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Discontinuity of care increases risk for unplanned hospital admissions among elderly patients
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Discontinuity of care within a general practice led to greater risk for emergency hospital admissions among patients older than 65 years, according to findings recently published in Annals of Family Medicine.
“Secondary health care services have been under considerable pressure in England as attendance rates increase, resulting in longer waiting times and demands on staff. Evidence suggests that many patients presenting for unscheduled secondary care could be managed in primary care,” Peter Tammes, PhD, MA, senior research associate at the University of Bristol Centre for Academic Primary Care in England, told Healio Family Medicine. “Our aim was to examine the association between continuity of care and risk of emergency hospital admission among older patients.”
Tammes and colleagues tested their hypothesis using two approaches.
In the nested case-control approach, they looked at patients with unplanned hospital admissions between April 1, 2012, and March 30, 2014. Control patients were those not admitted to the hospital.
In the prospective cohort approach, the observation period for patients’ general practitioner consultation history was April 1, 2010, to March 30, 2014, or earlier if patients left their current practice or if they were admitted to the hospital between April 2012 and March 2014.
The main outcome for both methods was the first unplanned hospital admission between April 2012 and March 2014. Tammes told Healio Family Medicine no distinction was made whether the admission was through an ED or through a general practitioner referral to a hospital specialty.
Researchers found that the retrospective nested case-control analysis showed a graded, inverse relationship between unplanned hospital admission and continuity of care for the appointed general practitioner (OR for patients having least continuity = 2.32; 95% CI, 1.48-3.63) and Bice and Bowerman indices. In the prospective cohort analysis, the Bice and Boxerman index revealed a nonsignificant, graded, inverse relationship of continuity of care with risk for unplanned hospital admission, although HR for patients experiencing least continuity = 2.27; 95% CI, 1.37-3.76 vs. those having complete continuity of care.
Tammes put the findings into context.
“It might be worthwhile for both the patient and the physician to build a patient-doctor relationship by trying to see or speak to the same, preferred or regular doctor when a patient needs a consultation,” he said. “Patients could also be assigned physicians, or, when patients are making appointments, they can be told the availability of the doctor they had last seen.” – by Janel Miller
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Kevin Biese, MD, MAT
Dr. Tammes and his team’s important confirmation of the value of continuity of care with one primary care provider is not surprising. Having a primary care provider who knows you well and sees you consistently is good for your health — particularly if you are an older adult with complicated medical conditions. Engaged PCPs can more accurately determine what is new about a patient’s health status, treating only that which needs to be treated, and avoiding hospital admissions that will not be of benefit.
Medically unnecessary hospital admissions harm older adults and engaged PCPs help avoid hospital admission in at least two ways. First, patients are less likely to need to come to the ED if they can access appropriate care before their health condition becomes an emergency. Second, if a patient with an engaged PCP arrives in the ED, it is easier for the ED provider to safely transition (discharge) the patient back home instead of admitting them into the hospital because there is a provider to care for the patient.
For PCPs to take great care of their patients when the patient presents to the ED, however, communication between PCPs and ED providers must be encouraged and supported. As set forth in the Geriatric Emergency Department Guidelines (https://www.acep.org/geriEDguidelines/#sm.0001f5hd941cxve2txcr26ygsvnwd), speaking directly with a primary care provider when a patient comes to the ED is always the right thing to do. The Geriatric Emergency Department Collaborative (https://www.americangeriatrics.org/programs/geriatrics-emergency-department-collaborative) disseminates best acute care practices for older adults, but to gain greater traction, the extra effort needed to ensure 24/7/365 coordinated care must be supported either through direct reimbursement, or, better still, evolution towards value–based care systems that inherently support continuity and coordinated care.
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