Even though 70 percent of U.S. physicians report undergoing subspecialty training that involves specific chronic diseases, such as asthma and diabetes, new research shows that a majority of patients seeking care for most of 14 high-cost chronic conditions examined turn to primary care physicians.
Conducted by researchers at the Robert Graham Center for Policy Studies in Family Medicine and Primary Care, the study is summarized in a policy brief(www.jabfm.org) in the January-February issue of the Journal of the American Board of Family Medicine.
Specifically, researchers used data from the 2008 National Ambulatory Medical Care Survey to track outpatient visits for each of 14 high-cost chronic conditions listed by CMS in its Chronic Conditions Dashboard(www.ccwdata.org) to determine if patients were seen by a primary care physician or a subspecialist.
Primary care physicians were designated as those in family medicine, general practice, internal medicine or pediatrics.
Researchers found that of more than 10 million patient visits for asthma, 85.5 percent were to a primary care physician. For depression, 53.3 percent of visits were to a primary care physician, and for chronic obstructive pulmonary disease, 84.5 percent of visits were to a primary care physician.
- New research published in the Journal of the American Board of Family Medicine shows that many patients with chronic diseases receive care from primary care physicians.
- Of the 14 high-cost chronic conditions for which researchers tracked data, more patients sought care from primary care physicians versus subspecialists in all but three disease categories.
- Researchers noted that patients' dependency on primary care may not be fully appreciated.
In addition, researchers found that primary care physicians handled
- 66.8 percent of nearly 5 million patient visits for osteoporosis,
- 50.2 percent of more than 15 million visits for diabetes,
- 63.6 percent of nearly 25 million visits for chronic kidney disease,
- 77.9 percent of more than 30 million visits for hyperlipidemia and
- 68.9 percent of more than 50 million patient visits for hypertension.
In fact, of the 14 chronic conditions for which researchers reviewed data, in only three disease instances -- arthritis, atrial fibrillation and ischemic heart disease -- did patients more often see a subspecialist than a primary care physician.
"These data demonstrate how much patients depend on primary care physicians to take care of these complex and chronic conditions," said Graham Center Director Andrew Bazemore, M.D., M.P.H., in a Jan. 8 press release(www.graham-center.org).
"Many of these patients have multiple chronic conditions, so a physician with expertise in the whole person and the broad range of medical diagnoses is instrumental to ensuring that all their health needs are met," he added.
In the research summary, Bazemore and his colleagues noted that primary care "has been acknowledged as essential to the success of health care reform and the nation's triple aim" (i.e., improving patient care and outcomes and lowering costs).
The researchers added that the degree to which chronically ill patients depend on primary care physicians "may not be fully appreciated," and they suggested that primary care physicians be described as "complex care physicians" given their obligation to not only identify patient needs, but also to oversee preventive services, facilitate behavioral change and coordinate care with other health care professionals.
The findings are particularly relevant to family physicians, according to corresponding author Manisha Sharma, M.D., of Baltimore, medical director of Evergreen Health Care and a visiting scholar at the Graham Center. As a practicing family physician, Sharma is all-too-familiar with the crush of patients seeking care for chronic health conditions.
However, even she was caught off guard by the sheer numbers of patients who sought primary care versus subspecialty care, as well as by the lengthy list of chronic diseases involved.
"It's a large chunk of chronic conditions, and that did surprise me," Sharma told AAFP News Now. She said America's health care paradigm is shifting toward preventive care and interventions, functions that some would call the heart and soul of family medicine.
"Family physicians are the true leaders when it comes to the art of complex care," said Sharma. "We're multi-focused and knowledgeable in many areas of care."
According to Sharma, family physicians -- more than physicians in any other primary care specialty -- are trained to look at social determinants of health, such as the neighborhoods and conditions in which patients live, work and play.
"We need to start looking at the things that are the 'underbelly' of all these chronic conditions and how they are layered one on top of the other," said Sharma. "If we want to have a healthier America as we move forward, I really do believe the conversation needs to shift toward the social determinants of health."
In addition, said Sharma, health care policymakers in the midst of creating new models of care and making important decisions about the care that is delivered would do well to listen to physicians in the trenches.
Primary care physicians and, in particular, family physicians "need to be in the room and at the table," said Sharma. "We need to be part of those conversations, because we know what goes on day-to-day with our patients."