William Cayley: Continuity—in and out of hospital in the US

bill_cayleyWe’re seeing a resurgence in primary care in the US—or are we?

In a recent post, Domhnall MacAuley comments on the way primary care seems to have “emerged from the shadows as central to the development of universal and sustainable healthcare in the US.”

While the resurgence of primary care seems to get much press, airtime, and other attention, actual trends in the way care is delivered make me wonder.

Recent years have seen steady growth in the hospitalist movement, with more and more family doctors in the US deciding (or being told!) not to practise in hospital, with groups and systems employing hospital focused specialists to provide ostensibly better and more comprehensive care in hospital. Numerous studies have attempted to demonstrate cost-savings or shorter lengths of stay when patients are cared for by a physician or team who is more available in the hospital to address needs as they arise, and theoretically more up to date on the ins and outs of what it takes to provide quality hospital care. The theory also goes that hospitalists will provide seamless coordination when care is transferred back to the “community doc.”

I’m not so sure.

Anecdotal reports suggest that hospitalists may actually rely more on consultation of specialists than would be done by a primary care or family doctor managing a person in hospital.

Published research has found that family physicians feel they provide less expensive care and generate lower overall charges for their patients, based on how they individualise the management of new symptoms and chronic conditions.

And, most significantly of all for the claim that hospitalists provide for shorter, less expensive hospital stays, a population-based cohort study of US Medicare patients cared for in hospital by either their primary care physician or a hospitalist, found that decreased lengths of stay and hospital costs associated with hospitalist care were offset by higher medical utilization and costs after discharge.

It is easy to focus on specific gains here or there in isolated parts of the medical system, but if the true genius and strength of primary care is the ability to provide comprehensive continuity care, we need to look at the bigger, broader picture.

Yes, there are many times that sick patients require specialist assistance with their care. I am not so certain that the simple fact of being admitted to hospital is one of them. The knowledge, understanding, and even trust and relationships, that are built up over a long-term physician-patient relationship, cannot be easily swapped out like a piece of equipment when a person moves from one care setting to another.

If primary care is to be about comprehensive care and continuity, we need to make sure we understand the vital contributions of the primary care, or family doctor, to care when patients are hospitalized and ill.

“I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare beyond my interest in being a full-spectrum family doctor.”

William E Cayley Jr practises at the Augusta Family Medicine Clinic, teaches at the Eau Claire Family Medicine Residency, and is a professor at the University of Wisconsin, Department of Family Medicine.