Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care..., 2021, Sandvik, Hetlevik, et al

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JohnTheJack

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Full title:
Continuity in general practice as predictor of mortality, acute hospitalisation, and use of out-of-hours care: a registry-based observational study in Norway

https://bjgp.org/content/early/2021/10/04/BJGP.2021.0340

Aim To analyse the association between longitudinal continuity with a named regular general practitioner (RGP) and use of out-of-hours (OOH) services, acute hospital admission, and mortality.

Design and setting Registry-based observational study in Norway covering 4 552 978 Norwegians listed with their RGPs.

Method Duration of RGP–patient relationship was used as explanatory variable for the use of OOH services, acute hospital admission, and mortality in 2018. Several patient-related and RGP-related covariates were included in the analyses by individual linking to high-quality national registries. Duration of RGP–patient relationship was categorised as 1, 2–3, 4–5, 6–10, 11–15, or >15 years. Results are given as adjusted odds ratio (OR) with 95% confidence intervals (CI) resulting from multilevel logistic regression analyses.

Results Compared with a 1-year RGP–patient relationship, the OR for use of OOH services decreased gradually from 0.87 (95% CI = 0.86 to 0.88) after 2–3 years’ duration to 0.70 (95% CI = 0.69 to 0.71) after >15 years. OR for acute hospital admission decreased gradually from 0.88 (95% CI = 0.86 to 0.90) after 2–3 years’ duration to 0.72 (95% CI = 0.70 to 0.73) after >15 years. OR for dying decreased gradually from 0.92 (95% CI = 0.86 to 0.98) after 2–3 years’ duration, to 0.75 (95% CI = 0.70 to 0.80) after an RGP–patient relationship of >15 years.

Conclusion Length of RGP–patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose–response relationship between continuity and these outcomes indicates that the associations are causal.
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Length of RGP–patient relationship is significantly associated with lower use of OOH services, fewer acute hospital admissions, and lower mortality. The presence of a dose–response relationship between continuity and these outcomes indicates that the associations are causal.
Click to expand...
I haven't read the paper, but surely assuming a long association with one GP as being causal for lower mortality and the rest is way too simplistic?

Thinking about what might cause someone to not have a long association -
* housing insecurity - people who own their own home will tend to have more stability in their address - and be better off financially. And so be able to afford better food; find it easier to participate in national health screening programmes because the letters and emails find them; live in houses that are healthier; live in neighbourhoods that are healthier.
* mental illness and substance abuse - tied up with poverty, but also the capacity to make choices that will help physical health
* dissatisfaction with their GPs - People with health conditions that aren't easily managed or are often stigmatised are more likely to be dissatisfied and are more likely to change doctors. Even just someone with a standard health condition is a lot more likely to be dissatisfied with their GP, or move to a different GP in order to get better care, than someone who is healthy and hardly ever goes to their GP.
* rural addresses. People in rural areas may not have much choice in GP, and so may stick with the one they can get to. Their lower use of out of hours care and hospital admissions could well be related to the difficulty in accessing those services, and some choice around that for minor health issues.
 
Now I've read the paper. I do think continuity of care is a good thing, so I can understand why the researchers might want to produce some evidence in support of that.

And there were some adjustments - for the patient's level of education, for their level of health (but not mental health) and 'centrality' (rural/urban), although little detail is given about the adjustments.

But, there was little acknowledgement that factors like personal income and mental health affect both 'continuity of care' and 'hospital use' rather than 'continuity of care' being a key driver of health outcomes.

The paper would have been a lot more persuasive if they had stratified the very large database into people with different characteristics, and shown how continuity of care might help people in each of those groups.
 
Subjectively seeing the same trusted health professionals over time is much more preferable than an ever changing sequence of strangers, however though I see continuity of ‘good’ care as desirable, continuity of ‘bad’ care can be disastrous.
 
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