Effects of Primary Care Coordination on Public Hospital Patients


Address correspondence and reprint requests to Dr. Dean Schillinger, San Francisco General Hospital, Primary Care Research Center, UCSF Box 1364, 1001 Potrero Ave., Bldg. 90, Ward 95, San Francisco, CA 94143-1364; telephone 415-206-8940; fax 415-206-5586; e-mail dean@itsa.ucsf.edu.


Objective: To evaluate the effect of primary care coordination on utilization rates and satisfaction with care among public hospital patients.

Design: Prospective randomized gatekeeper intervention, with 1-year follow-up.

Setting: The Adult General Medical Clinic at San Francisco General Hospital, a university-affiliated public hospital.

Patients: We studied 2,293 established patients of 28 primary care physicians.

Intervention: Patients were randomized based on their primary care physician's main clinic day. The 1,121 patients in the intervention group (Ambulatory Patient–Physician Relationship Organized to Achieve Coordinated Healthcare [APPROACH] group) required primary care physician approval to receive specialty and emergency department (ED) services; 1,172 patients in the control group did not.

Measurements and Main Results: Changes in outpatient, ED, and inpatient utilization were measured for APPROACH and control groups over the 1-year observation period, and the differences in the changes between groups were calculated to estimate the effect of the intervention. Acceptability of the gatekeeping model was determined via patient satisfaction surveys.

Results: Over the 1-year observation period, APPROACH patients decreased their specialty use by 0.57 visits per year more than control patients did ( P = .04; 95% confidence interval [CI]−1.05 to −0.01). While APPROACH patients increased their primary care use by 0.27 visits per year more than control patients, this difference was not statistically significant (P = .14; 95% CI, −0.11 to 0.66). Changes in low-acuity ED care were similar between the two groups (0.06 visits per year more in APPROACH group than control group, P = .42; 95% CI, −0.09 to 0.22). APPROACH patients decreased yearly hospitalizations by 0.14 visits per year more than control patients (P = .02; 95% CI, −0.26 to −0.03). Changes in patient satisfaction with care, perceived access to specialists, and use of out-of-network services between the 2 groups were similar.

Conclusions: A primary care model of health delivery in a public hospital that utilized a gatekeeping strategy decreased outpatient specialty and hospitalization rates and was acceptable to patients.