Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care...

Enhancing the effectiveness of health carefor Ontarians through research

Effects of Primary Care Supply in a Single Payer Health System

Astrid Guttmann MDCM, MSc1,2,3,4 Scott A. Shipman MD, MPH5 Kelvin Lam MSc1 David Goodman MD, MSc5 Therese Stukel PhD1,4,5

1 Institute for the Evaluative Clinical Sciences, Toronto, ON Canada 2 Paediatric Medicine, Hospital for Sick Children 3 Dept of Paediatrics, University of Toronto 4 Dept. of Health Policy, Management and Evaluation, University of Toronto 5 Center for Health Policy Research, The Dartmouth Institute for Health Policy and Clinical Practice


Funding Sources

• Physician Services Incorporated

• Canadian Institutes for Health Research


Objectives

• Set the context of primary care delivery for children in Ontario

• Present preliminary work on the association between primary care physician supply and health services access and utilization

• Consider findings in light of U.S. healthcare system and current policy discussions

Ontario1 in 3 Canadians

12 million residents

3 million children

60% urban

415,000 sq miles

3.5 persons/sq mile

Major cities: Toronto,Ottawa


Primary care for children in Ontario

• Universal insurance coverage

• Primary care delivered mainly by GPs/FPs

• Proportion provided by pediatricians increasing from 1990s to 2004

• Small increase in number of GPs but seeing fewer kids

• Number of pediatricians increased slightly Increasing proportion of practice devoted to primary care

• Declining overall primary care visit rates for children Disproportionately among low income children


In the setting of universal coverage,how does the local primary care

supply influence children’s receipt of health services?

Research Question


Calculating primary care physician supply (FTEs)

• Examined physician-level claims for all care delivered in the province of Ontario, 2003-2005

GP’s -- Defined the % of their overall activity that was primary care for children 0-17 yrs X overall FTE

General Pediatricians

• Defined % of billings that used primary care fee codes (non-consultative office based visits)

• % of overall activity X overall FTE


Calculating supply (cont’d)

• Used county as the local geographic measure

• Calculated supply using GP, Ped head count as well as primary care FTE

• Population = all children in Ontario ages 0-17 yrs

• Categorized per capita supply at the county level in increments of 500 children/ 1 primary care FTE (1500-1999, 2000-2499, 2500-2999, 3000-3499, >3500)


Outcomes assessed

• Self-reported access to primary care Primary Care Access Survey by Ontario Ministry

of Health, 2006

• Recommended utilization rates Newborn visit within 1 week of discharge

(per Canadian consensus guidelines) Preventive care (in first 2 years) – well baby,

annual exams, immunizations Any primary care over 2 years (for all children)

• Emergency department utilization rates


Outcomes, continued

• Discretionary utilization Visit rates for URI/ common cold Follow-up visits for URI/common cold Visits for acne

• Admissions for ambulatory care sensitive conditions For chronic in prevalent population

only


Analysis

• Unit of analysis : dissemination area

• Age group/sex adjusted strata

• Controlled for neighbourhood income Also bed supply for hospitalization models

• Poisson regression to model outcomes by supply category

Description of Physician and Population by Physician Supply Category

1500-1999 (High MD supply)

2000-2499 2500-2999 3000-34993500+

(Low MD supply)

Total MDs 5654 2821 1108 501 190

Total FTE for kids

741 382 132 46 11

% FTE = pediatrician

26.6 11.2 13.6 4.0 0

# counties 7 15 15 8 4

# of kids 1.3 mill 865,000 365,000 152,000 44,000

Median Income

62k 48k 47k 46k 41k

%rural 0.61 14.2 33.5 46.6 83.4

Access to primary care

% reporting access to a family doctor*

1500-1999

(high MD supply)94

2000-2499 94

2500-2999 93

3000-3499 90

>3500

(low MD supply) 67

*Among families with children in the home

Recommended services missed

0%

10%

20%

30%

40%

50%

60%

70%

80%

1

# of kids per Primary Care FTE

% o

f ch

ildre

n Children not receiving primary care

Children not receiving preventativecare

Newborns without postpartum visits

1500 – 1999

High MD supply

2001 - 2500 2501- 3000 3001 - 3500 >3500

Low MD supply

Adjusted rate ratios of children with no visits by supply

Supply No Preventive Care No Primary Care No Newborn Visits

1500 – 1999 1.00 (ref) 1.00 (ref) 1.00 (ref)

2000 – 2499 1.56 (1.54, 1.58) 1.27 (1.24, 1.31) 2.59 (2.46, 2.73)

2500 – 2999 1.91 (1.87, 1.94) 1.42 (1.38, 1.46) 3.19 (3.00, 3.40)

3000 – 3500 2.79 (2.70, 2.88) 1.69 (1.63, 1.76) 3.51 (3.25, 3.78)

>3500 5.22 (4.50, 6.06) 2.47 (2.14, 2.86) 7.44 (6.17, 8.96)

*adjusted for age, sex, income quintile

Discretionary Utilization (visits per 1000 children)

Supply Visits for Colds

Follow up Visits for

Colds

Visits for Acne

1500-1999

(high supply)121.4 11.3 8.0

2000-249986.7 7.0 7.2

2500-299964.9 4.4 5.9

3000-349949.1 2.9 5.7

>3500

(low supply) 20.4 0.8 4.5

Children’s ED visit rates by supply

0

50

100

150

200

250

300

350

400

450

500

1


Vis

its p

er

10

00

ch

ildre

n

All ED Visits per 1000 children All ED Visits with low acuity per 1000

1500 – 2000

High Supply

2000 - 2499 2500- 2999 3000 - 3499 >3500

Low supply


Hospitalizations for Ambulatory Care Sensitive Conditions

ACS Hospitalization Rates per 1000 children

0

10

20

30

40

50

1


Vis

its p

er 1

000

child

ren

ACS Acute Hospitalization per 1000 children ACS Asthma Hospitalization per 1000

ACS Diabetic Hospitalization per 1000


Conclusions

• Self-reported access only really impacted when fewer than 1 FTE MD per 3500 or more children

• Utilization (both recommended and discretionary) consistently increases as local primary care physician supply increases

• ED utilization is markedly affected by local primary care supply

• Some impact on ACS hospitalizations --?morbidity vs utilization


In a U.S. Context. . .• U.S. has far more primary care physicians per capita,and worse maldistribution

• U.S. might best improve access for children by first providing universal coverage for them

• With universal coverage, it does appear that desired utilization patterns are improved as local primary care supply increases (? whether this continues beyond with more than 1 MD per 1700 children)

Highest supply

<1000 kids/doc

1000-2000 2001-3000 >3000

Lowest supplyNo docs

% US children

17.9 62.7 12.8 6.2 0.4

% Ontario children

0 45.4 40.8 13.8 0

Enhancing the effectiveness of health care for Ontarians through research Effects of Primary Care...

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