Attitudes, perceptions and practice patterns of primary care practitioners towards house calls

KEYWORDS: Primary health care; general practitioners; health services

House calls are defined as visits made to patients or clients in their own home by a doctor or other professional.¹ Historically, doctors routinely and comprehensively delivered medical care to sick patients in patients’ homes, with house calls accounting for 40% of all doctor–patient encounters in the 1940s.² In Dutch, a general practitioner (GP) is known as a ‘Huisarts’, which directly translated means ‘home doctor’.³ In recent years, the proportion of all consultations that are house calls has dwindled to less than 1%.⁴ The decline had been attributed to multiple reasons including increased access to transportation, time constraints and economic considerations.

Many felt that house calls had become unnecessary because doctors were not able to do much in a patient’s home.⁵ However, one meta-analysis showed that house calls reduced mortality rates and admissions to long-term care for the general elderly population.⁶ The United States of America (US) Veterans Affairs System’s home-based primary care programme that uses interdisciplinary teams to meet the specific needs of fragile, chronically ill patients, was also shown to improve patient and caregiver satisfaction, reduce hospital readmissions at 6 months and improve caregiver quality of life overall.⁷

Patients and families are known to appreciate house calls, and it is commonly recognised that in making a house call, GPs are going the extra mile for patients.⁵ We therefore asked: ‘Why do some GPs make house calls and what are the reasons that others do not?’.

In Singapore, privately run clinics are the main provider of primary care services, seeing 81% of primary care attendances.⁸ As in Canada and New Zealand, the traditional model of primary care in Singapore has been based on individual GPs providing primary medical services on a fee-for-service basis.⁹ Rostering, capitation funding or other forms of patient enrolment or registration are not used, and most GPs have a relatively stable group of patients after the initial period required to build up a medical practice. Although patients are free to change their GPs, most choose to have long-standing relationships with one doctor.⁹ Unlike the National Health Service (NHS) in the United Kingdom where GPs usually work as part of a team that includes nurses, health-care assistants, practice managers and other staff, GPs in Singapore generally practice independently.¹⁰

Reasons for house calls made by GPs in Singapore can be arbitrarily divided into the management of acute medical conditions or chronic medical issues. House calls for acute medical conditions are traditionally made by GPs in private practice. GPs in the public primary health-care clinics (polyclinics) do not make house calls. Specialist physicians in Singapore (e.g. geriatricians and paediatricians) also generally do not make house calls, unlike their colleagues in the US^11–13 and Greece.¹⁴

Elderly, home-bound patients with chronic medical issues are cared for by doctors and nurses in specialised organisations that provide home-based medical care. The first home care service offered in Singapore (the Home Nursing Foundation) was established in 1976 and was wholly nurse-run.¹⁵ The involvement of GPs in home care became more common only ~20 years ago. Non-governmental organisations are the main providers of home care services in Singapore and these organisations often include multidisciplinary teams that function primarily on an appointment basis on weekdays during office hours and generally do not attend to acute medical conditions. There are a handful of Singaporean GPs in private practice who run a full-time house call practice equipped to care for patients with acute medical conditions as well as patients with chronic medical conditions.

There are, at present, no official statistics regarding the rate of house calls in Singapore and it does not seem to be a common practice among GPs. However, Singapore is increasingly recognising the importance of providing a spectrum of care for vulnerable patient groups and the accompanying policy challenges are gradually being met.¹⁶

Among the 7.3 billion people worldwide in 2015, an estimated 8.5%, or 617.1 million, are aged ≥65 years. The number of older people globally is projected to increase more than 60% in just 15 years: in 2030, there will be ~1 billion older people.¹⁷ Together with the shift in emphasis to community care and with increasing numbers of older, frail and often homebound patients, the need for house calls will increase. In the context of declining numbers of house calls and increasing need, this literature review aims to review the recent literature on the attitudes and perceptions of primary care practitioners towards making house calls.

We searched the electronic databases PubMed and Embase. Search terms used for PubMed were ((‘Attitude of Health Personnel’[Mesh]) OR ‘Perception’[Mesh]) OR ‘Practice Patterns, Physicians'’[Mesh]) AND (‘House Calls’[Mesh]) OR (‘Home Care Services’[Mesh] OR ‘Home Care Services, Hospital-Based’[Mesh]) AND ((‘Family Practice’[Mesh]) OR ‘Physicians, Family’[Mesh]) OR ‘General Practitioners’[Mesh]) OR ‘Physicians, Primary Care’[Mesh])) AND English[lang]’. For Embase, search terms used were: (‘house calls’/exp OR ‘house calls’ OR ‘home visits’/exp OR ‘home visits’ OR ‘home care’/exp OR ‘home care’) AND (‘general practitioners’/exp OR ‘general practitioners’ OR ‘primary care physicians’/exp OR ‘primary care physicians’ OR ‘primary care doctors’ OR ‘family physicians’) AND (‘health personnel attitude’/exp OR ‘health personnel attitude’ OR ‘practices’) AND [English]/lim.

The search was conducted in January 2018 for articles published before 31 December 2017. A total of 531 articles were identified and 44 duplicates were removed. Both authors screened this list of articles for study inclusion. Based on their titles and abstracts, 457 articles were excluded. House calls or home visits made exclusively by specialists such as palliative care physicians, paediatricians or geriatricians were excluded from this review about the attitudes of primary care practitioners towards house calls. Articles focusing solely on the physical factors affecting house call rates, such as diagnosis and patients’ ages, were also excluded. There was no restriction on the research design.

The remaining potentially relevant 30 articles were extracted and reviewed for inclusion. Of these, 20 were from the PubMed search and 10 from Embase, and 14 were excluded because they had no mention about the attitude of GPs towards house calls. Three Commentaries and Editorials were also excluded.

