Home and Community Care Digest

Home and Community Care Digest 7(3) September 2008

Access to Continuity of Primary Care Reduces Seniors' Utilization of Emergency Department Services

Abstract

People 65 and over are high users of emergency department services. Emergency departments often serve as a safety net for those who receive inadequate primary care. This Quebec study indicates that among seniors, emergency department use is associated with absence of a primary physician and low levels of continuity of care, especially for those living in urban areas. With an aging population, emergency department use by seniors is expected to escalate, particularly if primary care is not organized more effectively. In the context of recent government initiatives to promote "aging at home," more focus should be placed on primary care to ensure that the elderly are receiving appropriate care in the community and are not using emergency department services unnecessarily.
Background: This Canadian study investigated whether the access to and continuity of primary care was associated with emergency department use by seniors. Seniors are a growing group of emergency department users and the population of Canadians aged 65 and over is expected to double by 2026. Since emergency department services are often used as a substitute for primary care, emergency department utilization is an indicator of the adequacy of primary care. Most studies examining the impact of access to and continuity of primary care were conducted in the United States. This Quebec study gives a Canadian perspective to the issue.

Methods: This cross-sectional, population-based Quebec study examined a large random sample of people aged 65 and over (N=95,173) from provincial administrative databases for 2000 and 2001. Data on patient profile (age, sex, urban or rural residence, socio-economic status, co-morbidity), use of and access to physician services, and rate of emergency department use were analyzed. The study examined whether access to and continuity of primary care were determinants of emergency department use. Access to primary care was determined by two measures: (a) presence of primary care physician, and (b) physician to population ratio. Continuity of care was defined as the proportion of total primary care visits with the primary physician.

Findings: After adjusting for age, sex and co-morbidity, the study found that a decreased rate of emergency department use was associated with having a primary physician and greater continuity of care. The area of residence was another determinant of emergency department use: lower overall use of primary care services was a stronger predictor in urban residences, lack of a primary care physician was more likely to lead to increased emergency department use in rural areas (when compared to urban areas). Among seniors who had a primary physician, continuity of care was a greater predictor of low emergency department use in urban than rural areas (i.e., continuity of care had a stronger protective effect against emergency department use in urban than rural areas). This underlines the differences in primary care organization in rural and urban areas in Quebec.

Other factors found to increase emergency department use included high overall comorbidity, terminal illness, higher age, low socioeconomic status, presence of cardiovascular and digestive disease, living in an area with greater availability of general practitioners, and proximity to an emergency department.

Conclusions: The evidence that access to a primary physician and high continuity of care are associated with a decreased rate of emergency department use underlines the important role of primary care in ensuring that elderly people have access to appropriate health care services at the community level. The use of emergency department services as a safety net for seniors without adequate primary care may be reduced if primary care services can be reformed to ensure that seniors have access to a primary physician and with improvements in continuity of care. The study also suggests that increasing the number of general practitioners alone may not be sufficient to increase access to or continuity of primary care. Organizational measures such as evening and weekend coverage may need to be considered as well.

Reference: Ionescu-Ittu, R.., McCusker, J., Ciampi, A., Vadeboncoeur, A., Roberge, D., Larouche, D., Verdon, J., Pineault, R.. Continuity of Primary Care and Emergency Department Utilization Among Elderly People. CMAJ. 2007; 177 (11): 1362-1368.

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