The Impact of Primary Care Clinic and Family Physician Continuity on Patient Health Outcomes: A Retrospective Analysis From Alberta, Canada

Terrence McDonald; Paul E. Ronksley; Lisa L. Cook; Alka B. Patel; Judy Seidel; Brendan Cord Lethebe; Lee A. Green

doi:10.1370/afm.3107

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Table 1.

Patient Characteristics Overall and by Physician Continuity

Characteristic	Overall (N = 1,200,000)	Physician Continuity^{^a}			P Value
Characteristic	Overall (N = 1,200,000)	Low (n = 77,870)	Moderate (n = 547,680)	High (n = 574,450)	P Value
Gender, No. (%)
Female	669,046 (55.8)	46,757 (60.0)	315,585 (57.6)	306,704 (53.4)	<.001
Male	530,954 (44.2)	31,113 (40.0)	232,095 (42.4)	267,746 (46.6)	<.001
Age, median (IQR), y	50 (30-65)	35 (25-50)	45 (25-60)	55 (35-70)	<.001
Complexity level,^{^b} No. (%)					<.001
1-2	732,890 (61.1)	54,310 (69.7)	353,939 (64.6)	324,641 (56.5)
2-3	200,003 (16.7)	11,935 (15.3)	89,671 (16.4)	98,397 (17.1)
5-9	267,107 (22.3)	11,625 (14.9)	104,070 (19.0)	151,412 (26.4)
Geographic zone, No. (%)					<.001
1 (South)	94,052 (7.8)	3,655 (4.7)	35,198 (6.4)	55,199 (9.6)
2 (Calgary and area)	468,776 (39.1)	33,598 (43.1)	227,555 (41.5)	207,623 (36.1)
3 (Central)	128,221 (10.7)	12,788 (16.4)	60,457 (11.0)	54,976 (9.6)
4 (Edmonton)	410,881 (34.2)	22,812 (29.3)	184,383 (33.7)	203,686 (35.5)
5 (North)	98,070 (8.2)	5,017 (6.4)	40,087 (7.3)	52,966 (9.2)
Location, No. (%)
Metro	841,715 (70.1)	53,855 (69.2)	394,632 (72.1)	393,228 (68.5)
Rural	211,445 (17.6)	13,261 (17.0)	90,496 (16.5)	107,688 (18.7)
Urban	146,840 (12.2)	10,754 (13.8)	62,552 (11.4)	73,534 (12.8)
Physician continuity,^{^a} No. (%)
Low	77,870 (6.5)	77,870 (100.0)	0 (0.0)	0 (0.0)	<.001
Moderate	547,680 (45.6)	0 (0.0)	547,680 (100.0)	0 (0.0)	<.001
High	574,450 (47.9)	0 (0.0)	0 (0.0)	574,450 (100.0)	<.001
GCR, mean (SD), %	42 (41)	53 (31)	41 (40)	41 (45)	<.001
Clinic continuity,^{^c} No. (%)
None	350,180 (29.2)	5,944 (7.6)	194,120 (35.4)	150,116 (26.1)	<.001
NA	247,403 (20.6)	0 (0.0)	0 (0.0)	247,403 (43.1)	<.001
Low	167,033 (13.9)	28,322 (36.4)	112,401 (20.5)	26,310 (4.6)	<.001
High	190,633 (15.9)	31,577 (40.6)	123,284 (22.5)	35,772 (6.2)
Complete	244,751 (20.4)	12,027 (15.4)	117,875 (21.5)	114,849 (20.0)
Total visits/patient in study period, mean (SD)	14.0 (12.7)	13.4 (11.5)	13.7 (12.1)	14.4 (13.3)	<.001
Physician patient volume per day,^{^d} mean (SD)	29.4 (13.8)	27.8 (12.5)	28.5 (13.5)	30.5 (14.3)	<.001
ED visits during study period
Number/patient, mean (SD)	2.3 (4.5)	2.8 (5.2)	2.4 (4.6)	2.1 (4.4)	<.001
Patients with none, No. (%)	462,781 (38.6)	25,423 (32.6)	200,998 (36.7)	236,360 (41.1)	<.001
Number/patient among those with ≥1, mean (SD)	3.7 (5.3)	4.2 (5.9)	3.7 (5.3)	3.6 (5.3)	<.001
Hospitalizations during study period
Number/patient, mean (SD)	0.3 (0.8)	0.3 (0.8)	0.3 (0.8)	0.3 (0.8)	.02
Patients with none, No. (%)	974,793 (81.2)	62,689 (80.5)	443,307 (80.9)	468,797 (81.6)	<.001