Overall, 13 articles^{12,13,18–28} were found to be relevant, with information regarding the attitudes of GPs towards house calls. Three other articles^5,29,30 identified from the reference lists of these articles were also found to be relevant and included.

A total of 16 articles were obtained from the database search (Fig. 1). Of these, there were two qualitative studies,^25,26 10 questionnaire surveys^{12,14,18–24,31} and two review articles.^5,29 Additionally, one review article²⁷ and one questionnaire survey³¹ had only their abstracts available. The articles with only abstracts available were included because they were published by peer-reviewed journals; however, the full-texts of these articles could not be retrieved. Table 1 summarises each included article. The articles included are all level 3 (other evidence), based on the Strength of Recommendation Taxonomy (SORT).³²

Figure 1. Flow chart of the review

Table 1. Characteristics of included studies and major findings
SORT, strength of recommendation taxonomy

House calls were generally seen as an important service to provide.^{13,19,21,27,28,31} The reasons why GPs make house calls are summarised in Table 2.

Table 2. Reasons why GPs make house calls

Although GPs generally recognised the significance of house calls and believe that they are good for patients, not all had positive attitudes towards house calls. Table 3 summarises the common reasons for primary care practitioners not making house calls.

Table 3. Reasons why GPs do not make house calls

The image of doctors delivering care to sick patients at home is one of the enduring images in the collective consciousness of medicine.³ Over time, however, this image has lost its lustre. In this review, only 16 articles were found to be suitable. One possible reason for the paucity of research in this area might be the lack of new findings over the years. We found that the attitudes of GPs 30 years ago and 2 years ago were very similar.

Most doctors recognise the value of making house calls, but at the same time, many barriers have been identified to making house calls. In the research we found, being aware of the non-financial rewards and benefits of house calls was insufficient to entice most primary care practitioners to make more house calls. Knowledge did not necessarily translate to a positive attitude towards the making of house calls. It seemed that altruism could not stand up to the practicalities of maintaining a viable practice.

House calls are predicted to remain an integral part of medical care, especially with the shift of care from the hospitals to the community.²⁹ House calls are a valuable service, especially to frail and housebound patients.²⁹ In the climate of a growing ‘silver tsunami’, it is easy to understand the significance of this service. Policy-makers and health system planners need to address the sentiments of doctors towards providing this service.

There is understandably a call for a revision of the reimbursement for house calls.²² With the shift in emphasis from hospital to community care, funding policies may need to be modified to change payments for house calls. However, improved reimbursement might not increase the frequency of house calls but might only encourage their continuation.²² Adelman et al. found that although an overwhelming majority of doctors agreed with the statement that ‘reimbursement for house calls is inadequate’, this was not associated with making house calls in both univariate and multivariate analyses,¹³ suggesting that although sub-optimal reimbursement was a widespread issue, it was not the main reason for GPs not making more house calls.

Some of the articles suggested that subjective attitudes towards house calls are an important part of a physician’s decision to make house calls. Supporting this view is the finding that only half (46%) of doctors will make more house calls if reimbursement were improved.²² At the same time, doctors who made house calls were more likely to regard the medical liability risks of house calls as no greater than that of hospital or office practice.²² There were also doctors who simply reported that house calls were not enjoyable.^12,19 Boling et al.^12,19 distinguished between regular house callers (doctors who made routine house calls) and occasional house callers (doctors who do not make or only make emergency house calls), observing that regular house callers more often considered house calls enjoyable and were more likely to feel that house calls were needed, than occasional house callers. Regular house callers were also less likely than occasional house callers to report being too busy for house calls.

Negative attitudes towards house calls need to be addressed, and exposing medical students to house calls might be a way to foster positive attitudes.¹³ Incorporating house calls into the medical curriculum will address the issue of doctors feeling untrained to make house calls.^23,24,26 One study evaluating the exposure of family medicine residents to home visits showed that graduating residents had a confidence level of making house calls of 80%, compared to the 40% of entering residents.³⁰ Another study showed that graduates of programmes where faculty made house calls and programmes where residents made house calls on a longitudinal basis were significantly more likely to offer house calls in their practices.³³ This suggests that vocational education can offer positive experiences in house call training that translate to future physicians including house calls in their practices. Some have also recognised that the sustainability of existing and future home-based primary care programmes will rely on effective education in ‘house call medicine’.^3,30

However, barriers to making house calls are real and affect the attitudes of doctors towards house calls, while at the same time, the attitude of doctors also affects the way that these barriers are perceived. The decision to make a house call is based on both clinical judgment regarding individual patients and broader issues involving the whole practice.³¹ With an increasing emphasis on community care, especially of the elderly, the medical profession may need to alter the attitudes of GPs with respect to making house calls. Understanding the attitudes of GPs in their geographical and cultural contexts will facilitate the implementation of strategies to encourage the continuation of house calls.

Types of house calls were not distinguished in this review. Due to the paucity of articles and the differing definitions of primary care practitioners and their roles in different countries, along with differing contexts of practice, we could not describe separately home visits for acute medical problems or routine home visits for management of chronic medical problems. There were two articles^27,31 where only the abstracts were available. Most of the articles in this review are, at best, level 3 evidence-based on the SORT guidelines³² because of the nature of the studies – surveys and qualitative studies. However, the findings were reasonably consistent across these studies.

Primary care practitioners recognise the importance of house calls, especially in the care of elderly patients, but there are many unaddressed issues such as opportunity cost and clinical inadequacy in the home setting that have caused the decline in house calls over the years. Attempts should be made to address these issues in order for health care to keep up with increasing patient needs.

None.