures of patient satisfaction. Increases in list size are associated with worse performance on three clinical quality indicators and better performance on three, though the precision and size of the associations varies with the estimation method. The absolute values of the elasticities of the ten quality indicators with respect to list size are small: in all cases a 10% change in list size would change quality by less than 1%. The lack of evidence that large practices have markedly better quality suggests that encouraging practices to form larger, but looser, groupings, may not, in itself, improve their performance.

Impact of a case-management intervention for reducing emergency attendance on primary care: randomised control trial

BACKGROUND

The impact on primary care workload of case-management interventions to reduce emergency department (ED) attendances is unknown.

AIM

To examine the impact of a telephone-based case-management intervention targeting people with high ED attendance on primary care use.

DESIGN AND SETTING

A single-site data extract from a larger randomised control trial, using the patient-level data from primary care electronic health records (2015-2020), was undertaken.

METHOD

A total of 363 patients at high risk of ED usage were randomised to receive a 6-month case-management intervention (253 patients) or standard care (110 patients). Poisson regression models were used to calculate monthly rates of primary care use over time for the 2 years post-randomisation, comparing both arms. Usage was subclassified into face-to-face, telephone, letter, and community and secondary care referrals, stratified by patient demographics.

RESULTS

No significant difference was found in the mean annual rate of primary care events between the intervention and control arms (P = 0.70). Secondary care referrals saw a 26% reduction in the mean annual referral rate (incident rate ratio [IRR] 0.74, 95% confidence interval [CI] = 0.64 to 0.86, P<0.001) and letters sent increased by 6% in the intervention arm compared with the control arm (IRR 1.06, 95% CI = 1.01 to 1.11, P = 0.01). In the case-managed arm, in patients aged ≥80 years there was a 33% increase in primary care usage (IRR 1.33, 95% CI = 1.28 to 1.40, P<0.001); with a corresponding 10% decrease in patients aged <80 years when compared with controls (IRR 0.90, 95% CI = 0.87 to 0.92, P<0.001).

CONCLUSION

A targeted case-management intervention to reduce ED attendances did not increase overall primary care use. Redistribution of usage is seen among some patient groups, particularly older people, which may have important implications for primary healthcare planning.

Associations of primary care workforce composition with population, professional and system outcomes: retrospective cross-sectional analysis

Background: Diversification of types of staff delivering primary care may affect professional, population and system outcomes. Aim: To estimate associations between workforce composition and outcomes. Design and Setting: Cross-sectional analysis of 6210 GP practices in England in 2019. Method: Multivariable regression analysis relating numbers of staff in four groups (GPs; Nurses; Health Professionals; and Health Associate Professionals) to patient access and satisfaction, quality of clinical care and prescribing, use of hospital services, GP working conditions, and costs to National Health Service. Results: More GPs were associated with higher satisfaction for patients and GPs, More workers of other types had opposite associations with these outcomes. More Nurses and Health Associate Professionals were associated with lower cost per prescription but more prescribing activity. More GPs were associated with higher costs per prescription and lower use of narrow-spectrum antibiotics. Except for Health Associate Professionals, more staff were associated with more hospital activity. Higher NHS costs were associated most with more Nurses and least with more Health Professionals. The effects of different staff types on outcomes were largely independent. Conclusion: Professional, population and system outcomes show a variety of associations with primary care workforce composition. More Nurses are associated with lower quality in some aspects and higher costs and activity. More Health Professionals and Health Associate Professionals associates less than additional GPs with higher costs, but is associated with lower patient and GP satisfaction.

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.

Accessing primary care and the importance of 'human fit': a qualitative participatory case study

BACKGROUND

Good access to primary care is an important determinant of population health. While the academic literature on access to care emphasises its complexity, policies aimed at improving access to general practice in the UK have tended to focus on measurable aspects, such as timeliness or number of appointments.

AIM

To fill the gap between the complex understanding of primary care access in the literature and the narrow definition of access assumed in UK policies.

DESIGN AND SETTING

Qualitative, community-based participatory case study within the geographic footprint of a clinical commissioning group in the north west of England. Data collection took place from October 2015 to October 2016. Purposive sampling and snowball approaches were used to achieve maximum variation among service users and providers across general practice settings.

METHOD

Levesque et al's conceptual framework of patient-centred access was applied and the study used multiple qualitative methods (interviews, focus groups, and observation). Analysis was ongoing, iterative, inductive, and abductive with the theory.

