Unplanned hospitalisations, functional ability, and quality of life of enrolled older primary care patients: Associations with general practitioner and practice characteristics in New Zealand and the Netherlands

Abstract

Context. Various ways to improve the practice and organisation of primary care are being explored in response to ageing populations, but it remains unclear why attempts have been largely unsuccessful in demonstrating benefits to older people's health outcomes. Aim. To investigate the influence of GP and practice characteristics on hospitalisations, functional ability, and quality of life of older people in New Zealand and the Netherlands Methods. This is a secondary analysis of data from two primary care-based cluster randomised controlled trials: n=3,755 participants aged 75+ in 60 practices in New Zealand; n=3,141 participants aged 75+ in 59 practices in the Netherlands. Multilevel models of hospitalisation rates, functional ability, and QOL were separately fitted for each sample, and differences were examined according to GP and practice characteristics with adjustment for participants' characteristics. For the New Zealand sample, 36-month outcomes modelled were unplanned admission rates; Nottingham Extended Activities of Daily Living (NEADL, range 0-22); and QOL domain ratings from the WHOQOLBREF (range 0-100). For the Dutch sample, 12-month outcomes modelled were unplanned admission rates, Groningen Activity Restriction Scale (GARS, range 18-72), and EQ-5D summary index (Dutch tariff range -0.38-1.00). Results. Significant differences in rates of unplanned admissions were not observed in New Zealand practices, but participants seen by female GPs had lower admission rates when the analysis was restricted to ambulatory sensitive hospitalisations (IRR 0.83, CI 0.71 to 0.98). Differences in function and QOL according to GP and practice characteristics were consistently small (ranging from -0.26 to 0.19 points for NEADL scores and -1.64 to 0.97 points for QOL domain ratings). In the Dutch sample, unplanned admission rates were higher in larger practices (IRR 1.45, CI 1.15- 1.81) and those staffed with a practice nurse (IRR 1.74, CI 1.20-2.52), and participants seen by older, more experienced Dutch GPs reported slightly poorer QOL on follow-up (0.01 points lower EQ-5D scores). Conclusion. The findings challenge the expectation that primary care interventions focused on professional and organisational factors will reduce rates of unplanned hospitalisations or substantially influence older people's health outcomes in different country contexts.