Dataset Information

Substitution of outpatient hospital care with specialist care in the primary care setting: A systematic review on quality of care, health and costs.

ABSTRACT:

Rationale, aims and objective

Substituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting.

Method

The systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible.

Results

A total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers.

Conclusions

Despite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design.

SUBMITTER: van Hoof SJM

PROVIDER: S-EPMC6675042 | biostudies-literature | 2019

REPOSITORIES: biostudies-literature

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Publications

Substitution of outpatient hospital care with specialist care in the primary care setting: A systematic review on quality of care, health and costs.

van Hoof Sofie J M SJM Quanjel Tessa C C TCC Kroese Mariëlle E A L MEAL Spreeuwenberg Marieke D MD Ruwaard Dirk D

PloS one 20190801 8

<h4>Rationale, aims and objective</h4>Substituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting.<h4>Me ...[more]

PMID: 31369567

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Project description:BackgroundMany Western countries face the challenge of providing high-quality care while keeping the healthcare system accessible and affordable. In an attempt to deal with this challenge a new healthcare delivery model called primary care plus (PC+) was introduced in the Netherlands. Within the PC+ model, medical specialists perform consultations in a primary care setting. PC+ aims to support the general practitioners in gatekeeping and prevent unnecessary referrals to hospital care. The aim of this study was to examine the effects of a cardiology PC+ intervention on the Triple Aim outcomes, which were operationalized by patient-perceived quality of care, health-related quality of life (HRQoL) outcomes, and healthcare costs per patient.MethodsThis is a quantitative study with a longitudinal observational design. The study population consisted of patients, with non-acute and low-complexity cardiology-related health complaints, who were referred to the PC+ centre (intervention group) or hospital-based outpatient care (control group; care-as-usual). Patient-perceived quality of care and HRQoL (EQ-5D-5L, EQ-VAS and SF-12) were measured through questionnaires at three different time points. Healthcare costs per patient were obtained from administrative healthcare data and patients were followed for nine months. Chi-square tests, independent t-tests and multilevel linear models were used to analyse the data.ResultsThe patient-perceived quality of care was significantly higher within the intervention group for 26 out of 27 items. HRQoL outcomes did significantly increase in both groups (P <0.05) but there was no significant interaction between group and time. At baseline and also at three, six and nine months' follow-up the healthcare costs per patient were significantly lower for patients in the intervention group (P<0.001).ConclusionsWhile this study showed no improvements on HRQoL outcomes, PC+ seemed to be promising as it results in improved quality of care as experienced by patients and lower healthcare costs per patient.

Project description:BackgroundHealthcare systems are challenged by a demand that exceeds available resources. One policy to meet this challenge is task substitution-transferring tasks to other professions and settings. Our study aimed to explore stakeholders' perceived feasibility of transferring hospital-based monitoring of stable glaucoma patients to primary care optometrists.MethodsA case study was undertaken in the Rotterdam Eye Hospital (REH) using semi-structured interviews and document reviews. They were inductively analysed using three implementation related theoretical perspectives: sociological theories on professionalism, management theories, and applied political analysis.ResultsCurrently it is not feasible to use primary care optometrists as substitutes for optometrists and ophthalmic technicians working in a hospital-based glaucoma follow-up unit (GFU). Respondents' narratives revealed that: the glaucoma specialists' sense of urgency for task substitution outside the hospital diminished after establishing a GFU that satisfied their professionalization needs; the return on investments were unclear; and reluctant key stakeholders with strong power positions blocked implementation. The window of opportunity that existed for task substitution in person and setting in 1999 closed with the institutionalization of the GFU.ConclusionsTransferring the monitoring of stable glaucoma patients to primary care optometrists in Rotterdam did not seem feasible. The main reasons were the lack of agreement on professional boundaries and work domains, the institutionalization of the GFU in the REH, and the absence of an appropriate reimbursement system. Policy makers considering substituting tasks to other professionals should carefully think about the implementation process, especially in a two-step implementation process (substitution in person and in setting) such as this case. Involving the substituting professionals early on to ensure all stakeholders see the change as a normal step in the professionalization of the substituting professionals is essential, as is implementing the task substitution within the window of opportunity.

Project description:BackgroundAlthough many specialists serve as primary care physicians (PCPs), the type of patients they serve, the range of services they provide, and the quality of care they deliver is uncertain.ObjectiveTo describe trends in patient, physician, and visit characteristics, and compare visit-based quality for visits to generalists and specialists self-identified as PCPs.DesignCross-sectional study and time trend analysis.DataNationally representative sample of visits to office-based physicians from the National Ambulatory Medical Care Survey, 1997-2010.Main measuresProportions of primary care visits to generalist and specialists, patient characteristics, principal diagnoses, and quality.Key resultsAmong 84,041 visits to self-identified PCPs representing an estimated 4.0 billion visits, 91.5 % were to generalists, 5.9 % were to medical specialists and 2.6 % were to obstetrician/gynecologists. The proportion of PCP visits to generalists increased from 88.4 % in 1997 to 92.4 % in 2010, but decreased for medical specialists from 8.0 % to 4.8 %, p?=?0.04). The proportion of medical specialist visits in which the physician self-identified as the patient's PCP decreased from 30.6 % in 1997 to 9.8 % in 2010 (p?<?0.01). Medical specialist PCPs take care of older patients (mean age 61 years), and dedicate most of their visits to chronic disease management (51.0 %), while generalist PCPs see younger patients (mean age 55.4 years) most commonly for new problems (40.5 %). Obstetrician/gynecologists self-identified as PCPs see younger patients (mean age 38.3 p?<?0.01), primarily for preventive care (54.0 %, p?<?0.01). Quality of care for cardiovascular disease was better in visits to cardiologists than in visits to generalists, but was similar or better in visits to generalists compared to visits to other medical specialists.ConclusionsMedical specialists are less frequently serving as PCPs for their patients over time. Generalist, medical specialist, and obstetrician/gynecologist PCPs serve different primary care roles for different populations. Delivery redesign efforts must account for the evolving role of generalist and specialist PCPs in the delivery of primary care.

