Editorials
General medicine Health services administration
Volume 216 - Issue 9

Achieving continuity of care in general practice: the impact of patient enrolment on health outcomes

Authors:  Mark F Harris and Joel Rhee

Med J Aust 2022; 216 (9): 460-461. || doi: 10.5694/mja2.51508
Published online: 16 May 2022

The search for a cost-effective Australian model of comprehensive, coordinated patient-centred care that improves outcomes continues

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The search for a cost‐effective Australian model of comprehensive, coordinated patient‐centred care that improves outcomes continues

Continuity of care has long been regarded as a core characteristic of general practice.1 It is thought important because it encourages more appropriate and proactive use of health care services (including hospital care), improves communication between doctors and patients, reduces inconsistency of care, and increases the chances of early diagnosis and effective management of long term conditions. Continuity of care is also associated with greater patient satisfaction, self‐management, and chronic disease management, as well as with fewer hospitalisations and lower mortality.2,3

Continuity of primary care has been formalised in many countries; patients are required or at least encouraged to enrol with a single primary care practice to receive most or all of their primary care.4 In observational studies in Europe and Canada, voluntary enrolment was associated with improved access to primary care, especially for people from socio‐economically disadvantaged groups.5,6 However, this approach can also reduce freedom of choice for patients and cause difficulties when providing multidisciplinary care for people with chronic or multiple medical conditions.

Patient enrolment has not been adopted in Australia. In its stead, Medicare‐funded Chronic disease GP Management Plans and Team Care Arrangements were introduced to coordinate multidisciplinary care, care coordinators to improve consistency of care, and a patient‐controlled electronic health record to improve informational continuity.7 However, evidence that these measures achieve comparable continuity or outcomes is scarce, and evidence of errors and poor outcomes attributable to inadequate continuity of care continue to be reported.8,9

The article by Reed and colleagues in this issue of the MJA10 describes one of the few cluster randomised controlled trials to evaluate a complex intervention for improving continuity of care in general practice. It included voluntary patient enrolment, greater access to longer consultations, and timely follow‐up after emergency and inpatient hospital care. However, it did not achieve improvements in the primary outcome of self‐rated health, nor in the secondary outcomes of health literacy and health service and hospital use over 12 months. The study did find a difference in the number of quality‐adjusted life‐years gained, but the intervention was not cost‐effective from the public health provider perspective.10

The absence of significant effects in this trial could have several explanations. The selection of patients may have been too broad to detect significant effects, and the benefits of enrolment and continuity of care may have been confined to patients at greater risk of poor outcomes, such as older people and those with complex long term conditions. Further, the association between continuity of care and the quality of the relationship and communication between doctors and patients is bi‐directional and can evolve over longer periods than the twelve months of the study by Reed and colleagues.10

We may need to modify our assumptions about the value of enrolment in the context of Australian general practice. This is especially so in light of the findings of another recently completed cluster randomised controlled trial in Australia, in which levels of continuity in general practice were found to be high at baseline and to not change following enrolment.11 The benefits of enrolment may also be confounded by improved sharing of information and teamwork in the broader health system.

The “patient‐centred medical home” is a primary care model that aims to provide comprehensive and coordinated patient‐centred care and improve whole‐of‐practice quality. Like the intervention described by Reed and his co‐authors, enrolment, personal continuity, and practice payment reform are key elements, facilitating more continuous personal relationships between GPs and their patients, and helping practices to provide proactive care for patients with special needs outside the consultation.12 The Australian government has supported trials of a similar health care home model that includes enrolment in general practice of patients with long term conditions, bundled payments, and tools to identify patients at risk of hospitalisation.13 The results of this trial, concluded in June 2021, are eagerly awaited.

 

Authors

  • Mark F Harris1
  • Joel Rhee2
  • 1. Centre for Primary Health Care and Equity, University of New South Wales, Sydney, NSW
  • 2. University of New South Wales, Sydney, NSW

Correspondence: m.f.harris@unsw.edu.au

Competing interests

No relevant disclosures.

References

Linked content

  • MJA Podcast: Professor Mark Harris

  • MJA Research: A general practice intervention for people at risk of poor health outcomes: the Flinders QUEST cluster randomised controlled trial and economic evaluation

Provenance: Commissioned; not externally peer reviewed.

View this article on Wiley Online Library