Family physicians are the only providers of care for most patients with several chronic diseases, according to new research.
A population-based retrospective cohort study examined data from nearly 1 million patients with common chronic conditions in Alberta, Canada. Family doctors were the sole providers of care for 85.7% of patients with hypertension and 70.9% of those with diabetes.
The study is part of efforts to encourage more research “by primary care, for primary care,” study author Jessica Kirkwood, MD, family physician and assistant professor of family medicine at the University of Alberta in Edmonton, told Medscape Medical News. The prevalence of primary care involvement demonstrates the importance of involving family physicians in creating guidelines for management and developing clinical trials, Kirkwood said.
The study was published June 1 in Canadian Family Physician.
Who Provides Care?
The study focused on care provided from 2013-2017 for seven chronic conditions. The information collected consisted of data from administrative health databases, which track medical services provided by Alberta’s government-funded universal healthcare system.
Most patients’ care was managed by family physicians alone in four of the conditions studied: hypertension (85.7% solely by family physicians), diabetes (70.9%), chronic obstructive pulmonary disease (59.8%), and asthma (65.5%).
Specialists were more involved in the remaining three diseases. They provided the sole management in 49.1% of patients with ischemic heart disease, 42.2% of those with chronic kidney disease, and 35.6% of those with heart failure. For these conditions, family physicians remained involved in the care for a large proportion of patients. Specialist involvement may be more common with these diseases because they sometimes involve interventions that only specialists offer, like angiography and dialysis, said Kirkwood.
The study also found that nurse practitioners were involved in care for very few patients (less than 1%), in accordance with the small number of nurse practitioners working in primary care settings.
Kirkwood acknowledged that the data come with certain limitations because they were not intended for research purposes. One limitation is that some conditions may not have been recorded because of “shadow billing.” Salaried physicians and practitioners do not have an incentive to include all diagnostic codes in their records. By comparison, clinicians operating under a fee-for-service model would be likely to indicate all diagnoses.
Despite the widespread management of chronic conditions by family physicians, these doctors represented about 17% of the experts who contribute to guidelines and recommendations, according to a 2015 study that the investigators cited.
“Frankly, that’s concerning,” said Kirkwood, regarding the disconnect between the people creating the recommendations and the people using them. The guidelines should include the perspective of clinicians who regularly work with patients, she said. Providing that perspective would also make the design of clinical trials on interventions more informative, the researchers concluded.
“I know as a family doctor myself that some recommendations are completely overwhelming,” especially given the range of issues that primary care clinicians see, said Kirkwood. Including primary care representatives who are familiar with the demands of the position “hopefully will make the recommendations much more applicable to the people that they will affect,” she said.
Kirkwood also noted the need for sufficient support for family doctors to contribute to guideline creation and research, especially for doctors in rural communities who are not already affiliated with a university.
The involvement of primary care providers in research settings is a primary goal of Patients, Experience, Evidence and Research (PEER), a primary care-led group that collaborates with the College of Family Physicians of Canada. The current investigators are members of PEER.
Commenting on the study for Medscape, Martin Fortin, MD, clinical teaching professor at the University of Sherbrooke in Quebec, said, “This is a good opportunity to advocate for more studies to be done in the primary care context, where the majority of chronic disease management is done.”
However, Fortin wishes that more diagnoses had been included in the study, such as mental health and musculoskeletal conditions like back pain and osteoarthritis. These conditions are also commonly seen by primary care clinicians, according to Fortin.
Because the number of conditions studied is limited, the data may not reflect the true prevalence of multimorbidity, Fortin added.
Primary care doctors provide a broad perspective on the overall health of patients, compared with specialists who focus on particular conditions. Similarly, during drug trials, pharmaceutical companies aim to reduce complicating factors, even though the medications are prescribed for conditions where multimorbidity is common. “Medication should be tested in the real environment,” said Fortin.
Ultimately, he added, the study cannot address the complexity of the patients, but it nevertheless sheds light on who is providing care and where the research on these conditions should be done.
The study was conducted without outside funding. Kirkwood and Fortin reported no relevant financial relationships.
Can Fam Physician. Published June 1, 2023. Full text
Gwendolyn Rak is a health reporter for Medscape and Univadis based in Brooklyn, New York.
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