Characteristics of patients who access zero, one or multiple general practices and reasons for their choices: a study in regional Australia

The majority of people in Australia (87%) had visited a primary care physician or General Practitioner (GP) at least once during 2016–2017 and on average, people had visited a GP 6.1 times in that time period [1]. People who do not regularly visit a GP may not need to, or may face an access barrier. A systematic assessment of barriers to primary care, reported that availability, after hours services and affordability were particularly important barriers in the Australian context [2]. In Australia, people are free to choose their GP and/or practice on each occasion [3]. Although the majority of people in Australia have a preferred GP [4], a proportion of patients access multiple GPs and multiple practices. An Australian cross-sectional study reported that 11% of adults often visited different GPs [5]. Another Australian cross-sectional study conducted five years later found that 28% of adults had attended more than one general practice in the previous 12 months [6]. Although a study of almost 2500 Australian adults reported that multiple general practice attendance was associated with residence in metropolitan areas, increased risk of attendance at an emergency department (ED) and younger age [6]. Another Australian study of almost 8000 patients reported that patients who visited another practice did so due to appointment availability, convenience of location or for specific health problems [7]. Studies focussed specifically on utilisation of multiple general practices in rural, regional or remote contexts are rare. Utilisation of multiple general practices occurs for a multitude of reasons but may reflect patients exercising choice of healthcare provider, however exercising this choice is complex. A scoping review that assessed determinants of ‘patient choice’ in Western countries reported that younger patients, patients with higher educational attainment or income, or patients with less established relationships with healthcare providers, may be more willing, and/or able, to access different GPs [8]. Some people may be accessing multiple general practices in order to access specific services, such as gynaecological services [9].

Accessing GP care via multiple practices reduces continuity of care. A study of over 230,000 patients in England reported that a high degree of continuity of GP care was associated with reduced hospitalisation for ambulatory care sensitive conditions [10]. Findings from the English GP Patient survey suggest that older people and people with chronic physical or psychological health conditions are more likely to prefer continuity of care [11]. Findings from a systematic review of predominantly North American studies suggested that continuity of care was associated with reduced healthcare costs over time, higher levels of patient satisfaction and enhanced preventative medicine [12]. However, continuity of care may be associated with diminished access in the form of reduced availability of appointments [12]. In a systematic review of the barriers to and enablers of achieving continuity of care in rural Australia, continuity of care was reported to be associated with effective communication, availability of resources (including skilled and experienced health care providers) and reduced geographical distance [13].

The Australian GP workforce has become increasingly flexible to accommodate part time work and ongoing training requirements [14] which may impact a patient’s ability to visit the same GP. In rural Australia, continuity of GP care may be even more difficult to achieve due to geographical pockets of GP shortages or high staff turnover [15]. A study of almost 40,000 healthy adults aged 45–74 in Australia suggested that in general, rural people were less likely to receive preventative care, including exercise or dietary advice than their metropolitan counterparts [16] and experience higher prevalence of chronic health conditions compared to people residing in major cities [17] The aim of this study was to estimate the proportion of people in a regional Australian setting who access multiple general practices, their characteristics, their preventative health care, ED presentations and reasons for accessing multiple practices.

Crossroads-II [18] was a cross-sectional survey conducted from 2016 to 2018, and studied self-reported health, disease and utilisation of health services among people residing in 4 towns in the Goulburn Valley of regional Victoria, Australia. Households were randomly selected from local government lists. Surveys were conducted face-to-face at the participants’ residence by trained research assistants using RedCap electronic data capture tools (Vanderbilt University) [19]. People were eligible to participate if they had resided in the region for at least six months and were aged 16 years or above. Adults were invited to complete a separate children’s survey for children in their care, but results are not included here. Participating, non-pregnant adults aged 18 years or above were invited to attend a ‘clinic’ at which additional questionnaires were completed. Ethics was granted by the Goulburn Valley Human Ethics Research Committee in May 2016 (GVH20/16). Written consent was obtained from each participant. Participants were asked questions about utilisation and perspectives of GP services, receipt of lifestyle advice and screening tests, ED utilisation and demographic details, as per Additional file 1. Participants were asked ‘If you have visited more than one general practice in the past 12 months, please comment why’ and the responses were subsequently coded. A portion of adult participants attended a health screening clinic and were asked additional questions about receiving lifestyle advice and opinion of GP care using several questions from the United Kingdom GP Patient Survey [20] (Additional file 1).

Of the 3022 eligible houses (non-vacant, residential properties), at least one response was recorded from 1895 households (63% response rate, 2680 total household participants, data from 2657 participants are included in this study). Of the 1233 adults invited to the ‘clinic’, 748 (61%) attended.

