Am Fam Physician. 2008;78(7):online
Background: The main determinants of emergency department use by older persons are believed to be the severity of immediate medical needs and the burden of comorbidities; however, access to and continuity of primary care services may also be significant. Because reforms in the Canadian health care system are based on primary care for all patients, and the number of older patients is anticipated to double by 2026, Ionescu-Ittu and colleagues studied the impact of primary care services on emergency department visits by older patients.
The Study: The researchers studied health statistics on all residents of a Canadian province to identify those older than 65 years who made at least one health insurance claim during 2000 or 2001. After excluding residents of long-term care facilities and untraceable persons, a study sample of 95,173 persons was selected. For each participant, data were collected on age, sex, comorbidities, socio-economic status, location of residence (e.g., urban, rural), and location of the nearest emergency department. Data on availability of primary care services based on the physician-to-population ratio for the location of residence, and the continuity of care index (i.e., the proportion of total health care visits that were with the usual primary care physician) were also obtained.
The researchers used various statistical techniques to examine the relationship between availability and continuity of primary care services and emergency department use.
Results: During the two-year study, 52 percent of the study population did not use the emergency department, 18 percent used it on one day, 11 percent on two days, and 18 percent on three or more days. The overall rate of emergency department use was 2.14 per 1,000 risk-days. A primary care physician was identified for 83 percent of participants; for 79 percent of participants, this was a family physician. Patients with a primary care physician had a median of 11 primary care visits.
An increased rate of emergency department use was associated with low and medium levels of continuity of primary care and with lack of a primary care physician. In patients with a primary care physician, the level of continuity of care was related to emergency department use in a dose-response fashion. After adjusting for medical need, demographic variables, and other factors, increased emergency department use by older patients was significantly associated with lack of a primary care physician, low continuity of primary care, and low use of primary care services.
Conclusion: The authors conclude that having a primary care physician and a high level of continuity of primary care is associated with decreased emergency department use by older patients. They point out that increasing the number of primary care physicians alone is not sufficient to improve access or continuity. Physicians also must be matched with improvement in their service organization, particularly in providing out-of-hours coverage and access to services.