Search

BackgroundMany Western countries face the challenge of providing high-quality care while keeping the healthcare system accessible and affordable. In an attempt to deal with this challenge a new healthcare delivery model called primary care plus (PC+) was introduced in the Netherlands. Within the PC+ model, medical specialists perform consultations in a primary care setting. PC+ aims to support the general practitioners in gatekeeping and prevent unnecessary referrals to hospital care. The aim of this study was to examine the effects of a cardiology PC+ intervention on the Triple Aim outcomes, which were operationalized by patient-perceived quality of care, health-related quality of life (HRQoL) outcomes, and healthcare costs per patient.MethodsThis is a quantitative study with a longitudinal observational design. The study population consisted of patients, with non-acute and low-complexity cardiology-related health complaints, who were referred to the PC+ centre (intervention group) or hospital-based outpatient care (control group; care-as-usual). Patient-perceived quality of care and HRQoL (EQ-5D-5L, EQ-VAS and SF-12) were measured through questionnaires at three different time points. Healthcare costs per patient were obtained from administrative healthcare data and patients were followed for nine months. Chi-square tests, independent t-tests and multilevel linear models were used to analyse the data.ResultsThe patient-perceived quality of care was significantly higher within the intervention group for 26 out of 27 items. HRQoL outcomes did significantly increase in both groups (P ConclusionsWhile this study showed no improvements on HRQoL outcomes, PC+ seemed to be promising as it results in improved quality of care as experienced by patients and lower healthcare costs per patient.

Introduction: To deal with the pressures on the healthcare system, the healthcare system should focus on high-value health care by pursuing the three aims: improving the health of the population, improving the quality of care as experienced by patients and reducing the increase of healthcare costs. In the Netherlands, several initiatives focus on strengthening the primary care and substituting hospital care with primary care in order to keep the health care system sustainable. This study is concentrated on a cardiology primary care plus PC+ centre where cardiologists provide specialist consultations in a primary care setting. This PC+ intervention aims to improve the health of the population and patients’ experience of care while reducing the healthcare costs by decreasing the number of unnecessary referrals to specialist care in the hospital setting. Methods: This is a practice-based study with a longitudinal observational design. The study population consisted of adult patients with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre intervention group or hospital-based outpatient cardiology care control group. Data of the PC+ centre and the hospital were used to investigate the referral and follow-up patterns of intervention group patients compared to the control group. Furthermore, patients were asked to complete questionnaires at three different time points before consultation, directly after consultation, three months after consultation consisting of items about their demographics, health status SF-12, EQ-5D-5L and EQ-VAS and experience of care. Results: The data of the PC+ centre and the hospital consists of 1838 intervention patients and 2155 control patients. Preliminary results show that 27.9 % n= 513 of the intervention group was referred to hospital care after a consultation at the PC+ centre. Moreover, 437 intervention patients and 328 control patients were included in the questionnaire study. In 25 out of 27 items PC+ results in significantly higher levels of patient satisfaction compared to hospital-based outpatient care. The results of the EQ5D-5L indicate no differences in health status between the groups, taking into account the follow-up period of three months F=0.133; P=0.865. Discussion: PC+ is a new concept in the Dutch healthcare system and evidence about its effects is scarce. The findings of this study will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes. Conclusion: Whilethis study showed no effects on the health status of the patients, there are promising results looking at the patients’ experience of care and healthcare utilization. Lessons learned: The implementation, as well as the evaluation, of PC+ initiatives is a dynamic process which requires time and continuous interaction with the stakeholders. Limitations: This study does not yet provide insight in the actual effects of PC+ on healthcare costs. Suggestions for future research: Future research, concentrated on PC+, should continue focusing on the Triple Aim outcomes, with a particular focus on healthcare costs.

BACKGROUND: In an attempt to deal with the pressures on the healthcare system and to guarantee sustainability, changes are needed. This study is focused on a cardiology Primary Care Plus intervention in which cardiologists provide consultations with patients in a primary care setting in order to prevent unnecessary referrals to the hospital. This study explores which patients with non-acute and low-complexity cardiology-related health complaints should be excluded from Primary Care Plus and referred directly to specialist care in the hospital.METHODS: This is a retrospective observational study based on quantitative data. Data collected between January 1 and December 31, 2015 were extracted from the electronic medical record system. Logistic regression analyses were used to select patient groups that should be excluded from referral to Primary Care Plus.RESULTS: In total, 1525 patients were included in the analyses. Results showed that male patients, older patients, those with the referral indication 'Stable Angina Pectoris' or 'Dyspnoea' and patients whose reason for referral was 'To confirm disease' or 'Screening of unclear pathology' had a significantly higher probability of being referred to hospital care after Primary Care Plus.CONCLUSIONS: To achieve efficiency one should exclude patient groups with a significantly higher probability of being referred to hospital care after Primary Care Plus.TRIAL REGISTRATION NUMBER: NTR6629 (Data registered: 25-08-2017) (registered retrospectively).

