Effect Modification of Multimorbidity on the Association Between Regularity of General Practitioner Contacts and Potentially Avoidable Hospitalisations

Abstract

BACKGROUND: Scheduled regular contact with the general practitioner (GP) may lower the risk of potentially avoidable hospitalisations (PAHs). Despite the high prevalence of multimorbidity, little is known about its effect on the relationship between regularity of GP contact and PAHs. OBJECTIVE: To investigate potential effect modification of multimorbidity on the relationship between regularity of GP contact and probability of PAHs. DESIGN: A retrospective, cross-sectional study. PARTICIPANTS: 229,964 individuals aged 45 years and older from the 45 and Up Study in New South Wales, Australia, from 2009 to 2015. MAIN MEASURES: The main exposure was regularity of GP contact (capturing dispersion of GP contacts); the outcomes were PAHs evaluated by unplanned hospitalisations, chronic ambulatory care sensitive condition (ACSC) hospitalisations and unplanned chronic ACSC hospitalisations. Multivariable logistic regression models and population attributable fractions (PAF) were conducted to identify effect modification of multimorbidity, assessed by Rx-Risk comorbidity score. KEY RESULTS: Compared with the lowest quintile of regularity, the highest quintile had significantly lower predicted probability of unplanned admission (− 79.9 per 1000 people at risk, 95% confidence interval (CI) − 85.6; − 74.2), chronic ACSC (− 6.07 per 1000 people at risk, 95%CI − 8.07; − 4.08) and unplanned chronic ACSC hospitalisation (− 4.68 per 1000 people at risk, 95%CI − 6.11; − 3.26). Effect modification of multimorbidity was observed. Specifically, the PAF among people with no multimorbidity indicated that 31.7% (95%CI 28.7-34.4%) of unplanned, 36.4% (95%CI 25.1-45.9%) of chronic ACSC and 48.9% (95%CI 32.9-61.1%) of unplanned chronic ACSC hospitalisation would be reduced by a shift to the highest quintile of regularity. However, among people with 10+ morbidities, the proportional reduction was only 5.2% (95%CI 3.8-6.5%), 9.0% (95%CI 0.5-16.8%) and 17.8% (95%CI 5.4-28.5%), respectively. CONCLUSIONS: Weakening of the association between regularity and PAHs with increasing levels of multimorbidity suggests a need to improve primary care support to prevent PAHs for patients with multimorbidity.

Potentially preventable hospitalisations in rural community‐dwelling patients

“…24,25 It may be that primary care patients have little option but to either selfpresent or be referred to hospital for conditions that otherwise could be managed without hospital admission. 26 Improving access to CDM and home medicine review services for appropriate patients, the usage of which was relatively low in this study, may be one avenue to reduce PPH in rural areas. [27][28][29][30][31] Australian studies consistently show that indigenous Australians have a PPH risk approximately three times that of the wider population, with rural indigenous persons experiencing even higher rates.…”

“…While universal healthcare through Medicare substantially removes the financial barrier to accessing GP, there are limited options for escalation of treatment in the relatively low SES study population, such as use of private specialist medical services 24,25 . It may be that primary care patients have little option but to either self‐present or be referred to hospital for conditions that otherwise could be managed without hospital admission 26 . Improving access to CDM and home medicine review services for appropriate patients, the usage of which was relatively low in this study, may be one avenue to reduce PPH in rural areas 27–31 …”

Ten-Year Trends and Predictors of Unplanned Hospitalisation in Community-Dwelling Older People Receiving Home-Based Care

“…Presence of cognitive dysfunction monitoring of people with chronic conditions and/or multimorbidity, may reduce avoidable unplanned hospitalisations [19,20].…”

Rural Patients’ Perceptions of Their Potentially Preventable Hospitalisation: A Qualitative Study

“…Providing disease-specific education and encouraging patients to follow beneficial health recommendations are also effective in reducing PPHs ( 54 , 55 ). Regular use of primary healthcare services, notably GP attendance, has been associated with reduced PPHs ( 19 , 56 ). Patients here were noted to have high levels of trust in their “usual” GP, so promoting adherence to management recommendations during regular GP contact may be a promising means of reducing PPHs ( 57 ).…”