| dc.description.abstract | Summary
Background:
General practice (GP) medicine is a cornerstone in many countries’ health services. In Norway, the establishment of the regular general practitioner (GP) scheme in 2001 introduced a structural emphasis on gatekeeping and continuity of GP care by entitling all inhabitants (more than 99%) to a regular GP within a list‐based system. General practitioners providing continuity of care for their patients has been suggested to be beneficial for patients’ health and reduce the need for secondary health care treatment.
As in many other European countries, the current Norwegian policy is to reduce pressure on specialist health care by increasing preventive care and shifting tasks from secondary to primary health care. These recent developments and the expected increase in the number of older people in the years to come call for new knowledge on patients’ use of GP services to identify pitfalls and potentials for prevention, especially in the elderly and chronically ill. We wondered how patients consulted their GP before hospital admission and over time during the last decade. We also wondered how the patients were affected if suddenly exposed to a situation where their regular GP was unavailable for a longer period of time; could we detect a spill over to out‐of‐hours services or increased acute hospital admissions?
Aims:
To investigate patients' contact with GPs and how the use of health care services changes 1) prior to acute hospital admissions, 2) in a period when GPs’ responsibilities for health care services increased and 3) when patients are suddenly exposed to a situation where the regular GP was unavailable for a longer period of time.
Methods:
In Paper l, we used a longitudinal design, linking person‐level national register data on use of health services (GP and out‐of‐hours (OOH)) and municipal health care services for inhabitants aged 50 and older admitted to hospital for acute myocardial infarction, hip fracture, stroke, heart failure or pneumonia in four municipalities (Trondheim, Malvik, Melhus and Midtre Gauldal) in 2012‐2013, covering a population of 214,722 persons. We used binomial generalised estimation equation models with a logit function to investigate the percentage with GP/OOH contacts before the hospital admission; per month during the year before the admission; and per triplet of days (2–4, 5–7, …., 29–31 days) the month before the admission. We performed the analysis separately for each of the selected patient groups.
In Paper ll, we used survey data and clinical measurements from the Norwegian HUNT3 study (2006‐2008) linked with national administrative data on the GP list assignment and consultations with GP services. We grouped participants aged 40‐59 years according to sex and their baseline status regarding hypertension and anxiety/depression symptoms. We registered GP consultations in 2007‐2016 and used general estimation equation models to estimate the percentage with monthly GP consultations each year during follow‐up. We used multilevel models with participants nested in their assigned regular GP to calculate GP level intra‐class correlation coefficients, reflecting to what extent patients’ consultation patterns could be attributed to the individual GP.
In Paper lll, we used a longitudinal design, linking person‐level national register data on the use of health services (GP and OOH) and GP affiliation for 2,529,311 Norwegians assigned to the patient lists of 2,501 regular GPs who, after 12 months of stable practice, had a sudden discontinuity of care lasting two or more months between 2007 and 2017. Patient follow‐up with monthly registrations of health care use were analysed during the same time periods before (2 to 7 months before), during (1 month before to 1 month after) and after (2 to 13 months after) the episode of discontinuity. Logistic regression models compared monthly GP consultations, out‐of‐hours consultations, acute hospital admissions and Ambulatory Care Sensitive Conditions (ACSC) admissions in periods during and after the discontinuity to the period before the discontinuity, for five age groups separately.
Results:
In Paper l, we identified 66,952 participants, of whom 720 were admitted to hospital for acute myocardial infarction, 645 for hip fracture, 740 for stroke, 399 for heart failure and 853 for pneumonia in the two‐year study period. The majority of these acutely admitted patients had contact with general practitioners each month before the emergency hospital admission, especially contacts with a regular GP. A general increase in GP contacts was observed towards the time of hospital admission, but development differed between the patient groups.
Patients admitted with heart failure had the steepest increase of monthly GP contacts. A sizable percentage did not contact their regular GP or OOH services the month before admission, in particular men aged 50‐64 admitted with myocardial infarction or stroke In Paper ll, we identified 47,550 HUNT3 participants that were registered with 102 different GPs in Nord‐Trøndelag County, Norway, in 2007. Adjusted for age, we observed an overall increase in GP consultations in 2007‐2016, particularly in those with a better health status at baseline. About 2% of the variance of patient consultations could be attributed to differences between GPs and 10% to the use of lengthy consultations. Out‐of‐hours consultations did not change much in the study period 2007‐2016.
In Paper lll, we found that all age groups had a 3‐5% decreased odds of monthly regular GP consultations during the discontinuity, followed by normalisation. The odds of monthly outof‐ hours consultations increased 3‐6% during the discontinuity for all adult age groups. The odds of hospital admissions increased during and after the discontinuity in those older than 65 years, particularly for ACSC admissions.
Conclusion:
The results from all three papers in this thesis point to the important role of the regular GP in the population. Most people saw their GP on a regular basis, both before an acute hospital admission (Paper l) and overall (all three papers). Nevertheless, in Paper l, a substantial percentage of the patients did not see their GPs the month before a hospital admission. This group of patients could represent a possible target for prevention, although they cannot be easily reached. We found indications of an increased use of GP services (but not OOH use) in Norway partly due to changes in help‐seeking behaviour among the healthier part of the population (Paper ll). More frequent consultations could indicate better prevention, monitoring and treatment. However, as GP services are under considerable capacity pressure, prioritisation principles and following‐up of patients with varying needs are topics for further scrutiny. Overall, patients seem to access help when faced with a sudden discontinuity of care from their regular GP (Paper lll). However, the increase in acute hospital admissions for ambulatory care sensitive conditions in the older age groups after such a discontinuity suggests a crucial role of the GP and warrants attention and further research. | |
