Comorbidity and the Use of Primary Care and Specialist Care in the Elderly

Papers by Starfield et al, Ostby et al and Fortin et al highlight the challenge of providing chronic disease care in primary care. Missing from each of these papers is discussion of the impact of race/ethnicity and social class on care. While race and social class measures are often omitted from many data sets, they can be imputed with fair accuracy using patient Zip codes or other measures of residence. It is worth the additional effort to include these variables because of the implications for primary care to vulnerable patients.

Starfield et al show that higher morbidity burden is associated with more specialty, but not primary care visits among elderly Medicare beneficiaries. It is not clear whether this finding would hold for African American patients or poor patients. African Americans are referred less often for specialty care(1-3) which in turn contributes to racial disparity in expensive technology. These disparities likely reflect reduced access to specialists among physicians caring for African American patients.(4) Given this restricted access to specialty care, it is quite possible that patient morbidity is associated with primary care visits among these vulnerable patients. In other words, family physicians and other primary care providers working in practices caring for poor and minority patients are likely to spend much more of their time caring for patients with chronic disease in the absence of specialty consultation. This problem is likely to be further compounded by multimorbidity. Fortin et al show that multimorbidity is quite prevalent among adults in family practice. However, multimorbidity is even higher among poorer patients.(5) This means that providers working in underserved practices will not only encounter more morbidity, but more multimorbidity. Ostby et al suggest that there is not sufficient time to manage patients with chronic disease in primary care. If this is true for middle class patients, then it doubly true for poor patients. Providers working in underserved practices, such as federally qualified community health centers, will not have adequate time to address to fully address the needs of their patients with chronic disease. When one considers the added challenge of language, cross- cultural communication, and psychosocial needs of vulnerable patients,(6,7) the task becomes Hurculean.

What are the solutions? First, primary care practices, particularly those serving vulnerable patients, require adequate infrastructure needed to provide chronic care.(8) Without such practice redesign, and the resources necessary to support it, care will inevitably suffer. The federally sponsored Health Disparities Collaboratives not withstanding, practices serving vulnerable patients will require external subsidies necessary to finance these improvements in infrastructure if quality improvements are to be sustained.

Second, family physicians and other primary care providers have underestimated the task before them.(9) Acute, chronic, preventive, and psychosocial demands compete for providers attention during the 18 minute office visit.(10) Primary practice panels, particularly those in underserved practices, are often too large and visits too infrequent to adequately address patient needs. Under fee-for-service reimbursement, there simply is no alternative than to see patients more frequently thus allowing fewer issues to be addressed in a single visit. An excessively large panel of patients precludes doing so and renders open accessing scheduling untenable.

Last, financially viable models of care are needed that allow primary care providers to collaborate with ancillary health care in the provision of primary care. This may mean use of personnel explicitly trained to implement collaborative and culturally appropriate care plans that cut across multiple morbidities. It may also mean use of community health workers to facilitate delivery of appropriate preventive care In this way, cross cutting issues such as activity, diet, smoking, and medication adherence could be reliably addressed. In the absence of such changes, prospects for addressing disparities in health care, much less disparities in health are remote.

1. Clancy CM, Franks P. Utilization of specialty and primary care: the impact of HMO insurance and patient-related factors. J Fam Pract 1997;45:500-508.

2. Earle CC, Neumann PJ, Gelber RD, Weinstein MC, Weeks JC. Impact of referral patterns on the use of chemotherapy for lung cancer. J Clin Oncol 2002;20:1786-1792.

3. Ayanian JZ, Landrum MB, Guadagnoli E, Gaccione P. Specialty of ambulatory care physicians and mortality among elderly patients after myocardial infarction. N Engl J Med 2002;347:1678-1686.

4. Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med 2004;351:575-84.

5. van den AM, Buntinx F, Metsemakers JF, Roos S, Knottnerus JA. Multimorbidity in general practice: prevalence, incidence, and determinants of co-occurring chronic and recurrent diseases. J Clin Epidemiol 1998;51:367-375.

6. Fiscella K. Is lower income associated with greater biopsychosocial morbidity? Implications for physicians working with underserved patients. J Fam Pract 1999;48:372-377.

7. Fiscella K, Williams DR. Health disparities based on socioeconomic inequities: implications for urban health care. Acad Med 2004;79:1139- 1147.

8. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA 2002;288:1775-1779.

9. Grumbach K, Bodenheimer T. A primary care home for Americans: putting the house in order. JAMA 2002;288:889-893.

10. Jaen CR, Stange KC, Nutting PA. Competing demands of primary care: a model for the delivery of clinical preventive services. J Fam Pract 1994;38:166-171.

Competing interests:   None declared