ED = emergency department; CRG = clinical risk grouper; GCR = group care rate; IQR = interquartile range; KPC = known provider of care; NA = not applicable; UPC = usual provider of care.
↵a Based on KPC index. Low = 0%-40% of visits were to the attached family physician; moderate = 41%-80% of visits; high = 81%-100% of visits.
↵b Based on CGR.
↵c Based on GCR. None = 0% (always went elsewhere if not seeing their FP); NA = always saw their own FP (KPC index of 100% with no opportunity for group care); low = 1%-50%; high = 51%-99%; complete = 100% (always saw one of their FP’s partners if not their own FP).
↵d For the physician associated with the patient.

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Table 2.

Patient Characteristics by Clinic Continuity

Characteristic	Clinic Continuity^{^a}					P Value
Characteristic	None	NA	Low	High	Complete	P Value
Patients, No. (%)	350,180 (29.2)	247,403 (20.6)	167,033 (13.9)	190,633 (15.9)	244,751 (20.4)
Age, median (IQR), y	45 (30-60)	55 (35-65)	45 (30-60)	45 (30-60)	50 (30-65)	<.001
Sex, No. (%)
Male	152,080 (43.4)	124,704 (50.4)	62,516 (37.4)	78,314 (41.1)	113,340 (46.3)	<.001
Female	198,100 (56.6)	122,699 (49.6)	104,517 (62.6)	112,319 (58.9)	131,411 (53.7)
Complexity level,^{^b} No. (%)						<.001
1-2	221,631 (63.3)	159,360 (64.4)	88,637 (53.1)	113,142 (59.4)	150,120 (61.3)
3-4	59,613 (17.0)	35,793 (14.5)	33,753 (20.2)	33,368 (17.5)	37,476 (15.3)
5-9	68,936 (19.7)	52,250 (21.1)	44,643 (26.7)	44,123 (23.1)	57,155 (23.4)
Geographic zone, No. (%)						…
1 (South)	21,586 (6.2)	25,355 (10.2)	10,366 (6.2)	13,606 (7.1)	23,139 (9.5)
2 (Calgary and area)	154,541 (44.1)	83,350 (33.7)	76,004 (45.5)	76,540 (40.2)	78,341 (32.0)
3 (Central)	26,995 (7.7)	23,805 (9.6)	19,041 (11.4)	24,525 (12.9)	33,855 (13.8)
4 (Edmonton)	119,370 (34.1)	89,076 (36.0)	53,328 (31.9)	63,725 (33.4)	85,382 (34.9)
5 (North)	27,688 (7.9)	25,817 (10.4)	8,294 (5.0)	12,237 (6.4)	24,034 (9.8)
Location						…
Metro	265,873 (75.9)	164,938 (66.7)	124,912 (74.8)	133,617 (70.1)	152,375 (62.3)
Urban	42,142 (12.0)	34,370 (13.9)	17,285 (10.3)	23,466 (12.3)	29,577 (12.1)
Rural	42,165 (12.0)	48,095 (19.4)	24,836 (14.9)	33,550 (17.6)	62,799 (25.7)
Physician continuity,^{^c} No. (%)						<.001
Low	5,944 (1.7)	0 (0.0)	28,322 (17.0)	31,577 (16.6)	12,027 (4.9)
Moderate	194,120 (55.4)	0 (0.0)	112,401 (67.3)	123,284 (64.7)	117,875 (48.2)
High	150,116 (42.9)	247,403 (100.0)	26,310 (15.8)	35,772 (18.8)	114,849 (46.9)
Total visits/patient, mean (SD)	13.5 (11.5)	10.2 (8.5)	20.2 (17.1)	16.1 (14.4)	12.7 (10.8)	<.001
Physician patient volume/day,^{^d} median (IQR)	27.2 (20.4-37.5)	27.5 (20.9-38.0)	25.7 (19.4-34.6)	25.2 (19.1-34.3)	25.1 (19.1-34.2)	<.001
ED visits during study period
Number/patient, mean (SD)	2.2 (4.3)	1.5 (3.2)	3.3 (6.0)	2.7 (5.3)	2.0 (4.1)	<.001
Patients with none, No. (%)	128,849 (36.8)	122,561 (49.5)	46,630 (27.9)	62,078 (32.6)	102,663 (41.9)	<.001
Number/patient among those with ≥1, mean (SD)	3.6 (4.9)	3.0 (3.9)	4.6 (6.6)	4.0 (6.0)	3.5 (4.8)	<.001
Hospitalizations during study period
Number/patient, mean (SD)	0.3 (0.8)	0.2 (0.6)	0.5 (1.1)	0.3 (0.9)	0.2 (0.7)	<.001
Patients with none, No. (%)	282,855 (80.8)	213,299 (86.2)	123,288 (73.8)	149,748 (78.6)	205,603 (84.0)	<.001
Number/patient among those with ≥1, mean (SD)	1.5 (1.2)	1.4 (1.0)	1.7 (1.6)	1.6 (1.4)	1.5 (1.0)	<.001

