reports

The impact of not having a primary care physician among people with chronic conditions

Toronto, ON, Canada: Institute for Clinical Evaluative Sciences.

Institute for Clinical Evaluative Sciences, Toronto, ON, Canada

BACKGROUND: Primary care plays a pivotal role in health care systems as the first point of access to care. According to recent surveys, nearly one in ten (nine percent) of Ontarians reported not having a regular medical doctor, and many more people said they had problems accessing primary care.
Individuals with chronic illnesses and conditions place substantial demands on the health care system. One might expect that these individuals in particular would experience adverse consequences from not receiving appropriate primary care.
PURPOSE AND METHODS: The purpose of this study was to examine specific health system impacts related to Ontarians with chronic health conditions who did not have a primary care physician at the time they were surveyed. Data from Cycle 1.1 of the Canadian Community Health Survey (CCHS) from 2000–01 were obtained and analyzed, along with a 20% random sample of Ontario’s population (2003–05). This information was then linked to data on health care use in Ontario in 2005–06.
Several sub-groups of Ontarians with chronic health conditions were examined in relation to emergency department (ED) visits and medical non-elective hospital admissions. These sub-groups were: people without a regular medical doctor (CCHS data); people with a history of fewer than three physician visits in the previous two-year period (20% random population sample data); and people with a history of three or more physician visits but whose scores were low (< 50%) on a continuity of care index (20% random population sample data). Continuity of care was defined as the proportion of visits made by each person to the same physician. Regression analyses were used to control for sociodemographic characteristics and case mix.
Among Ontarians with at least one chronic condition, 4.6 percent reported having no regular medical provider (CCHS data analysis); 5.2 percent had made fewer than three visits to a physician in a two-year period (20% random population sample data analysis); and 10.1 percent showed patterns of health system usage suggesting low continuity of care (20% random population sample data analysis).

FINDINGS ABOUT ONTARIANS WITHOUT A REGULAR DOCTOR: After adjustment, Ontarians with chronic conditions who said they did not have a regular medical doctor (CCHS data analysis) were 1.22 times more likely to have visited an emergency department (ED) (95% CI 1.02, 1.46) in the previous two years than those who reported having a regular doctor. This translates to an estimated 17,741 excess ED visits.
People in this same sub-group were also 1.32 times more likely to have had a medical non-elective hospital admission 95% CI (0.85, 2.06) in the previous two years compared to those who reported having a regular doctor. This translates to an estimated 1,932 excess hospital admissions attributable to not having a regular doctor.

FINDINGS ABOUT ONTARIANS WHO MADE FEW PHYSICIAN VISITS: After adjustment, people with chronic illness who made fewer than three physician visits in a two-year period (20% random population sample) were 1.17 times more likely to have sought care in a hospital ED (95% CI 1.15, 1.19) in the previous two years compared to those who had made more than three physician visits. This translates to an estimated 16,868 excess ED visits attributable to not having a regular doctor. People in this same sub-group were also 1.19 times more likely to have had a medical non-elective hospital admission (95% CI 1.13, 1.24) compared to those who had made more than three physician visits. This translates to an estimated 3,863 excess hospital admissions attributable to not having a regular doctor.

FINDINGS ABOUT ONTARIANS WITH LOW CONTINUITY OF CARE: After adjustment, people with chronic illness who made three or more physician visits but for whom continuity of care was low had 1.55 times more ED visits (95% CI 1.53, 1.56) than those with high continuity of care (20% random population sample). This translates to an estimated 101,313 excess ED visits. They also had 1.35 times more medical non-elective hospital admissions (95% CI 1.32, 1.38), which translates to an estimated 13,481 excess admissions.

CONCLUSION: Our analyses of data on Ontarians with chronic health conditions demonstrate that the majority of these people— 90 to 95 percent—reported having a regular medical doctor at the time they were surveyed. The patterns of care we observed in this group suggest they experienced few serious access barriers to primary care.
However, among the remaining minority of people with chronic conditions, we were able to link three specific patient groups with potentially avoidable and costly demands on the health care system. These included thousands of excess ED visits and thousands of excess medical non-elective hospital admissions. Such potentially avoidable ED visits and hospital admissions contribute to the crowding of Ends and to hospital bed shortages. They are also highly likely to be associated with preventable suffering and clinical deterioration which can sometimes be irreversible.
We believe that all three patient groups—those who did not have a regular medical doctor; those whose records showed relatively few physician visits in the previous two years; and those whose pattern of health system usage suggested low continuity of care—represent Ontarians with chronic illness who are having trouble accessing primary care.
We also believe that, given these impacts on health services and on people, implementing policies to address the current shortage of primary health care physicians in Ontario should be seen as a top health system priority.