A general practice intervention for people at risk of poor health outcomes: the Flinders QUEST cluster randomised controlled trial and economic evaluation

Abstract

Objective To determine whether a multicomponent general practice intervention cost‐effectively improves health outcomes and reduces health service use for patients at high risk of poor health outcomes. Design, setting Clustered randomised controlled trial in general practices in metropolitan Adelaide. Participants Three age‐based groups of patients identified by their general practitioners as being at high risk of poor health outcomes: children and young people (under 18 years), adults (18–64 years) with two or more chronic diseases, and older people (65 years or more). Intervention Enrolment of patients with a preferred GP, longer general practice appointments, and general practice follow‐up within seven days of emergency department and hospital care episodes. Intervention practices received payment of $1000 per enrolled participant. Main outcome measures Primary outcome: change in self‐rated health between baseline and 12‐month follow‐up for control (usual care) and intervention groups. Secondary outcomes: numbers of emergency department presentations and hospital admissions, Medicare specialist claims and Pharmaceutical Benefits Scheme (PBS) items supplied, Health Literacy Questionnaire scores, and cost‐effectiveness of the intervention (based on the number of quality‐adjusted life‐years [QALYs] gained over 12 months, derived from EQ‐5D‐5L utility scores for the two adult groups). Results Twenty practices with a total of 92 GPs were recruited, and 1044 eligible patients participated. The intervention did not improve self‐rated health (coefficient, –0.29; 95% CI, –2.32 to 1.73), nor did it have significant effects on the numbers of emergency department presentations (incidence rate ratio [IRR], 0.90; 95% CI, 0.69–1.17), hospital admissions (IRR, 0.90; 95% CI, 0.66–1.22), Medicare specialist claims (IRR, 1.00; 95% CI, 0.91–1.09), or PBS items supplied (IRR, 0.99; 95% CI, 0.96–1.03), nor on Health Literacy Questionnaire scores. The intervention was effective in terms of QALYs gained (v usual care: difference, 0.032 QALYs; 95% CI, 0.001–0.063), but the incremental cost‐effectiveness ratio was $69 585 (95% CI, $22 968–$116 201) per QALY gained, beyond the willingness‐to‐pay threshold. Conclusions Our multicomponent intervention did not improve self‐rated health, health service use, or health literacy. It achieved greater improvement in quality of life than usual care, but not cost‐effectively. Trial registration Australian New Zealand Clinical Trials Registry, ACTRN12617001589370 (prospective).

Achieving continuity of care in general practice: the impact of patient enrolment on health outcomes

“…However, it did not achieve improvements in the primary outcome of self‐rated health, nor in the secondary outcomes of health literacy and health service and hospital use over 12 months. The study did find a difference in the number of quality‐adjusted life‐years gained, but the intervention was not cost‐effective from the public health provider perspective 10 …”

“…The study did find a difference in the number of quality-adjusted life-years gained, but the intervention was not cost-effective from the public health provider perspective. 10 The absence of significant effects in this trial could have several explanations. The selection of patients may have been too broad to detect significant effects, and the benefits of enrolment and continuity of care may have been confined to patients at greater risk of poor outcomes, such as older people and those with complex long term conditions.…”

“…The selection of patients may have been too broad to detect significant effects, and the benefits of enrolment and continuity of care may have been confined to patients at greater risk of poor outcomes, such as older people and those with complex long term conditions. Further, the association between continuity of care and the quality of the relationship and communication between doctors and patients is bi‐directional and can evolve over longer periods than the twelve months of the study by Reed and colleagues 10 …”

“…Further, the association between continuity of care and the quality of the relationship and communication between doctors and patients is bi-directional and can evolve over longer periods than the twelve months of the study by Reed and colleagues. 10 We may need to modify our assumptions about the value of enrolment in the context of Australian general practice. This is especially so in light of the findings of another recently completed cluster randomised controlled trial in Australia, in which levels of continuity in general practice were found to be high at baseline and to not change following enrolment.…”

“…The article by Reed and colleagues in this issue of the MJA 10 describes one of the few cluster randomised controlled trials to evaluate a complex intervention for improving continuity of care in general practice. It included voluntary patient enrolment, greater access to longer consultations, and timely follow‐up after emergency and inpatient hospital care.…”