Effect of Patient Experience on Bypassing a Primary Care Gatekeeper: a Multicenter Prospective Cohort Study in Japan

Abstract

Background: To discuss how best to implement the gatekeeping functionality of primary care; identifying the factors that cause patients to bypass their primary care gatekeepers when seeking care should be beneficial.

Objective: To examine the association between patient experience with their primary care physicians and bypassing them to directly obtain care from higher-level healthcare facilities.

Design and methods: This prospective cohort study was conducted in 13 primary care clinics in Japan. We assessed patient experience of primary care using the Japanese version of Primary Care Assessment Tool (JPCAT), which comprises six domains: first contact, longitudinality, coordination, comprehensiveness (services available), comprehensiveness (services provided), and community orientation. The primary outcome was the patient bypassing their usual primary care physician to seek care at a hospital, with this occurring at least once in a year. We used a Bayesian hierarchical model to adjust clustering within clinics and individual covariates.

Key results: Data were analyzed from 205 patients for whom a physician at a clinic served as their usual primary care physician. The patient follow-up rate was 80.1%. After adjustment for patients' sociodemographic and health status characteristics, the JPCAT total score was found to be inversely associated with patient bypass behavior (odds ratio per 1 SD increase, 0.44; 95% credible interval, 0.21-0.88). The results of various sensitivity analyses were consistent with those of the primary analysis.

Conclusions: We found that patient experience of primary care in Japan was inversely associated with bypassing a primary care gatekeeper to seek care at higher-level healthcare facilities, such as hospitals. Our findings suggest that primary care providers' efforts to improve patient experience should help to ensure appropriate use of healthcare services under loosely regulated gatekeeping systems; further studies are warranted.

Keywords: Japan; bypassing; gatekeeping; patient experience; primary care.

Figure 1

Patient flow chart

Figure 2

Factors associated with bypassing a primary care gatekeeper (N = 205). JPCAT, Japanese version of Primary Care Assessment Tool; OR, odds ratio; CI, credible interval; Error bars indicate 95% CIs. Bayesian hierarchical modeling (random slope model). Adjusted for age, sex, education, household income, duration of relationship with usual primary care physician, number of other sources of care, SF-12 PCS, SF-12 MCS, and hospitalization in past 6 months. OR per 1 SD increase