Can continuity of primary care decrease emergency care use?

Problem

NHS emergency departments (ED) have been under considerable pressure. Many patients presenting to EDs, however, could be managed in primary care. This suggests that aspects of general practice might be associated with ED attendance and unplanned hospital admission. In particular, our research question was whether better continuity of care (CoC) is associated with a lower rate of emergency hospital admission.

Approach

This study focused on elderly patients since they have on average a higher emergency hospital admission rate and visit a GP practice more often. To construct a CoC index for individual patients, we used records from 10,000 patients aged over 65 randomly selected from the Clinical Practice Research Datalink (CPRD), linked with Hospital Episode Statistics (HES). This allowed us to calculate the CoC index as defined by Bice and Boxerman which quantifies for each patient the extent to which he or she saw the same health care provider between April 2012 and March 2014. CoC values ranged from 0 (continuity completely lacking) to 1 (complete continuity). Patients who had three or more GP consultations (either face-to-face or telephone) during the observation period were included in the analysis. Using HES we determined for these patient whether they had an emergency hospital admission subsequent to the date of their third GP consultation till April 2014. Cox proportional hazards model were applied to estimate the hazard ratio (HR) associated with CoC. The CoC index was divided into six categories: a CoC of zero indicated having seen every time a different GP, a CoC of one indicating having seen the same GP every time, and quartile ranges for CoC values between 0 and 1.

Findings

After adjusting for age, gender, deprivation, urban/rural location, previous hospital admission and a range of co-morbidities, the risk of an emergency hospital admission for patients with a CoC of zero did not differ significantly from patients having a CoC index of one (HR 1.10, 95%CI 0.82-1.50) . Compared to patients having a CoC index of one, the risk of an emergency hospital admission was lower for patients with a CoC index in the first and second quartiles (HRs 0.84: 95%CI 0.72-0.99 and 0.85: 95%CI 0.71-1.01 respectively), while this risk dropped further for patients with a CoC index in the third and fourth quartiles (HRs 0.79: 95%CI 0.66-0.94 and 0.74: 95%CI 0.62-0.88 respectively). However, when adjusting for the number of GP consultations this association between CoC and hospital admission disappeared.

Consequences

While we found some evidence for a relationship between greater continuity of care and lower use of unscheduled secondary care, the relationship appeared complex and dependent on the frequency of GP consultations.