Objective: Consistent evidence on the effects of specialist services in the primary care setting is lacking. Therefore, this study evaluated the effects of an in-house internist at a GP practice on the number of referrals to specialist care in the hospital setting. Additionally, the involved GPs and internist were asked to share their experiences with the intervention.Design: A retrospective interrupted times series study.Setting: Two multidisciplinary general practitioner (GP) practices.Intervention: An internist provided in-house patient consultations in two GP practices and participated in the multidisciplinary meetings.Subjects: The referral data extracted from the electronic medical record system of the GP practices, including all referral letters from the GPs to specialist care in the hospital setting.Main outcome measures: The number of referrals to internal medicine in the hospital setting. This study used an autoregressive integrated moving average model to estimate the effect of the intervention taking account of a time trend and autocorrelation among the observations, comparing the pre-intervention period with the intervention period.Results: It was found that the referrals to internal medicine did not statistically significant decrease during the intervention period.Conclusions: This small explorative study did not find any clues to support that an in-house internist at a primary care setting results in a decrease of referrals to internal medicine in the hospital setting.Key points:An in-house internist at a primary care setting did not result in a significant decrease of referrals to specialist care in the hospital setting. The GPs and internist experience a learning-effect, i.e. an increase of knowledge about internal medicine issues.

Rationale, aims and objectiveSubstituting outpatient hospital care with primary care is seen as a solution to decrease unnecessary referrals to outpatient hospital care and decrease rising healthcare costs. This systematic review aimed to evaluate the effects on quality of care, health and costs outcomes of substituting outpatient hospital care with primary care-based interventions, which are performed by medical specialists in face-to-face consultations in a primary care setting.MethodThe systematic review was performed using the PICO framework. Original papers in which the premise of the intervention was to substitute outpatient hospital care with primary care through the involvement of a medical specialist in a primary care setting were eligible.ResultsA total of 14 papers were included. A substitution intervention in general practitioner (GP) practices was described in 11 papers, three described a joint consultation intervention in which GPs see patients together with a medical specialist. This study showed that substitution initiatives result mostly in favourable outcomes compared to outpatient hospital care. The initiatives resulted mostly in shorter waiting lists, shorter clinic waiting times and higher patient satisfaction. Costs for treating one extra patient seemed to be higher in the intervention settings. This was mainly caused by inefficient planning of consultation hours and lower patient numbers.ConclusionsDespite the fact that internationally a lot has been written about the importance of performing substitution interventions in which preventing unnecessary referrals to outpatient hospital care was the aim, only 14 papers were included. Future systematic reviews should focus on the effects on the Triple Aim of substitution initiatives in which other healthcare professions than medical specialists are involved along with new technologies, such as e-consults. Additionally, to gain more insight into the effects of substitution initiatives operating in a dynamic healthcare context, it is important to keep evaluating the interventions in a longitudinal study design.

Background In an attempt to deal with the pressures on the health-care system and to guarantee sustainability, changes are needed. This study focuses on a cardiology primary care plus intervention. Primary care plus (PC+) is a new health-care delivery model focused on substitution of specialist care in the hospital setting with specialist care in the primary care setting. The intervention consists of a cardiology PC+ centre in which cardiologists, supported by other health-care professionals, provide consultations in a primary care setting. The PC+ centre aims to improve the health of the population and quality of care as experienced by patients, and reduce the number of referrals to hospital-based outpatient specialist care in order to reduce health-care costs. These aims reflect the Triple Aim principle. Hence, the objectives of the study are to evaluate the cardiology PC+ centre in terms of the Triple Aim outcomes and to evaluate the process of the introduction of PC+. Methods/Design The study is a practice-based, quantitative study with a longitudinal observational design, and an additional qualitative study to supplement, interpret and improve the quantitative study. The study population of the quantitative part will consist of adult patients (≥18 years) with non-acute and low-complexity cardiology-related health complaints, who will be referred to the cardiology PC+ centre (intervention group) or hospital-based outpatient cardiology care (control group). All eligible patients will be asked to complete questionnaires at three different time points consisting of questions about their demographics, health status and experience of care. Additionally, quantitative data will be collected about health-care utilization and related health-care costs at the PC+ centre and the hospital. The qualitative part, consisting of semi-structured interviews, focus groups, and observations, is designed to evaluate the process as well as to amplify, clarify and explain quantitative results. Conclusions This study will evaluate a cardiology PC+ centre using quantitative and supplementary qualitative methods. The findings of both sub-studies will fill a gap in knowledge about the effects of PC+ and in particular whether PC+ is able to pursue the Triple Aim outcomes. Trial registration NTR6629 (Data registered: 25-08-2017) (registered retrospectively). Electronic supplementary material The online version of this article (10.1186/s12913-017-2580-x) contains supplementary material, which is available to authorized users.

