Substitution of outpatient hospital care with specialist care in the primary care setting: A systematic review on quality of care, health and costs

Abstract

Rationale, aims and objective Substituting 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. Method The 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. Results A 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. Conclusions Despite 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.

Comparison of patient perceptions of primary care quality across healthcare facilities in Korea: A cross-sectional study

“…[1,3] Evidence supports this perspective, indicating shorter waiting lists, shorter clinic waiting times, and higher patient satisfaction after the substitution interventions. [25] Nonetheless, we found that the levels of trust and user satisfaction were highest for hospitals. This user view might be partly linked to the belief that good facilities and equipment of large hospitals guarantee good qualities of care.…”

“…[3] Unnecessary utilization of hospital outpatient care is one of the main contributors of escalating healthcare costs. [25] Substituting hospital outpatient care with primary care is recommended as a solution to accomplish efficient and cost-effective healthcare delivery. [1,3] Evidence supports this perspective, indicating shorter waiting lists, shorter clinic waiting times, and higher patient satisfaction after the substitution interventions.…”

“…[21] Due to the absence of functional gatekeeping (virtually equivalent to direct access to hospitals), [23,24] hospital ambulatory care has been over-utilized, and many hospitals in turn have expanded their outpatient units. [21] Furthermore, their intensive use of expensive technology and over-provision of treatment services have burdened the National Health Insurance system, [6,16,17,25] undermining efficiencies in health expenditure and equity in resource allocation. [16] Previous studies estimated that at least 15% to 33% of hospital outpatient visits were deliverable in primary care facilities, [24,26] and 29% of the national expenditure on ambulatory care was for the hospital sector.…”

“…[16] To overcome these problems, reforming health systems to make better use of resources is crucial. [25] National policy changes are urgently needed to shift focus from a specialty-and curative-care orientation to a more cost-effective health system based on high-quality primary care. [20,21,27] As the first step to reinforce the primary care system, understanding public perception of primary care will be essential.…”

Cost and Quality Impacts of Treatment Loci for Type 2 Diabetes Patients with Moderate Disease Severity: Hospital- vs. GP-Basedmonitoring

“…Substantial research has been conducted investigating patterns of care delivery, for example, comparing the relative effectiveness of specialists and generalists [1], [2], and the substitution of care provided by specialists in general-practice settings for hospital-based outpatient care [3].…”