RESULTS

The comprehensiveness of Levesque et al's access theory resonated with diverse participant experiences. However, while its strength was to highlight the importance of people's abilities to access care, this study's data suggest equal importance of healthcare workforce abilities to make care accessible. Thus, the authors present a definition of access as the 'human fit' between the needs and abilities of people in the population and the abilities and capacity of people in the healthcare workforce, and provide a modified conceptual framework reflecting these insights.

CONCLUSION

An understanding of access as 'human fit' has the potential to address longstanding problems of access within general practice, focusing attention on the need for staff training and support, and emphasising the importance of continuity of care.

Raising ethnicity recording in NHS Lothian from 3% to 90% in 3 years: processes and analysis of data from Accidents and Emergencies

Background

The disproportionate burden of COVID-19 on ethnic minority populations has recently highlighted the necessity of maintaining accessible, routinely collected, ethnicity data within healthcare services. Despite 25 years of supportive legislation and policy in the UK, ethnicity data recording remains inconsistent, which has hindered needs assessment, evaluation and decision-making. We describe efforts to improve the completeness, quality and usage of ethnicity data within our regional health board, NHS Lothian.

Methods

The Ethnicity Coding Task Force was established with the aim of increasing ethnicity recording within NHS Lothian secondary care services from 3 to 90% over 3 years. We subsequently analysed these data specifically focusing on Accident and Emergency (A&E) use by ethnic group.

Results

We achieved 91%, 85% and 93% completeness of recording across inpatients, outpatients and A&E, respectively. Analysis of A&E data found a mixed pattern of attendance amongst ethnic minority populations and did not support the commonly perceived relationship between lower GP registration and higher A&E use within this population.

Conclusions

We identified a successful approach to increase ethnicity recording within a regional health board, which could potentially be useful in other settings, and demonstrated the utility of these data in informing assessment of healthcare delivery and future planning.

Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities

Policy Points The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. While there is a large amount of literature on the economic aspects of delivering primary care services, there is a need for more comprehensive overviews of this evidence. In this article, we offer such an overview. Evidence suggests that there are several strategies involving coverage, financing, service delivery, and governance arrangements which can, if implemented, have positive economic impacts on the delivery of primary care services. These include arrangements such as worker task-shifting and telemedicine. The implementation of any such arrangements, based on positive economic evidence, should carefully account for potential impacts on overall health care access and quality. There are many opportunities for further research, with notable gaps in evidence on the impacts of increasing primary care funding or the overall supply of primary care services.

CONTEXT

The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. To strengthen primary health care, policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits.

METHODS

We collated and synthesized published systematic reviews of evidence on the economic aspects of different models of delivering primary care services. Building on previous efforts, we adapted existing taxonomies of primary care components to classify our results according to four categories: coverage, financing, service delivery, and governance.

FINDINGS

We identified and classified 109 reviews that met our inclusion criteria according to our taxonomy of primary care components: coverage, financing, service delivery, and governance arrangements. A significant body of evidence suggests that several specific primary care arrangements, such as health workers' task shifting and telemedicine, can have positive economic impacts (such as lower overall health care costs). Notably absent were reviews on the impact of increasing primary care funding or the overall supply of primary care services.

CONCLUSIONS

There is a great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services. Despite progress over the last decade, significant evidence gaps on the economic implications of different models of primary care services remain, which could help inform the basis of future research efforts.

Predicting unplanned hospital visits in older home care recipients: a cross-country external validation study

Background

Accurate identification of older persons at risk of unplanned hospital visits can facilitate preventive interventions. Several risk scores have been developed to identify older adults at risk of unplanned hospital visits. It is unclear whether risk scores developed in one country, perform as well in another. This study validates seven risk scores to predict unplanned hospital admissions and emergency department (ED) visits in older home care recipients from six countries.

Methods

We used the IBenC sample (n = 2446), a cohort of older home care recipients from six countries (Belgium, Finland, Germany, Iceland, Italy and The Netherlands) to validate four specific risk scores (DIVERT, CARS, EARLI and previous acute admissions) and three frailty indicators (CHESS, Fried Frailty Criteria and Frailty Index). Outcome measures were unplanned hospital admissions, ED visits or any unplanned hospital visits after 6 months. Missing data were handled by multiple imputation. Performance was determined by assessing calibration and discrimination (area under receiver operating characteristic curve (AUC)).

