A retrospective, observational, and cross sectional study using data from the Clinical Practice Research Datalink «Barker I, Steventon A, Deeny SR. Association betwe...»1 contains the electronic medical records of participating general practices, and includes contacts with healthcare professionals, details of diagnostic tests, referrals to specialist healthcare, diagnosed health conditions, personal characteristics, and the start and end dates of patient registrations with general practices.
The person level data was used to assess the relationship between continuity of care and hospital admissions, and examined how the association differs between high and low users of primary care. The hospital admissions for ambulatory care sensitive conditions which were manageable in primary care were addressed. Ambulatory care sensitive conditions include long term conditions, such as asthma, where good quality care should prevent episodes of flare-ups; acute conditions, such as gangrene, where timely and effective care stops the condition developing; and conditions that are preventable by vaccination, such as influenza and pneumonia. This study dealt with longitudinal continuity of care.
They included patients who were aged between 62 and 82 and who experienced at least two contacts with overall 200 general practices in England between April 2011 and March 2013. Those who died before March 2013, were excluded.
The low continuity of care group (Provider of care index 0-0.4) comprised 52 550 patients (22.8%), the medium group (Provider of care index 0.4-0.7) 96 902 patients (42.1%), and the high group (Provider of care index 0.4-0.7) 81 020 patients (35.2%). These groups were similar in terms of their age, sex, and socioeconomic deprivation score. However, patients in the low continuity group had more contacts with general practitioners on average than the other groups (13.11 per person, compared with 11.34 per person in the medium group and 10.37 in the high group).
When adjusting for these covariates (age, sex; socioeconomic deprivation score, number of contacts with a general practitioner, number of active previous long term health conditions, and number of previous referrals to specialist care), patients with higher continuity of care tended to have fewer admissions for ambulatory care sensitive conditions. Compared with people with low continuity of care, people with medium continuity of care had fewer admissions for ambulatory care sensitive conditions 8.96% (95% confidence interval (CI) 5.63% to 14.22%). People with high continuity of care had 12.49% (95 % CI 9.45% to 19.29%) fewer admissions than those with low continuity of care. Overall, across all patients with at least two contacts with a general practitioner, a 0.2 increase in the usual provider of care index score was associated with a reduction in admissions for ambulatory care sensitive conditions of 6.22% (95% CI 4.87% to 7.55%). The evidence for a link between the usual provider of care index score and admissions was greatest among the most frequent users of general practice.
For patients in the two highest fifths of general practice utilisation (12-17 contacts and ≥18 contacts), a 0.2 increase in the usual provider of care index score was associated with a reduction in ambulatory care sensitive admissions of 3.32% (95% CI 0.76% to 5.82%) and 3.97% (95% CI 1.91% to 6.00%), respectively (P<0.001). The associations were less statistically significant at lower levels of general practice utilisation.
Retrospective observational and cross sectional study «Tammes P, Purdy S, Salisbury C ym. Continuity of P...»2 using a data from the Clinical Practice Research Datalink (CPRD) obtained on each patient's date of consultations, sex, and year of birth. Patients in CPRD who could be linked by their National Health Service number to Hospital Episode Statistics data, which showed emergency hospital admissions in the fiscal years 2012-2014 was studied.
It is assumed that the general practitioner regularly seen by the patient knows that patient well This study stated that better continuity of care specifically with that physician might be associated with a lower risk of emergency hospital admission at the individual patient level. Study focused on older adults as they are seen more frequently in primary care than younger adults and are at greater risk for acute hospital admission. Hypothesis was tested using 2 approaches: a prospective cohort approach to assess the general impact of continuity of care on emergency admissions and a nested case-control approach to assess whether seeing general practitioners other than the usual one increases the risk or odds of emergency admission during the following 30 days.
The prospective cohort approach, the observation period for patients was from April 1, 2010, to March 30, 2014, or earlier if patients left their current practice, for example, moving or dying, or if they were admitted to the hospital between April 2012 and March 2014. Patients were selected if they made at least 2 general practitioner consultations after March 2012; in total 8,248 patients were included in the prospective cohort analysis. In total, 1,828 of the 8,248 patients had an emergency hospital admission within that time period. Overall, 95 (1.1%) and 575 (6.9%)of patients never and always saw the same general practitioner when visiting that physician's practice As these patients consulted a general practitioner less frequently, study adjusted for the number of general practitioner consultations in analyses.
For the nested case-control approach, patients with an emergency hospital admission between April 1, 2012, and March 30, 2014 were identified. Patients were included only if they had at least 2 general practitioner consultations in the 2 years before hospital admission, of which the last was within 30 days before that admission. A period of 30 days was chosen to capture a time span over which the general practitioner's care might affect the chance of an emergency admission. In total, 1,215 patients were selected as potential case patients.
Control patients were defined as those not experiencing an emergency hospital admission, and were matched with case patients on the following characteristics: general practitioner practice, age-group, and occurrence of last general practitioner consultation 30 days before hospitalization of the matched case patients with at least 1 other consultation made in the previous 2 years.
In the prospective cohorts unadjusted model, patients with less than perfect continuity of care (BB index score < 1) experienced a higher incidence of emergency hospital admission. A similar pattern was seen after adjustment, although the higher incidence was statistically significant only for those with a BB index score of 0. When examining the trend across the 6 categories of scores (1 = highest, 6 = lowest) as discrete categories, the hazard ratio per each increasing category was 1.042 (95% CI, 0.997-1.090; P = 0.07). The practice average BB index score was not associated with a patient's risk of an emergency hospital admission in either the unadjusted models or the adjusted models. A sensitivity analysis with BB index scores divided into tertiles showed no significant association.
Scores on the BB index varied widely among the 2,892 patients in the retrospective nested case control analysis. Almost 300 (9.8%) of the patients always saw the same general practitioner when visiting the practice, corresponding to a score of 1. Again, patients with a BB index score of 0 or 1 consulted a general practitioner less frequently. In the unadjusted model, there was an association between less than perfect continuity of care and higher odds of emergency hospital admission. A similar result was seen in the adjusted model, particularly showing higher odds among those with an index score of less than 0.4. When analyzing the 6 BB index score categories as discrete scores (1 = highest, 6 = lowest), the associated odds ratio per each increase in category was 1.162 (95% CI, 1.067-1.265; P = 0.001). A sensitivity analysis with BB index scores divided into tertiles showed that patients whose scores were in the low and middle tertiles had odds ratios of 1.589 (95% CI, 1.212-2.084; P = .001) and 1.304 (95% CI, 1.013-1.678; P = 0.04), respectively, when compared with counterparts whose index scores were in the high tertile (highest continuity), showing a gradient of increasing risk of emergency hospital admission.