Self-management capability in patients with long-term conditions is associated with reduced healthcare utilisation across a whole health economy: cross-sectional analysis of electronic health records.

OBJECTIVE: To quantify the association between patient self-management capability measured using the Patient Activation Measure (PAM) and healthcare utilisation across a whole health economy. RESULTS: 12 270 PAM questionnaires were returned from 9348 patients. In the adjusted analyses, compared with the least activated group, highly activated patients (level 4) had the lowest rate of contact with a general practitioner (rate ratio: 0.82, 95% CI 0.79 to 0.86), emergency department attendances (rate ratio: 0.68, 95% CI 0.60 to 0.78), emergency hospital admissions (rate ratio: 0.62, 95% CI 0.51 to 0.75) and outpatient attendances (rate ratio: 0.81, 95% CI 0.74 to 0.88). These patients also had the lowest relative rate (compared with the least activated) of 'did not attends' at the general practitioner (rate ratio: 0.77, 95% CI 0.68 to 0.87), 'did not attends' at hospital outpatient appointments (rate ratio: 0.72, 95% CI 0.61 to 0.86) and self-referred attendance at emergency departments for conditions classified as minor severity (rate ratio: 0.67, 95% CI 0.55 to 0.82), a significantly shorter average length of stay for overnight elective admissions (rate ratio 0.59, 95% CI 0.37 to 0.94),and a lower likelihood of 30- day emergency readmission (rate ratio: 0.68 , 95% CI 0.39 to 1.17), though this did not reach significance. CONCLUSIONS: Self-management capability is associated with lower healthcare utilisation and less wasteful use across primary and secondary care.

Association between continuity of care in general practice and hospital admissions for ambulatory care sensitive conditions: cross sectional study of routinely collected, person level data.

OBJECTIVE:  To assess whether continuity of care with a general practitioner is associated with hospital admissions for ambulatory care sensitive conditions for older patients. DESIGN:  Cross sectional study. SETTING:  Linked primary and secondary care records from 200 general practices participating in the Clinical Practice Research Datalink in England. PARTICIPANTS:  230 472 patients aged between 62 and 82 years and who experienced at least two contacts with a general practitioner between April 2011 and March 2013. MAIN OUTCOME MEASURE:  Number of hospital admissions for ambulatory care sensitive conditions (those considered manageable in primary care) per patient between April 2011 and March 2013. RESULTS:  We assessed continuity of care using the usual provider of care index, which we defined as the proportion of contacts occurring between April 2011 and March 2013 that were with the most frequently seen general practitioner. On average, the usual provider of care index score was 0.61. Continuity of care was lower among practices with more doctors (average score 0.59 in large practices versus 0.70 in small practices). Higher continuity of care was associated with fewer admissions for ambulatory care sensitive conditions. When modelled, controlling for demographic and clinical patient characteristics, an increase in the usual provider of care index of 0.2 for all patients would reduce these admissions by 6.22% (95% confidence interval 4.87% to 7.55%). There was greater evidence for an association among patients who were heavy users of primary care. Heavy users also experienced more admissions for ambulatory care sensitive conditions than other patients (0.36 admissions per patient for those with ≥18 contacts with a general practitioner, compared with 0.04 admissions per patient for those with 2-4 contacts). CONCLUSIONS:  Strategies that improve the continuity of care in general practice may reduce secondary care costs, particularly for the heaviest users of healthcare. Promoting continuity might also improve the experience of patients and those working in general practice.

Effect of a national requirement to introduce named accountable general practitioners for patients aged 75 or older in England: regression discontinuity analysis of general practice utilisation and continuity of care.

OBJECTIVE: To assess the effect of introducing named accountable general practitioners (GPs) for patients aged 75 years on patterns of general practice utilisation, including continuity of care. DESIGN: Regression discontinuity design applied to data from the Clinical Practice Research Datalink to estimate the treatment effect for compliers aged 75. SETTING: 200 general practices in England. PARTICIPANTS: 255 469 patients aged between 65 and 85, after excluding those aged 75. INTERVENTION: From April 2014, general practices in England were required to offer patients aged 75 or over a named accountable GP. This study compared having named accountable GPs for patients aged just over 75 with usual care provided for patients just under 75. OUTCOMES: Number of contacts (face-to-face or telephone) with GPs, longitudinal continuity of care (usual provider of care, or UPC, index), number of referrals to specialist care and numbers of common diagnostic tests. Outcomes were measured over 9 months following assignment to a named accountable GP and for a comparable period for those unassigned. RESULTS: The proportion of patients with a named accountable GP increased from 3.5% to 79.8% at age 75. No statistically significant effects were detected for continuity of care (estimated treatment effect 0.00, 95% CI -0.01 to 0.02) or the number of GP contacts per person (estimated treatment effect -0.11, 95% CI -0.31 to 0.09) over 9 months. No significant change was seen in the number of referrals, blood pressure or HbA1c diagnostic tests per person. A statistically significant treatment effect of -0.05 cholesterol tests per person (95% CI -0.07 to -0.02) was estimated; however, sensitivity analysis indicated that this effect predated the introduction of named accountable GPs. CONCLUSIONS: Continuity of care is valued by patients, but the named accountable GP initiative did not improve continuity of care or change patterns of GP utilisation in the first 9 months of the policy.