Study Finds Primary Care Physicians Essential to Managing Cases Involving Multiple Chronic Diseases

Contact:
Angela Sharma
Annals of Family Medicine
(913) 269-2269
asharma@aafp.org

LEAWOOD, Kan. - People with co-morbidity (the simultaneous occurrence of unrelated diseases) turn to primary care physicians for care more frequently than they do specialists, according to a new study released in the May/June 2003 issue of Annals of Family Medicine.  The study also found that most health care visits by patients with co-morbidity are not for the selected conditions, but are for other illnesses. 

"These findings suggest the need for an approach to health care that is oriented more toward patients' overall healthcare needs rather than diseases," explained the study's lead author, Barbara Starfield, M.D., M.P.H., F.R.C.G.P., from Johns Hopkins University School of Public Health.  "We need to seriously re-examine the nature of the relationship between primary care physicians and specialists.  It is imperative that clinicians develop a new paradigm of care characterized by expanded communication and more effective coordination between primary care physicians and specialists."
 
The impact of co-morbidity in the U.S. population is considerable.  According to background information provided in the study, in 1999 65 percent of U.S. elderly patients had two or more types of chronic conditions.  The per capita annual expenditures associated with co-morbidity were immense.  The researchers note per capital medical expenditures at, "$1,154 for persons with one type, $2,394 for those with two types, $4,701 for those with three, and $13,973 for those with four or more." Moreover, co-morbidity presents challenges to a health care system that has been traditionally focused on individual diseases with limited collaboration between primary care physicians and specialist physicians. 

Recognizing the prevalence and impact of chronic physical health problems, Starfield and colleagues set out to examine the extent to which primary care and specialist physicians can play a role in the care of individuals with variable degrees of co-morbidity.  The researchers' ultimate goal was to determine the most appropriate locus of intervention for long-term case management.  Using a case-mix measure, the authors conducted an analysis of 170,447 patients with 11 chronic health care conditions to determine patterns of health care use. Visits were classified as to whether they were to primary care physicians or specialists, and whether they involved the chosen condition or other conditions.

The researchers found that "patients in higher co-morbidity groups have considerably greater resource use than patients in lower co-morbidity groups."  Furthermore, they report, "the number of visits for co-morbidity exceeded the visits for the condition in all co-morbidity groups and for visits to both primary care physicians and to specialists.  The number of visits to primary care physicians for both the condition as well as for co-morbid conditions exceeded the number of visits to specialists."  They note that "these patterns differed only for uncommon conditions in which specialists played a greater role in the care of the condition, but not for co-morbid conditions."

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Editor's Note: This research was partially supported by a grant from the Bureau of Primary Health Care, Health Resources and Services Administration, Department of Health and Human Services, to the Primary Care Policy Center for the Underserved at Johns Hopkins University, by the Johns Hopkins University's ACG Case-Mix Research and Development Fund and by a grant from the Robert Wood Johnson Foundation.

Annals of Family Medicine is a peer-reviewed research journal that provides a cross-disciplinary forum for new, evidence-based information affecting the primary care discipline.  Launched in May 2003, the journal is sponsored by six family medical organizations, including the American Academy of Family Physicians (AAFP), the American Board of Family Practice (ABFP), the Society of Teachers of Family Medicine (STFM), the Association of Departments of Family Medicine (ADFM), the Association of Family Practice Residency Directors (AFPRD) and the North American Primary Care Research Group (NAPCRG).  The journal is published six times per year and contains original research from the clinical, biomedical, social and health services areas, as well as contributions on methodology and theory, selected reviews, essays and editorials.  A board of directors with representatives from each of the sponsoring organizations oversees the Annals. Complete editorial content and interactive discussion groups can be accessed free of charge on the journal's Web site, www.annfammed.org.