Reorganising dermatology care: predictors to substitute secondary care with primary care

摘要

Background : Substitution of healthcare is a way to control for rising healthcare costs. The intervention Primary Care Plus PC+ of the Dutch pioneer site ‘Blue Care’ aims to achieve this by facilitating consultations of medical specialists in the primary care setting. One of the specialisms involved is dermatology. Objective : This study focused on evaluating the referral decision after dermatology care in PC+, i.e. back to GP or referral to outpatient hospital care, and to evaluate the predictors. Methods : This retrospective study used monitoring data of patients visiting PC+ for dermatology care between January 2015 and March 2017. The referral decision after PC+ was the primary outcome. Stepwise logistic regression modelling was used to describe variations in referral decision, with patient’s age and gender, number of consultations in PC+, patient’s diagnosis and treating specialist as predicting factors. Results : 2,812 patients who visited PC+ for dermatology care were included in the analysis. Of those patients, 80.2% N=2,254 was referred back to the general practitioner GP and 19.8% N=558 was referred to outpatient hospital care. In the multivariable model, only treating specialist and patient’s diagnosis were independently influencing the referral decisions after PC+. Compared to specialist 1, patients treated by specialist 2 AOR = 1.88, 95% CI = 1.48–2.39, 3 AOR 1.97, 95% CI = 1.44–2.69 or another specialist AOR 1.80, 95% CI = 1.29–2.52 were more likely to be referred to outpatient hospital care after PC+. Compared to patients diagnosed with ‘Premaligne dermatosis’, patients with ‘Malignant dermatosis’ AOR 12.98, 95% CI = 7.96-21.17, ‘Inflammatory dermatoses’ AOR 2.12, 95% CI = 1.33-3.38 and an unknown diagnosis AOR 2.24, 95% CI = 1.45-3.45 were more likely to be referred to outpatient hospital care. Patient with ‘Eczema other’ AOR 0.36, 95% CI = 0.19-0.66, ‘Dermatoses by microorganism’ AOR 0.32, 95% CI = 0.16-0.66 and ‘Hair and nail disorders’ AOR 0.23, 95% CI = 0.09-0.59 were less likely to be referred to outpatient hospital care. The final model explained 19.3% of the variation in referral decisions. Discussion : In PC+, integrated care is stimulated through facilitating consultations of medical specialists in the primary care setting. The findings of this study can be used to discuss with GPs and dermatologist the optimisation of PC+ for dermatology care by learning from each other in order to achieve substitution by shifting specialised care to primary care. Conclusion : Looking at the referral decision after dermatology care in PC+, a majority of the patients were referred back to their GP. Treating specialist and patient’s diagnosis are independently influencing this referral decision. Lessons learned : Dermatology care seems to be suitable for PC+. However, not every specialist and diagnosis fit the profile of PC+. Limitations : The number of predictors included in this study was restricted. Follow-up data of patients visiting PC+ was not taken into account. Suggestions for future research : According to the Triple Aim, it is recommended to also look at the experienced quality of care, patient’s health and cost of care.