ED = emergency department; CRG = clinical risk grouper; FP = family physician; GCR = group care rate; IQR = interquartile range; KPC = known provider of care; NA = not applicable.
Note: See Table 1 footnotes for category definitions.
↵a Based on GCR.
↵b Based on CRG.
↵c Based on KPC index.
↵d For the physician associated with the patient.

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Table 3.

Associations of Physician Continuity and Clinic Continuity With ED and Hospital Use, by Patient Complexity^{^a}

Characteristic	ED Visits, Incidence Rate Ratio (95% CI)			Hospitalizations, Incidence Rate Ratio (95% CI)
Characteristic	Low Complexity	Moderate Complexity	High Complexity	Low Complexity	Moderate Complexity	High Complexity
Physician continuity^{^b}	1.00 (1.00-1.00)	1.00 (1.00-1.00)	1.00 (1.00-1.00)	1.00 (1.00-1.00)	1.00 (1.00-1.00)	1.00 (1.00-1.00)
Clinic continuity^{^c}
NA	0.81 (0.80-0.81)	0.79 (0.78-0.81)	0.68 (0.67-0.70)	0.77 (0.75-0.78)	0.67 (0.66-0.68)	0.78 (0.76-0.79)
None	Ref	Ref	Ref	Ref	Ref	Ref
Low	1.04 (1.03-1.06)	1.05 (1.04-1.07)	1.04 (1.02-1.06)	1.12 (1.10-1.14)	1.11 (1.07-1.15)	1.10 (1.08-1.13)
High	0.94 (0.93-0.95)	0.97 (0.95-0.99)	0.94 (0.92-0.95)	0.97 (0.95-0.98)	1.02 (0.99-1.06)	0.97 (0.95-0.99)
Complete	0.79 (0.78-0.80)	0.81 (0.80-0.83)	0.72 (0.71-0.73)	0.77 (0.75-0.78)	0.83 (0.80-0.86)	0.69 (0.67-0.70)
Sex, male	1.10 (1.09-1.11)	0.98 (0.97-1.00)	1.07 (1.06-1.08)	0.86 (0.84-0.89)	1.01 (1.01-1.01)	1.03 (1.01-1.05)
Age, per 5 years	0.98 (0.98-0.98)	1.00 (0.99-1.00)	1.00 (1.00-1.00)	0.93 (0.93-0.93)	1.01 (1.03-1.14)	1.03 (1.03-1.04)
Total visits, per visit	1.05 (1.05-1.05)	1.03 (1.03-1.03)	1.02 (1.02-1.02)	1.05 (1.05-1.05)	1.02 (1.02-1.02)	1.02 (1.02-1.02)
Physician visit volume, per patient/day	1.00 (1.00-1.00)	1.00 (1.00-1.00)	1.00 (1.00-1.00)	1.00 (1.00-1.00)	1.00 (1.00-1.00)	1.00 (1.00-1.00)
Location
Metro	Ref	Ref	Ref	Ref	Ref	Ref
Urban	1.41 (1.39-1.42)	1.44 (1.42-1.47)	1.28 (1.26-1.30)	1.41 (1.38-1.43)	1.36 (1.31-1.40)	1.35 (1.32-1.38)
Rural	2.68 (2.66-2.70)	2.46 (2.42-2.50)	2.33 (2.30-2.36)	1.76 (1.73-1.78)	1.65 (1.60-1.69)	1.74 (1.70-1.77)

CRG = clinical risk grouper; ED = emergency department; FP = family physician; GCR = group care rate; KPC = known provider of care; NA = not applicable; Ref = reference group.
Note: Adjusted for sex, age, visits in study period, average physician patient volume per day, and location.
↵a Based on CRG. Low = 1-2; moderate = 3-4; high = 5-9.
↵b Per 1% increase in KPC index.
↵c Based on GCR; see Table 1 footnotes for category definitions.