Project description:BackgroundInnovations are proliferating at the primary-secondary care interface, affecting referral to secondary care and resource use. Evidence about the range of effects and implications for the healthcare system of different types of innovation have not previously been summarised.AimTo review the available evidence on initiatives affecting primary care referral to specialist secondary care.SettingStudies of primary-secondary care interface.MethodSystematic review of trials, using adapted Cochrane Collaboration (effective practice and organisation of care) criteria. Studies from 1980 to 2001 were identified from a wide range of sources. Strict inclusion criteria were applied, and relevant clinical, service and cost data extracted using an agreed protocol. The main outcome measures were referral rates to specialist secondary care.ResultsOf the 139 studies initially identified. 34 met the review criteria. An updated search added a further 10 studies. Two studies provided economic analysis only. Referral was not the primary outcome of interest in the majority of included studies. Professional interventions generally had an impact on referral rates consistent with the intended change in clinician behaviour. Similarly, specialist 'outreach' or other primary care-based specialist provider schemes had at least a small effect upon referral rates to secondary care with the direction of effect being that intended or rational from a clinical and sociological perspective. Of the financial interventions, one was aimed primarily at changing the numbers or proportion of referrals from primary to specialist secondary care, and the direction of change was as expected in all cases. The quality of the reporting of the economic components of the 14 studies giving economic data was poor in many cases. When grouped by intervention type, no overall pattern of change in referral costs or total costs emerged.ConclusionThe studies identified were extremely diverse in methodology, clinical subject, organisational form, and quality of evidence. The number of good quality evaluations of innovative schemes to enhance the existing capacity of primary care was small, but increasing. Well-evaluated service initiatives in this area should be supported. Organisational innovations in the structure of service provision need not increase total costs to the National Health Service (NHS), even though costs associated with referral may increase. This review provides limited, partial, and conditional support for current primary care-oriented NHS policy developments in the United Kingdom.

Project description:BackgroundEarly detection and effective management of risk factors can potentially delay progression of chronic kidney disease (CKD) to end-stage kidney disease, and decrease mortality and morbidity from cardiovascular (CV) disease. We evaluated a specialist nurse-led intervention in the primary care setting to address accepted risk factors in a study sample of adults at 'high risk of CKD progression', defined as uncontrolled type II diabetes and/or hypertension and a history of poor clinic attendance.MethodsThe study was a non-controlled quality improvement study with pre- and post- intervention comparisons to test feasibility and potential effectiveness. Patients within two primary care practices were screened and recruited to the study. Fifty-two patients were enrolled, with 36 completing 12-months follow-up. The intervention involved a series of sessions led by the nephrology Nurse Practitioner with assistance from practice nurses. These sessions included assessment, education and planned medication and lifestyle changes. The primary outcome measured was proteinuria (ACR), and the secondary outcomes estimated glomerular filtration rate (eGFR) and 5-year absolute CV risk. Several 'intermediary' secondary outcomes were also measured including: blood pressure, serum total cholesterol, glycosylated haemoglobin (HbA1c), body mass index (BMI), prevalence of active smoking, a variety of self-management domains, and medication prescription. Analysis of data was performed using linear and logistic regression as appropriate.ResultsThere was a significant improvement in ACR (average decrease of -6.75 mg/mmol per month) over the course of the study. There was a small but significant decrease in eGFR and a reduction in 5 year absolute CV risk. Blood pressure, serum total cholesterol, and HbA1c all decreased significantly. Adherence to lifestyle advice improved with a significant reduction in prevalence of active smoking, although there was no significant change in BMI. Self-management significantly improved across all relevant domains.ConclusionsThe results suggest that a collaborative model of care between specialist renal nurses and primary care clinicians may improve the management of risk factors for progression of CKD and CV death. Further larger, controlled studies are warranted to definitively determine the effectiveness and costs of this intervention.Trial registrationAustralian and New Zealand Clinical Trials Registry number: ACTRN12613000791730.

Dataset Information

Substitution of outpatient hospital care with specialist care in the primary care setting: A systematic review on quality of care, health and costs.

Rationale, aims and objective

Method

Results

Conclusions

Publications

Substitution of outpatient hospital care with specialist care in the primary care setting: A systematic review on quality of care, health and costs.

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