Complements or substitutes? Associations between volumes of care provided in the community and hospitals

Abstract

Policymakers often suggest that expansion of care in community settings may ease increasing pressures on hospital services. Substitution may lower overall health system costs, but complementarity due to previously unidentified needs might raise them. We used new national data on community and primary medical care services in England to undertake system-level analyses of whether activity in the community acts as a complement or a substitute for activity provided in hospitals. We used two-way fixed effects regression to relate monthly counts of community care and primary medical care contacts to emergency department attendances, outpatient visits and admissions for 242 hospitals between November 2017 and September 2019. We then used national unit costs to estimate the effects of increasing community activity on overall system expenditure. The findings show community care contacts to be weak substitutes with all types of hospital activity and primary care contacts are weak substitutes for emergency hospital attendances and admissions. Our estimates ranged from 28 [95% CI 21, 45] to 517 [95% CI 291, 7265] community care contacts and from 34 [95% CI 17, 1283] to 1655 [95% CI − 1995, 70,145] GP appointments to reduce one hospital service visit. Primary care and planned hospital services are complements. Increases in community services and primary care activity are both associated with increased overall system expenditure of £34 [95% CI £156, £54] per visit for community care and £41 [95% CI £78, £74] per appointment in general practice. Expansion of community-based services may not generate reductions in hospital activity and expenditure.

Does increasing physician volume in primary healthcare facilities under the hierarchical medical system help reduce hospital service utilisation in China? A fixed-effects analysis using province-level panel data

“…However, in our model, we did not find significant associations between increases in primary healthcare physician volume and reductions in public hospital inpatient admissions or outpatient expenses, either before or after the national policy was implemented. Our findings are consistent with those of a previous study in the UK, where increases in primary healthcare services were not associated with reduced hospital activity or expenditure 25. It should be noted that the UK has a strict gatekeeping system that requires referral from primary healthcare facilities in order to obtain hospital care.…”

“…Several studies in developed countries, such as the UK and Australia, as well as studies in China, have shown that increasing access to primary healthcare services is associated with reduced hospital outpatient visits and inpatient admissions. [24][25][26][27][28] However, evidence on the association between physician staffing improvement and hospital utilisation after China facilitated the establishment of the hierarchical medical system is still lacking.…”

“…Our findings are consistent with those of a previous study in the UK, where increases in primary healthcare services were not associated with reduced hospital activity or expenditure. 25 It should be noted that the UK has a strict gatekeeping system that requires referral from primary healthcare facilities in order to obtain hospital care. Although China does not have such a strict referral system, primary healthcare facilities are taking on a similar role as gatekeepers under the hierarchical medical system.…”

“…Therefore, it is important to understand whether the improved physician capacity in primary healthcare facilities helps further reduce hospital service utilisation under the context of the hierarchical medical system. Several studies in developed countries, such as the UK and Australia, as well as studies in China, have shown that increasing access to primary healthcare services is associated with reduced hospital outpatient visits and inpatient admissions 24–28. However, evidence on the association between physician staffing improvement and hospital utilisation after China facilitated the establishment of the hierarchical medical system is still lacking.…”