Results

Risk score performance varied across countries. In Iceland, for any unplanned hospital visits DIVERT and CARS reached a fair predictive value (AUC 0.74 [0.68–0.80] and AUC 0.74 [0.67–0.80]), respectively). In Finland, DIVERT had fair performance predicting ED visits (AUC 0.72 [0.67–0.77]) and any unplanned hospital visits (AUC 0.73 [0.67–0.77]). In other countries, AUCs did not exceed 0.70.

Conclusions

Geographical validation of risk scores predicting unplanned hospital visits in home care recipients showed substantial variations of poor to fair performance across countries. Unplanned hospital visits seem considerably dependent on healthcare context. Therefore, risk scores should be validated regionally before applied to practice. Future studies should focus on identification of more discriminative predictors in order to develop more accurate risk scores.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02521-2.

Implementing a person centred collaborative health care model - A qualitative study on patient experiences

BACKGROUND

Collaborative Health Care (CHC) is a unique model in which ambulance services, home health care, hospital care and the national telephone helpline for healthcare in Sweden - Swedish health care direct (SHD1177) collaborate to provide the fastest possible health care for inhabitants living in eleven municipalities in western region of Sweden.

AIM

To explore how patients experience and perceive health care received in the CHC.

METHOD

Qualitative descriptive study using open-ended individual telephone interviews with fifteen community dwelling persons with experiences of care throughthe model CHC were conducted.

RESULTS

Two main categories and six subcategories were identified. The category "Thoughts of time in regard to acute health care" include "CHC leads to shorter waiting time for health care", "Knowledge about the staff working hours" and "To alert or not alert". The category "Thoughts on unplanned health care from CHC" involved "Receiving health care in my home", "Coordination from SHD1177 surprises" and "Accessibility of health care values higher than continuity".

CONCLUSION

Integrated health care models such as CHC are time saving and highly appreciated by community dwelling persons. The benefits of provision of coherent health care like in CHC, addresses the need to implement innovative integrated healthcare models in today's health care.

The analysis of the geographical distribution of emergency departments' frequent users: a tool to prioritize public health policies?

Background

The individual factors associated to Frequent Users (FUs) in Emergency Departments are well known. However, the characteristics of their geographical distribution and how territorial specificities are associated and intertwined with ED use are limited. Investigating healthcare use and territorial factors would help targeting local health policies. We aim at describing the geographical distribution of ED’s FUs within the Paris region.

Methods

We performed a retrospective analysis of all ED visits in the Paris region in 2015. Data were collected from the universal health insurance’s claims database. Frequent Users (FUs) were defined as having visited ≥3 times any ED of the region over the period. We assessed the FUs rate in each geographical unit (GU) and assessed correlations between FUs rate and socio-demographics and economic characteristics of GUs. We also performed a multidimensional analysis and a principal component analysis to identify a typology of territories to describe and target the FUs phenomenon.

Results

FUs accounted for 278,687 (11.7%) of the 2,382,802 patients who visited the ED, living in 232 GUs. In the region, median FUs rate in each GU was 11.0% [interquartile range: 9.5–12.5]. High FUs rate was correlated to the territorial markers of social deprivation. Three different categories of GU were identified with different profiles of healthcare providers densities.

Conclusion

FUs rate varies between territories and is correlated to territorial markers of social deprivation. Targeted public policies should focus on disadvantaged territories.

Avoidable Hospitalizations in Persons with Dementia: a Population-Wide Descriptive Study (2000-2015)

Background

Whether avoidable hospitalizations in community-dwelling persons with dementia have decreased during primary care reforms is unknown.

Methods

We described the prevalence and trends in avoidable hospitalizations in population-based repeated yearly cohorts of 192,144 community-dwelling persons with incident dementia (Quebec, 2000-2015) in the context of a province-wide primary care reform, using the provincial health administrative database.

Results

Trends in both types of Ambulatory Care Sensitive Condition (ACSC) hospitalization (general and older population) and 30-day readmission rates remained constant with average rates per 100 person-years: 20.5 (19.9-21.1), 31.7 (31.0-32.4), 20.6 (20.1-21.2), respectively. Rates of delayed hospital discharge (i.e., alternate level of care (ALC) hospitalizations) decreased from 23.8 (21.1-26.9) to 17.9 (16.1-20.1) (relative change -24.6%).