Context : Rising expenditures threaten the sustainability of many healthcare systems. In the Netherlands for example, health spending is predicted to rise from 13% of GDP in 2010, to 22% in 2040 [1], straining the affordability of the system [2]. In response, some governments have reformed their nation’s healthcare sector [3]. However, integrating the delivery of healthcare services could provide a more practical solution to curbing rising expenditures [4]. Substitution of care is therefore high on the (political) agenda in the Netherlands [5]. In unison, the government defined nine pioneer sites (i.e. ‘Proeftuinen’) in which stakeholders experiment with the restructuring of service delivery based on the population management (PM) concept. Although a widely accepted definition is lacking [6], PM initiatives generally address a population’s health needs at all points along the health and well-being continuum through integration. Regional stakeholders are thus expected to establish partnerships with each other, aimed at improving Triple Aim outcomes [7]. In the majority of the pioneer sites, stakeholders have focused their efforts on integrating primary and secondary care, resulting in so-called Primary Care Plus (PC+) initiatives in which medical specialists are placed in primary care settings to treat patients with less complex medical needs. By better integration between primary and secondary care, these initiatives aim to reduce the amount of unnecessary referrals to expensive hospital settings. Instead, patients are treated in less expensive, yet equally adequate, primary care settings. Target participants : This workshop, chaired by Dirk Ruwaard, professor at Maastricht UMC / Maastricht University, presents results of several research projects within the ‘Academic Collaborative Center for Sustainable Health Care’ focused on integrated care. Specifically, the workshop addresses integration of primary and secondary care and it is intended for all who are interested or involved in such initiatives. We will commence by describing which decisions shaped the creation of PC+ centers, to what extent interests and ideals of stakeholders conflicted, and how these conflicts were resolved. Next, we illustrate how the Dutch antitrust regulations influence the prosperity of initiatives attempting to integrated primary and secondary care. Having overcome these legislative hurdles, the workshop will illustrate how the patients experience care in PC+ centers. Is the care truly patient centered for example? Similarly, the workshop will highlight the perspective of health professionals. Based on a novel sustainable employability framework, we discuss to what extent working in PC+ creates new and exciting opportunities, or places a strenuous burden on medical specialists and GPs. Subsequently, the topic of rising health expenditures is addressed. To what extend do PC+ initiatives succeed in their attempt to curb the trend of rising healthcare costs? Has care been substituted towards primary care settings or do PC+ centers serve as an extra ‘layer’ in an already complex and expensive system? Lastly, the workshop provides sufficient opportunity for the attendees to critically assess these initiatives, share their own thoughts and experiences, and engage in a discussion led by Dirk Ruwaard. References : 1- van Ewijk C, van der Horst A, Besseling P. Toekomst voor de zorg. Den Haag: CPB, 2013. 2- Ministry of Health Welfare and Sports (MHWS). Naar beter betaalbare zorg. Rapport Taskforce Beheersing Zorguitgaven. Den Haag: MHWS, 2012. 3- Cutler DM. Equality, efficiency, and market fundamentals: the dynamics of international medical-care reform. Journal of Economic Literature 2002; 40:881-906. 4- Hildebrandt H, Schulte T, Stunder B. Triple Aim in Kingzigtal, Germany: Improving population health, integrating health care and reducing costs of care - lessons for the UK. Journal of Integrated Care 2012; 20:205-22. 5- Ministerie van Volksgezondheid WeS. Bestuurlijk hoofdlijnenakkoord 2012-2015. Den Haag: Ministry of Health Welfare and Sports (MHWS), 2011. 6- Struijs JN, Drewes HW, Heijink R, Baan CA. How to evaluate population management? Transforming the Care Continuum Alliance population health guide toward a broadly applicable analytical framework. Health Policy 2014. 7- Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, Health, and Cost. Health Affairs 2008; 27:759-69.

Healthcare organizations commonly collaborate by sharing human resources attempting to improve quality of care and/or reduce costs. However, little is known about the effects of working at such int...