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Evidence Pertaining to a Healthy Primary Care Workforce

The ACFP is proud of the partnership it has with PEER and fully supports the evidence-based perspective they bring to decision-making. Family Physicians play a vital role in primary health care and within each community they serve, the following document proves this.

Please take the time to read, to share, and to fight for and with your family physicians. We are #strongertogether.

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RE: Evidence Pertaining to a Healthy Primary Care Workforce

March 13, 2020

In light of recent Alberta government decisions regarding Family Medicine/primary care funding, members of the PEER team (evidence and knowledge translation experts) wished to provide an overview of the evidence on the impact of Family Medicine on health care utilization and costs and overall patient health. In summary, access to a primary care workforce which provides comprehensive patient care improves patient outcomes (death) and decreases health care utilization (emergency room visits, hospitalizations and readmissions) and health care costs.

Family Physicians provide the overwhelming majority (~70% in Alberta) of all health care visits in Alberta and Canada.1 Family physicians see more patients with multiple co-morbidities than specialists2 and perform as well as specialists in managing common diseases such as diabetes, depression and cardiovascular disease in the elderly.3,4,5

Patients who have a regular family physician report using emergency services less than half the time as those without a physician (4.3% versus 9.6%) and being admitted to hospital less than half the time (1.7% versus 4%).6

Adding Family Physicians to a population improves health outcomes greater than any other physician group. For every additional 10 family physicians per 100,000 population, there are 15 fewer deaths, 40 fewer hospitalizations7 and an average increase in life expectancy of 52 days.8

Alberta studies demonstrate that continuity of care with a patients’ Family Physician improves outcomes in patients with chronic diseases including:

  • Decreased re-admissions and death for congestive heart failure patients at 1 year9
    • ~10-15% fewer compared to no follow up visits
    • 3-4% fewer compared to follow up with an ‘unfamiliar physician (ex. cardiologist)
  • Decreased number of emergency visits (60-75% relative) and hospitalizations (~25%) for asthmatic patients.10

In addition, a study of over 50,000 potentially preventable hospital admissions of Alberta chronic disease kidney (CKD) patients found that not having a family physician increased admission rates by ~15%.11

Ontario communities that lost > 3 Family Physicians per 100,000 population had a ~20% decrease in 5 year breast cancer survival.12 Using 2019 Alberta population,13 Alberta Family Physician numbers,14 breast cancer incidence and death rates15 (where annually 470 Alberta women currently die of breast cancer) if Alberta were to lose 129 family physicians, an additional 470 potentially avoidable breast cancer deaths will occur over 5 years.

Canadian patients who have contact with their Family Physician 1-2 times in a year were twice as likely to engage in colorectal cancer screening than those without contact with a Family Physician.16 Greater density of primary care physicians decreases the proportion of advanced colorectal cancers.17

Numerous other studies find that access to primary care reduces infant mortality,18 obesity rates,19 late stage urologic malignancies,20 and mortality from cervical cancer.21

Finally, caring for complex patients takes time. Patients of comprehensive Family Physicians in Alberta who bill extended visit modifiers to manage these complex patients, are less likely to end up in the emergency room or be admitted to hospital.22 Those physicians who bill extended time modifiers earn on average $60,000 less than their counterparts.

This summary demonstrates the evidence supporting primary care, including the importance of access, continuity and comprehensiveness of primary care. Ultimately the health of all Albertans will benefit from a system that recognizes and supports the contributions of its Family Physicians.