Conclusions

These figures shed light on the importance of the phenomenon, its lack of improvement for most outcomes over the years, and the need to develop evidence-based policies to prevent avoidable hospitalizations in this vulnerable population.

Progression to unscheduled hospital admissions in people with diabetes: a qualitative interview study

BACKGROUND

People with diabetes often have difficulty maintaining optimal blood glucose levels, risking progressive complications that can lead to unscheduled care. Unscheduled care can include attending emergency departments, ambulance callouts, out-of-hours care, and non-elective hospital admissions. A large proportion of non-elective hospital admissions involve people with diabetes, with significant health and economic burden.

AIM

To identify precipitating factors influencing diabetes-related unscheduled hospital admissions, exploring potential preventive strategies to reduce admissions.

DESIGN & SETTING

Thirty-six people with type 1 (n = 11) or type 2 (n = 25) diabetes were interviewed. They were admitted to hospital for unscheduled diabetes-related care across three hospitals in Scotland, Northern Ireland, and the Republic of Ireland. Participants were admitted for peripheral limb complications (n = 17), hypoglycaemia (n = 5), hyperglycaemia (n = 6), or for comorbidities presenting with erratic blood glucose levels (n = 8).

METHOD

Factors precipitating admissions were examined using framework analysis.

RESULTS

Three aspects of care influenced unscheduled admissions: perceived inadequate knowledge of diabetes complications; restricted provision of care; and complexities in engagement with self-care and help-seeking. Limited specialist professional knowledge of diabetes by staff in primary and community care, alongside inadequate patient self-management knowledge, led to inappropriate treatment and significant delays. This was compounded by restricted provision of care, characterised by poor access to services - in time and proximity - and poor continuity of care. Complexities in patient engagement, help-seeking, and illness beliefs further complicated the progression to unscheduled admissions.

CONCLUSION

Dedicated investment in primary care is needed to enhance provision of and access to services. There should be increased promotion and earlier diabetes specialist team involvement, alongside training and use of technology and telemedicine, to enhance existing care.

Stuff you think you can handle as a parent and stuff you can't'. Understanding parental health-seeking behaviour when accessing unscheduled care: A qualitative study

Background

Unscheduled health care constitutes a significant proportion of health‐care utilization. Parental decision making when accessing unscheduled care for their children is multifaceted and must be better understood to inform policy and practice.

Design

Nineteen semi‐structured interviews and one focus group (n = 4) with parents of children younger than twelve in Ireland were conducted. Participants had accessed unscheduled care for their children in the past. Data were thematically analysed.

Results

Parents accessed unscheduled care for their children after reaching capacity to manage the child's health themselves. This was informed by factors such as parental experience, perceived urgency and need for reassurance. Parents considered the necessity to access care and situated their health‐seeking behaviour within a framework of ‘appropriateness’. Where parents sought unscheduled care was largely determined by timely access, and inability to secure a general practitioner (GP) appointment often led parents to access other services. Parents expressed a need for more support in navigating unscheduled care options.

Conclusions

Better resources to educate and support parents are required, and structural issues, such as accessibility to GPs, need to be addressed to enable parents to better navigate the unscheduled health system and manage their children's health. The discourse around ‘appropriate’ and ‘inappropriate’ access to health care has permeated parental decision making when accessing unscheduled health care for their children. What constitutes appropriate access should be examined, and a shift away from this framing of health‐seeking behaviour may be warranted.

Patient or Public Contribution

There was no explicit patient or public involvement. All authors hold experience as users of the health system.

Primary Care Variation in Rates of Unplanned Hospitalizations, Functional Ability, and Quality of Life of Older People

PURPOSE

To investigate variability in older people's outcomes according to general practitioner (GP) and practice characteristics in New Zealand and the Netherlands.

METHODS

We used data from 2 primary care-based, cluster-randomized, controlled trials to separately fit mixed models of unplanned admission rates, functional ability, and quality of life (QOL) and examine variation according to GP- and practice-level characteristics after adjusting for participant-level characteristics. For the New Zealand sample (n = 3,755 aged 75+ years in 60 practices), we modeled 36-month unplanned admission rates, Nottingham Extended Activities of Daily Living (NEADL) scale, and QOL domain ratings from the brief version of the World Health Organization Quality of Life assessment tool. For the Netherlands sample (n = 3,141 aged 75+ years in 59 practices), we modeled 12-month unplanned admission rates, Groningen Activity Restriction Scale scores, and EuroQOL 5 dimensions (EQ-5D) summary index.