Most participants indicated that they had accessed a GP in the previous 12 months (93%) on an average of 6.5 ± 8.8 occasions (median 4.0, range 0–112). Most participants (n = 2096, 78.9%) attended one general practice, while (n = 383) 14.4% attended more than one practice and (n = 178) 6.7% attended zero practices. When compared with respondents who attended at least one general practice, respondents who reported attending zero general practices were more often male (56% vs 50%, p < 0.001), younger (40 ± 17 vs 55 ± 19 years, p < 0.001), of excellent health status (24% vs 12%, p < 0.001) and fewer had attended an ED in the previous 12 months (10% vs 21%, p = 0.006), as per Table 1.

Mean waiting time was 4.3 days (median of 2.0, range 0 to 90 days), with no significant difference observed between respondents who accessed single or multiple general practices. Fourteen percent of participants said that they had accessed GPs across multiple practices (average of 2.1 practices, mode = 2, range 2–4) in the previous 12 months. Bulk billing was more commonly reported by users of multiple general practices than single general practices (71% vs 63%, p = 0.003). Respondents who utilised single general practices more commonly reported being very satisfied than users of multiple practices (63% vs 52%, p < 0.001) and having excellent levels of confidence than users of multiple practices (50% vs 42%, p = 0.006). Multiple general practice attendees were more likely to have also presented to ED than attenders of one or zero practice (29, 20, 10% respectively, p < 0.005). Respondents from the regional centre were more likely to travel less distance (< 5 km) to the general practice than respondents from the smaller towns, see Table 2.

Patients who utilised one GP practice were more likely to have had their blood pressure, skin, and cholesterol checked in the previous 2 years than patients who utilised multiple practices, as per Table 3. Participants who had not accessed a GP practice in the previous 12 months were significantly less likely to have had screening tests (Table 3) or advice regarding exercise and weight loss (Table 4) than participants who had accessed at least one GP practice. There were very few differences in patient opinion of various aspects of GP care between patients who had accessed zero, one or multiple practices, see Table 4.

The logistic regression model suggested that the significant factors in utilising more than one GP practice were (in order of effect size): age, residence in the regional centre compared with the smaller towns, attendance at an ED, distance to the GP, frequency of GP visits and being bulk billed, see Table 5.

This analysis was repeated to assess variables associated with use of no general practices in the previous 12 months, compared with at least one general practice. Attendance at no general practice in the previous 12 months was significantly associated with males (OR 2.09, 1.39–3.16), younger age (OR 0.95, 0.94–0.96), excellent health status (OR 2.39, 1.50–3.80), less confidence in GP (OR 0.56, 0.36–0.86) and less use of ED (OR 0.35, 0.18–0.70), see Table 6.

The most common reasons for attending multiple general practices (availability of appointments and accessing a subsequent GP for ‘simple’ issues but retaining a preferred GP [5]) were among the top 3 reasons mentioned by each group of respondents. Respondents aged < 65 years more commonly mentioned reasons related to convenience and cost than respondents aged 65+ years. Location of GP services (either convenience or due to patient relocation/travel) were more commonly mentioned by respondents in smaller towns than in the regional centre. Specific services and cost were mentioned more commonly by females than males. Cost appeared to be a factor for respondents who were less satisfied with GP services compared with more satisfied respondents, as per Table 7.

We have found that in this rural area, most people had seen a GP in the previous 12 months (93%), slightly higher than the 87% of people reported to had visited a GP at least once during 2015–2016 in Australia [21]. There was evidence that the respondents who had not accessed a general practice in the previous 12 months were more often males, and unsurprisingly, younger people, and/or people reporting excellent health status, likely reflecting episodic GP care for acute health issues. These findings are in agreement with patterns reported in the Australian Bureau of Statistics’ Patient Experiences survey [22]. The frequency of visits (6.5 in previous 12 months) was similar to the 6.1 visits per capita reported for 2015–2016 in Australia [23]. The majority of respondents (78%) reported accessing only one general practice, which suggests continuity of informational care (information relevant to the patient’s care is readily available to the patient and healthcare provider). Over half of respondents had seen multiple GPs in this time, reducing relational continuity. The proportion of people attending multiple practices (14%) is similar to the proportion reported by other, albeit predominantly urban studies (11% [4], 19% [21], 28% [5]) and ours is the first study focussed specifically on a regional setting. Participants from the regional centre in this study were significantly more likely to access multiple practices than participants from the surrounding smaller towns. This may relate to a higher number of practices, practices offering a greater variety of services, increased accessibility, bulk billing and choice in the regional centre. In addition, respondents from the regional centre were more likely to live closer to their GP(s) than respondents from smaller towns, particularly for those who accessed multiple general practices.

The results from this study suggest that patients who receive care from a single general practice typically have higher satisfaction and confidence in their GP, are more likely to have screening tests and less likely to go to an ED. Although patients typically have a preferred GP, and following, a preferred practice, a proportion access a GP at another practice, at times due to a lack of appointment availability. Initiatives that enhance continuity of GP care in rural areas may assist to reduce inequities in health outcomes for older people and people living with chronic ill health.