Regular primary care lowers hospitalisation risk and mortality in seniors with chronic respiratory diseases

Abstract

Background: Exacerbations in chronic respiratory diseases (CRDs) are sensitive to seasonal variations in exposure to respiratory infectious agents and allergens and patient factors such as non-adherence. Hence, regular general practitioner (GP) contact is likely to be important in order to recognise symptom escalation early and adjust treatment.

Objective: To examine the association of regularity of GP visits with all-cause mortality and first CRD hospitalisation overall and within groups of pharmacotherapy level in older CRD patients.

Design: A retrospective cohort design using linked hospital, mortality, Medicare and pharmaceutical data for participant, exposure and outcome ascertainment. GP visit pattern was measured during the first 3 years of the observation period. Patients were then followed for a maximum of 11.5 years for ascertainment of hospitalisations and deaths.

Participants: We studied 108,455 patients aged >or=65 years with CRD in Western Australia (WA) during 1992-2006.

Main measures: A GP visit regularity score (range 0-1) was calculated and divided into quintiles. A clinician consensus panel classified levels of pharmacotherapy. Cox proportional hazards models, controlling for multiple factors including GP visit frequency, were used to calculate hazard ratios and confidence intervals.

Key results: Differences in survival curves and hospital avoidance pattern between the GP visit regularity quintiles were statistically significant (p = 0.0279 and p < 0.0001, respectively). The protective association between GP visit regularity and death appeared to be confined to the highest pharmacotherapy level group (P for interaction = 0.0001). Higher GP visit regularity protected against first CRD hospitalisation compared with the least regular quintile regardless of pharmacotherapy level (medium regular: HR = 0.84, 95% CI = 0.77-0.92; 2nd most regular: HR = 0.74, 95% CI = 0.67-0.82; most regular HR = 0.77, 95% CI = 0.68-0.86).

Conclusions: The findings indicate that regular and proactive 'maintenance' primary care, as distinct from 'reactive' care, is beneficial to older CRD patients by reducing their risks of hospitalisation and death.

Figure 1

Estimated survival functions for chronic respiratory disease patients in strata of GP visit regularity quintile with all-cause death as outcome. The functions are adjusted for number of GP visits, gender, age at start of follow-up, ethnicity, area-based socioeconomic status, residential remoteness, the Charlson Index of Comorbidity and indigenous status. The survival curves for 2nd least regular and medium regular merge together.

Figure 2

Estimated survival functions for CRD patients in strata of GP visit regularity quintile with first CRD hospitalisation as outcome. The functions are adjusted for number of GP visits, gender, age at start of follow-up, ethnicity, area-based socioeconomic status, residential remoteness, the Charlson Index of Comorbidity and indigenous status. CRD = chronic respiratory disease.