RESULTS

None of the GP or practice characteristics were significantly associated with rates of unplanned admissions in the New Zealand sample, but we found greater rates of admission in larger practices (incidence rate ratio [IRR], 1.45; 95% CI, 1.15-1.81) and practices staffed with a practice nurse (IRR, 1.74; 95% CI, 1.20-2.52) in the Netherlands sample. In both samples, differences were consistently small where there were significant associations with function (range, -0.26 to 0.19 NEADL points in the New Zealand sample; no associations in the Netherlands sample) and QOL (range, -1.64 to 0.97 QOL points in New Zealand; -0.01 EQ-5D points in the Netherlands).

CONCLUSIONS

In the absence of substantial differences in older people's function and QOL, it remains unclear whether intriguing GP- or practice-related variations in admission rates represent low- or high-quality practice.

First Nations emergency care in Alberta: descriptive results of a retrospective cohort study

Background

Worse health outcomes are consistently reported for First Nations people in Canada. Social, political and economic inequities as well as inequities in health care are major contributing factors to these health disparities. Emergency care is an important health services resource for First Nations people. First Nations partners, academic researchers, and health authority staff are collaborating to examine emergency care visit characteristics for First Nations and non-First Nations people in the province of Alberta.

Methods

We conducted a population-based retrospective cohort study examining all Alberta emergency care visits from April 1, 2012 to March 31, 2017 by linking administrative data. Patient demographics and emergency care visit characteristics for status First Nations persons in Alberta, and non-First Nations persons, are reported. Frequencies and percentages (%) describe patients and visits by categorical variables (e.g., Canadian Triage and Acuity Scale). Means, medians, standard deviations and interquartile ranges describe continuous variables (e.g., age).

Results

The dataset contains 11,686,288 emergency care visits by 3,024,491 unique persons. First Nations people make up 4% of the provincial population and 9.4% of provincial emergency visits. The population rate of emergency visits is nearly 3 times higher for First Nations persons than non-First Nations persons. First Nations women utilize emergency care more than non-First Nations women (54.2% of First Nations visits are by women compared to 50.9% of non-First Nations visits). More First Nations visits end in leaving without completing treatment (6.7% v. 3.6%).

Conclusions

Further research is needed on the impact of First Nations identity on emergency care drivers and outcomes, and on emergency care for First Nations women.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06415-2.

The role of personalised professional relations across care sectors in achieving high continuity of care

Background

High continuity of care has a positive impact on health outcomes, but insight into the mechanisms underlying this impact is limited. Information continuity, on which our study focuses, is especially important when relational continuity is not given, which is often the case at hospital admission or hospital discharge. The aim of this study is to provide insight into the information flows between general practices and hospitals in Germany, and to identify factors associated with these flows of information.

Methods

This is a qualitative interview study in a purposeful sample of staff from hospitals and general practices (general practitioners, care assistants in general practice, hospital management, hospital physicians, and nursing staff). Interviews were conducted via telephone or face-to-face using a self-developed semi-structured interview guide. Stepwise systematic content analysis was used to structure collected material into themes and sub-themes that related to the study aim. Data was analysed by two researchers in several cycles, alternating between inductive and deductive approaches.

Results

A total of 49 interviews were conducted. Duration of the interviews varies between 21 and 78 min (mean duration 43 min). Across all groups, more than two thirds of participants were female (n = 34, 69%). The analysis highlighted six interdependent main themes regarding factors that affect information flows between hospitals and general practices: organisational, legal, financial, patient factors, individual characteristics, and emotional & social factors. The latter theme emerged as particularly rich and was therefore divided into four subthemes: appreciation and understanding of the respective other, (intrinsic) motivation, socialisation, and relationships. Organised meetings and events were mentioned as strategies to address emotional and social factors.

Conclusions

Digitalisation can facilitate information flows between care providers. However, knowing each other and good personal relations remain important for effective collaboration. Cooperation between all stakeholders is needed to aim to achieve continuity of care.

Trial registration: DRKS00015183 on DRKS/ Universal Trial Number (UTN): U1111-1218–0992. Date of registration 23/08/2018.

