Patients' perspectives on a new delivery model in primary care: A propensity score matched analysis of patient-reported outcomes in a Dutch cohort study.

RATIONALE, AIMS AND OBJECTIVE: Primary Care Plus (PC+) focuses on the substitution of hospital-based medical care to the primary care setting without moving hospital facilities. The aim of this study was to examine whether population health and experience of care in PC+ could be maintained. Therefore, health-related quality of life (HRQoL) and experienced quality of care from a patient perspective were compared between patients referred to PC+ and to hospital-based outpatient care (HBOC). METHODS: This cohort study included patients from a Dutch region, visiting PC+ or HBOC between December 2014 and April 2018. With patient questionnaires (T0, T1 and T2), the HRQoL and experience of care were measured. One-to-two nearest neighbour calliper propensity score matching (PSM) was used to control for potential selection bias. Outcomes were compared using marginal linear models and Pearson chi-square tests. RESULTS: One thousand one hundred thirteen PC+ patients were matched to 606 HBOC patients with well-balanced baseline characteristics (SMDs <0.1). Regarding HRQoL outcomes, no significant interaction terms between time and group were found (P > .05), indicating no difference in HRQoL development between the groups over time. Regarding experienced quality of care, no differences were found between PC+ and HBOC patients. Only travel time was significantly shorter in the HBOC group (P ≤ .001). CONCLUSION: Results show equal effects on HRQoL outcomes over time between the groups. Regarding experienced quality of care, only differences in travel time were found. Taken as a whole, population health and quality of care were maintained with PC+ and future research should focus more on cost-related outcomes.

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: 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.

Substitution of outpatient care with primary care: a feasibility study on the experiences among general practitioners, medical specialists and patients.

BACKGROUND: Reinforcing the gatekeeping role of general practitioners (GPs) by embedding specialist knowledge into primary care is seen as a possibility for stimulating a more sustainable healthcare system and avoiding unnecessary referrals to outpatient care. An intervention called Primary Care Plus (PC+) was developed to achieve these goals. The objective of this study is to gain insight into: (1) the content and added value of PC+ consultations according to stakeholders, and (2) patient satisfaction with PC+ compared to outpatient care. METHODS: A feasibility study was conducted in the southern part of the Netherlands between April 2013 and January 2014. Data was collected using GP, medical specialist and patient questionnaires. Patient characteristics and medical specialty data were collected through the data system of a GP referral department. RESULTS: GPs indicated that they would have referred 85.4 % of their PC+ patients to outpatient care in the hypothetical case that PC+ was not available. Medical specialists indicated that about one fifth of the patients needed follow-up in outpatient care and 75.9 % of the consultations were of added value to patient care. The patient satisfaction results appear to be in favour of PC+. CONCLUSION: PC+ seems to be a feasible intervention to be implemented on a larger scale, because it has the potential to prevent unnecessary hospital referrals. PC+ will be evaluated on a larger scale regarding the effects on health outcomes, quality of care and costs (Triple Aim principle).

Factors influencing home discharge after inpatient rehabilitation of older patients: a systematic review.

BACKGROUND: Although rehabilitation for older patients has the potential to improve function and prevent admission to nursing homes, returning home after discharge is not possible for all patients. Better understanding of patient factors related to discharge home may lead to more realistic rehabilitation goals, more targeted rehabilitation interventions and better preparation of both patient and informal caregiver for discharge. Various studies provided insight into factors related to home discharge after stroke rehabilitation, but we still lack insight into factors related to home discharge in non-stroke patients. Therefore, the aim of this review is to provide an overview of factors influencing home discharge in older non-stroke patients admitted to an inpatient rehabilitation unit. METHODS: A systematic literature search was executed in the databases PubMed, EMBASE, CINAHL and Web of Science to retrieve articles published between January 2000 and October 2015. The search focused on factors related to home discharge after rehabilitation for older patients. Studies were included if home discharge after rehabilitation was assessed as an outcome measure and if the non-stroke population was, on average, 65 years or older and admitted to an inpatient rehabilitation unit. RESULTS: Eighteen studies were included. The methodological quality was moderate to good in 15 studies. The factors significantly associated with home discharge are younger age, non-white ethnicity, being married, better functional and cognitive status, and the absence of depression. CONCLUSIONS: Because various factors are significantly associated with home discharge of older non-stroke patients after rehabilitation, we recommend assessing these factors at admission to the rehabilitation unit. Further research into the factors that lack sufficient evidence concerning their association with home discharge is recommended.