Sincerely,

Michael Kolber BSc, MD, CCFP MSc University of Alberta, Department of Family Medicine
Christina Korowynk MD, CCFP University of Alberta, Department of Family Medicine
G. Michael Allan MD, CCFP Professor University of Alberta Department of Family Medicine’


References:

1. Stewart, M, Ryan B. Ecology of Health Care in Canada. Can Fam Phys 2015; 61(5): 449-53
2. Starfield B, Lemke KW, Bernhardt T et al. Comorbidity: implications for the importance of primary care in ‘case’ management. Ann Fam Med 2003;1(1):8-14.
3. Harris S, Yale J-F, Dempsey E. Can family physicians help patients initiate basal insulin therapy successfully? Can Fam Phys 2008; 54:550-8
4. Wisniewski SR, Rush AJ, Nierenberg AA et al. Can Phase III Trial Results of Antidepressant Medications Be Generalized to Clinical Practice? Am J Psychiatry 2009; 166: 599–607
5. Strandberg TE, Pitkala KH, Berglind S et al. Multifactorial intervention to prevent recurrent cardiovascular events in patients 75 years or older: Am Heart J 2006; 152:585292
6. Fung CS, Wong CK, Fong DY et al. Having a family doctor was associated with lower utilization of hospital-based health services. BMC Health Serv Res 2015;15:42.
7. Chang CH, O’Malley AJ, Goodman DC. Association between Temporal Changes in Primary Care Workforce and Patient Outcomes. Health Serv Res 2017;52(2):634-655.
8. Basu S, Berkowitz SA, Phillips RL et al. Association of Primary Care Physician Supply with Population Mortality in the United States, 2005-2015. JAMA Intern Med 2019;179(4):506-514.
9. McAlister FA, Youngson E, Bakal JA et al. Impact of physician continuity on death or urgent readmission after discharge among patients with heart failure. CMAJ 2013. DOI:10.1503
10. Cree M, Bell NR, Johnson D et al. Increased Continuity of Care Associated with Decreased Hospital Care and Emergency Department Visits for Patients with Asthma. Disease Management 2006; 9(1): 63-71
11. Wiebe N, Klarenbach SW, Allan GM et al. Potentially Preventable Hospitalization as a Complication of CKD: A Cohort Study. Am J Kidney Dis. 2014;64(2):230-238
12. Gorey KM, Luginaah IN, Fung KY et al. Physician Supply and Breast Cancer Survival. J Am Board Fam Med 2010;23:104 –108.
13. Government of Alberta. Alberta population estimates Sept 30, 2019 From https://www.alberta.ca/population-statistics.aspx. Accessed Mar 9, 2020
14. Alberta College of Family Physicians. Year in Review 2019. From https://acfp.ca/wpcontent/uploads/2020/02/Attachment-6.1-Year-In-Review-2019-3.pdf. Accessed Mar 9, 2020
15. Canadian Cancer Statistics 2019. Toronto, ON: Canadian Cancer Society; 2019. Available at: cancer.ca/Canadian-Cancer-Statistics-2019-EN
16. Zarychanski R, Chen Y, Bernstein CN et al. Frequency of colorectal cancer screening and the impact of family physicians on screening behaviour. CMAJ 2007;177(6):593-7
17. Ananthakrishnan AN, Hoffmann RG, Saeian K. Higher physician density is associated with lower incidence of late-stage colorectal cancer. J Gen Intern Med. 2010 Nov;25(11):1164-71.
18. Russo LX, Scott A, Sivey P et al. Primary care physicians and infant mortality: Evidence from Brazil. PLoS ONE 2019; 14(5): e0217614.
19. Gaglioti AH, Petterson S, Bazemore A et al. Access to Primary Care in US Counties Is Associated with Lower Obesity Rates. J Am Board Fam Med 2016;29(2):182-90.
20. Nguyen KD, Hyder ZZ, Shaw MD, Maness SB, Cookson MS, Patel SG, Stratton KL. Effects of primary care physician density, urologist presence, and insurance status on stage of diagnosis for urologic malignancies. Cancer Epidemiol 2018; 52:10-14.
21. Campbell RJ, Ramirez AM, Perez K, Roetzheim RG. Cervical cancer rates and the supply of primary care physicians in Florida. Fam Med 2003;35(1):60-4.
22. MacDonald T, Green L. A Cluster Analysis Exploring the Relationship between Daily Patient Volume, Provider Panel Size, Service Day Provision and Patient Health Outcomes in Alberta General Practitioner Practices. Oral Presentation, Family Medicine Summit March 6, 2020.

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