Primary care continuity and potentially avoidable hospitalization in persons with dementia

BACKGROUND/OBJECTIVE

To measure the association between high primary care continuity and potentially avoidable hospitalization in community-dwelling persons with dementia. Our hypothesis was that high primary care continuity is associated with fewer potentially avoidable hospitalizations.

DESIGN

Population-based retrospective cohort (2012-2016), with inverse probability of treatment weighting using the propensity score.

SETTING

Quebec (Canada) health administrative database, recording most primary, secondary and tertiary care services provided via the public universal health insurance system.

PARTICIPANTS

Population-based sample of 22,060 community-dwelling 65 + persons with dementia on March 31st, 2015, with at least two primary care visits in the preceding year (mean age 81 years, 60% female). Participants were followed for 1 year, or until death or long-term care admission.

EXPOSURE

High primary care continuity on March 31st, 2015, i.e., having had every primary care visit with the same primary care physician, during the preceding year.

MAIN OUTCOME MEASURES

Primary: Potentially avoidable hospitalization in the follow-up period as defined by ambulatory care sensitive conditions (ACSC) hospitalization (general and older population definitions), 30-day hospital readmission; Secondary: Hospitalization and emergency department visit.

RESULTS

Among the 22,060 persons, compared with the persons with low primary care continuity, the 14,515 (65.8%) persons with high primary care continuity had a lower risk of ACSC hospitalization (general population definition) (relative risk reduction 0.82, 95% CI 0.72-0.94), ACSC hospitalization (older population definition) (0.87, 0.79-0.95), 30-day hospital readmission (0.81, 0.72-0.92), hospitalization (0.90, 0.86-0.94), and emergency department visit (0.92, 0.90-0.95). The number needed to treat to prevent one event were, respectively, 118 (69-356), 87 (52-252), 97 (60-247), 23 (17-34), and 29 (21-47).

CONCLUSION

Increasing continuity with a primary care physician might be an avenue to reduce potentially avoidable hospitalizations in community-dwelling persons with dementia on a population-wide level.

How does general practitioner discontinuity affect healthcare utilisation? An observational cohort study of 2.4 million Norwegians 2007-2017

OBJECTIVES

Patients may benefit from continuity of care by a personal physician general practitioner (GP), but there are few studies on consequences of a break in continuity of GP. Investigate how a sudden discontinuity of GP care affects their list patients' regular GP consultations, out-of-hours consultations and acute hospital admissions, including admissions for ambulatory care sensitive conditions (ACSC).

DESIGN

Cohort study linking person-level national register data on use of health services and GP affiliation with data on GP activity and GP characteristics.

SETTING

Primary care.

PARTICIPANTS

2 409 409 Norwegians assigned to the patient lists of 2560 regular GPs who, after 12 months of stable practice, had a sudden discontinuity of practice lasting two or more months between 2007 and 2017.

PRIMARY AND SECONDARY OUTCOME MEASURES

Monthly GP consultations, out-of-hours consultations, acute hospital admissions and ACSC admissions in periods during and 12 months after the discontinuity, compared with the 12-month period before the discontinuity using logistic regression models.

RESULTS

All patient age groups had a 3%-5% decreased odds of monthly regular GP consultations during the discontinuity. Odds of monthly out-of-hours consultations increased 2%-6% during the discontinuity for all adult age groups. A 7%-9% increase in odds of ACSC admissions during the period 1-6 months after discontinuity was indicated in patients over the age of 65, but in general little or no change in acute hospital admissions was observed during or after the period of discontinuity.

CONCLUSIONS

Modest changes in health service use were observed during and after a sudden discontinuity in practice among patients with a previously stable regular GP. Older patients seem sensitive to increased acute hospital admissions in the absence of their personal GP.

