Effects of primary care coordination on public hospital patients |
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Authors: | Dr D Schillinger MD K Bibbins-Domingo MD PhD K Vranizan MA P Bacchetti PhD J M Luce MD A B Bindman MD |
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Institution: | (1) Primary Care Research Center, San Francisco General Hospital, 1001 Potrero Ave., Bldg, 90, Ward 95, UCSF Box 1364, 94143-1364 San Francisco, CA;(2) Department of Medicine, University of California, San Francisco, San Francisco, Calif;(3) Department of Epidemiology and Biostatistics, UCSF, San Francisco, Calif |
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Abstract: | OBJECTIVE: To evaluate the effect of primary care coordination on utilization rates and satisfaction with care among public hospital
patients.
DESIGN: Prospective randomized gatekeeper intervention, with 1-year follow-up.
SETTING: The Adult General Medical Clinic at San Francisco General Hospital, a university-affiliated public hospital.
PATIENTS: We studied 2,293 established patients of 28 primary care physicians.
INTERVENTION: Patients were randomized based on their primary care physician’s main clinic day. The 1,121 patients in the intervention
group (Ambulatory Patient-Physician Relationship Organized to Achieve Coordinated Healthcare APPROACH] group) required primary
care physician approval to receive specialty and emergency department (ED) services; 1,172 patients in the control group did
not.
MEASUREMENTS AND MAIN RESULTS: Changes in outpatient, ED, and inpatient utilization were measured for APPROACH and control groups over the 1-year observation
period, and the differences in the changes between groups were calculated to estimate the effect of the intervention. Acceptability
of the gatekeeping model was determined via patient satisfaction surveys.
RESULTS: Over the 1-year observation period, APPROACH patients decreased their specialty use by 0.57 visits per year more than control
patients did (P=.04; 95% confidence interval CI] −1.05 to −0.01). While APPROACH patients increased their primary care use by 0.27 visits
per year more than control patients, this difference was not statistically significant (P=.14; 95% CI, −0.11 to 0.66). Changes in lowacuity ED care were similar between the two groups (0.06 visits per year more
in APPROACH group than control group, P=.42; 95% CI, −0.09 to 0.22). APPROACH patients decreased yearly hospitalizations by 0.14 visits per year more than control
patients (P=.02; 95% CI, −0.26 to −0.03). Changes in patient satisfaction with care, perceived access to specialists, and use of out-of-network
services between the 2 groups were similar.
CONCLUSIONS: A primary care model of health delivery in a public hospital that utilized a gatekeeping strategy decreased outpatient specialty
and hospitalization rates and was acceptable to patients. |
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Keywords: | primary care coordination public hospital patients gate keeping utilization |
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