Family doctor visit after a hospital stay for selected chronic conditions

Percentage of patients seen by a family doctor within 7 or 30 days of discharge after a hospital stay related to one of the following chronic conditions: high blood pressure, diabetes, chronic obstructive pulmonary disease (COPD), asthma, heart failure, ischaemic heart disease (e.g., angina, heart attack), or chronic renal failure. (see data definition)

What do you see?

  • What is the difference between visit rates at 7 and 30 days after discharge?
  • Are there differences in the follow-up rates between the mainly urban zones or PCNs (Calgary and Edmonton) compared to the more rural zones or PCNs (North, Central, South)? What might account for these differences?
  • Are follow-up rates changing over time? What might account for this?
  • Are there certain conditions which seem to receive more follow-up care by a family doctor than others? How does this vary across zones/PCNs?

Whether you’re a patient, provider, or health system administrator, thinking about why these differences might exist can start conversations and lead to solutions for improved quality of healthcare.

*Data courtesy of Alberta Health Services and Alberta Health

Understanding this chart

Family doctors have a major role in caring for patients with chronic conditions. It is important for patients with a chronic condition to see their family doctor after they have been discharged from the hospital. This ensures that the family doctor knows about any test results and/or changes in the patient’s condition or treatment plan (e.g., medications, other healthcare providers the patient is seeing) as a result of the hospital stay. It allows the family doctor to review what happened while the patient was in hospital and make sure any required follow-up or tests are completed. Timely follow-up by a family doctor may also help reduce the chance that the patient has to go back to hospital for the same problem, develops further problems or even dies.

This measure is related to information transfer ― family doctors need to know that their patients have been in hospital. Patients and family doctors can both impact this measure. Patients are often encouraged to contact their family doctor’s office to book an appointment after they are discharged from hospital. Family doctors who know their patients have been in hospital may call the patient to come in for follow-up. Follow-up may be early (within 7 days) or later (within 30 days) depending on the situation and patients’ needs.

Considerations when reviewing the results

  • Includes only patients who did not get readmitted within the time period (7 or 30 days), based on the most responsible diagnosis that caused the stay in the hospital.
  • Includes only visits where a family doctor is seen. It does not include visits with a team member in the doctor’s office (e.g., nurse or pharmacist) or by a program or service provided by a primary care network (PCN).
  • May include family doctor visits for problems not related to the patient’s chronic condition or hospital stay.
  • Consider whether early (7 days) or later (within 30 days) follow-up is most appropriate for your patients with these chronic conditions. Think about what can be done to increase the number of patients seen within that period.

The Health Quality Council of Alberta uses the Alberta Quality Matrix for Health as a way of organizing information and thinking around the complexity of the healthcare system. The information in this chart can be used as input to think and have conversations about primary healthcare in Alberta using the lens of the dimensions of quality shown on the right:

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Dimensions of Quality

  • Acceptability
  • Accessibility
  • Appropriateness
  • Effectiveness
  • Efficiency
  • Safety