Internação hospitalar de pessoas idosas de um grande centro urbano brasileiro e seus fatores associados

Resumo Objetivo Avaliar a frequência de Internação Hospitalar (IH) nos últimos doze meses em pessoas idosas atendidos na Atenção Primária à Saúde (APS) e seus fatores associados por meio de uma Avaliação Geriátrica Ampla (AGA). Métodos Estudo transversal, com amostra aleatória de 400 pessoas idosas atendidas em uma Unidade Básica de Saúde (UBS). A avaliação da frequência de IH por pelo menos 24 horas foi autorreferida (sim; não). Utilizou-se questionário sociodemográfico e de saúde, instrumentos para avaliar as atividades básicas e instrumentais da vida diária, status cognitivo, sintomas depressivos, queda e medo de cair. A regressão logística múltipla foi utilizada para investigar os fatores associados à IH. Resultados A média de idade foi de 75,23 (±8,53), 63,2% dos participantes eram do sexo feminino, 62,6% relataram um estado de saúde ruim/razoável e 38% relataram hospitalização nos últimos doze meses. Idade mais avançada, com pior percepção de saúde, doenças crônicas, uso diário de medicamentos, dependentes para as atividades básicas e instrumentais da vida diária, comprometimento do status cognitivo e queda no ano anterior demonstraram associação com a hospitalização. Saber ler e escrever foi associado com menor risco de hospitalização. Conclusão A frequência de IH de pessoas idosas atendidas em UBS foi alta e foi associada a fatores modificáveis e não modificáveis, indicando que a abordagem multidimensional é uma ferramenta importante no cuidado da pessoa idosa na atenção primária à saúde.

Identifying multimorbid patients with high care needs - A study based on electronic medical record data

Background

Patients with multimorbidity who frequently contact the general practice, use emergency care or have unplanned hospitalisations, may benefit from a proactive integrated care intervention. General practitioners are not always aware of who these ‘high need’ patients are. Electronic medical records are a potential source to identify them.

Objectives

To find predictors of high care needs in general practice electronic medical records of patients with multimorbidity and assess their predictive value.

Methods

General practice electronic medical records of 245,065 patients with ≥2 chronic diseases were linked to hospital claims data. Probit regression analysis was conducted to predict i) having at least 12 general practice contacts per year, ii) emergency department visit(s), and iii) unplanned hospitalisation(s). Predictors were patients’ age, sex, morbidity, health services and medication use in the previous year.

Results

11% of multimorbid patients had ≥12 general practice contacts, which could be reliably predicted by the number of contacts in the previous year (PPV 42%). The model containing all predictors had only slightly better predictive value (PPV 44%). Emergency department visits and unplanned hospitalisations (12% and 7% of multimorbid patients, respectively) could be predicted less accurately (PPV 27% and 20%). Those with frequent contact with the general practice hardly overlapped with ED visitors (29%) or persons with unplanned hospitalisations (17%).

Conclusion

Among multimorbid populations various ‘high need’ groups exist. Patients with high needs for general practice care can be identified by their previous use of general practice care. To identify frequent ED visitors and persons with unplanned hospitalisations, additional information is needed.

Improved strategies to counter the COVID-19 pandemic: Lockdowns vs. primary and community healthcare

COVID-19 pandemic mitigation strategies are mainly based on social distancing measures and healthcare system reinforcement. However, many countries in Europe and elsewhere implemented strict, horizontal lockdowns because of extensive viral spread in the community which challenges the capacity of the healthcare systems. However, strict lockdowns have various untintended adverse social, economic and health effects, which have yet to be fully elucidated, and have not been considered in models examining the effects of various mitigation measures. Unlike commonly suggested, the dilemma is not about health vs wealth because the economic devastation of long-lasting lockdowns will definitely have adverse health effects in the population. Furthermore, they cannot provide a lasting solution in pandemic containment, potentially resulting in a vicious cycle of consecutive lockdowns with in-between breaks. Hospital preparedness has been the main strategy used by governments. However, a major characteristic of the COVID-19 pandemic is the rapid viral transmission in populations with no immunity. Thus, even the best hospital system could not cope with the demand. Primary, community and home care are the only viable strategies that could achieve the goal of pandemic mitigation. We present the case example of Greece, a country which followed a strategy focused on hospital preparedness but failed to reinforce primary and community care. This, along with strategic mistakes in epidemiological surveillance, resulted in Greece implementing a second strict, horizontal lockdown and having one of the highest COVID-19 death rates in Europe during the second wave. We provide recommendations for measures that will reinstate primary and community care at the forefront in managing the current public health crisis by protecting hospitals from unnecessary admissions, providing primary and secondary prevention services in relation to COVID-19 and maintaining population health through treatment of non-COVID-19 conditions. This, together with more selective social distancing measures (instead of horizontal lockdowns), represents the only viable and realistic long-term strategy for COVID-19 pandemic mitigation.