If you want to keep patients from visiting the ER on a regular basis, make sure they see their primary care physician whenever necessary.
This is the kind of advice primary care physicians have been giving for years, and now a recent study in California provides evidence to support it.
Nadereh Pourat, Ph.D., M.S.P.H., a professor of health policy at the University of California, Los Angeles, was lead author of the study, which analyzed the effects of having an ongoing relationship with a primary care clinician. The study, "In California, Primary Care Continuity Was Associated With Reduced Emergency Department Use and Fewer Hospitalizations,"(content.healthaffairs.org) was published in Health Affairs in July.
The researchers sought to learn whether receipt of insurance coverage and a consistent relationship with a primary care health professional (i.e., an M.D., D.O. or nurse practitioner specializing in family medicine or general internal medicine) could reduce rates of hospitalizations and ER visits. What they found was that patients who stayed with their chosen primary care clinician had a higher probability of having no ER visits (2.1 percent change) and no hospital admissions (1.7 percent change).
- Researchers in California sought to learn whether insurance coverage and a consistent relationship with a primary care clinician could reduce rates of hospitalizations and ER visits.
- During the first two years of the study, patients were not required to stay with their chosen primary care physician, and researchers noted that the resulting lower levels of adherence to a single clinician correlated with higher rates of hospitalization and ER visits.
- The likelihood of patients being hospitalized or visiting the ER dropped in the third year of the study, when patients were required to see the same clinician from visit to visit.
"Primary care providers have probably been saying this for years, but by actually quantifying that impact, it can get the attention of policymakers," Pourat said.
Patients tracked in the study had been uninsured for a long time and had experienced other barriers to access; most were women older than 50 who spoke English as their primary language. The study focused on Orange County, where more than 49,000 previously uninsured adults were enrolled in an initiative that expanded Medicaid eligibility from 2007 to 2010.
During the first two years of the study, the county did not require patients to stay with their chosen primary care clinician. As a result, only 40 percent of visits during the study's second year were considered to be adherent to the chosen primary care clinician, with researchers noting that nonadherence contributed to high rates of ER and hospital visits.
"The chronically uninsured go wherever they can to get care," Pourat said. "They go to one provider because of short waiting times and go to another for other services. Once they got coverage, they did not change their behavior."
When the study began its third year, patients were required to visit their chosen primary care clinician for nonurgent care and could change primary care professionals only twice a year.
"If a patient stays with the same provider, you build rapport with the physician, who understands the patient's history and can focus on weight reduction, getting more exercise, taking medication more regularly and also knows what medication has bad side effects," Pourat said. "You lose a lot of those interactions when the patient moves around."
Although a small reduction in hospital or ER visits may appear minor on paper, Pourat noted that a three-day stay in a hospital cost $9,000 in California, according to 2012 estimates.
"A small percentage could make a huge difference because these are not inexpensive services," she said.
Pourat said the research sample included a lot of healthy individuals who did not need ongoing medical care and noted that researchers might have found bigger reductions in ER visits and hospitalizations if they had focused on patients with chronic illness. Researchers also noted that they did not have extensive data on patient outcomes to determine whether the program affected health status.
"We would like to look more closely at what happens in the ER or during a hospital visit to determine how many visits were avoidable," Pourat said.
As the authors noted, even recently insured Medicaid patients will respond to policy measures that are designed to promote continuity of care via medical homes.
"It's not enough to give people insurance coverage and expect all good things to follow," Pourat said. "Coverage is a necessary first step, but you have to focus on how care is delivered if you want the patient's health to improve."