Association between continuity and access in primary care: a retrospective cohort study

Lisa L. Cook; Richard P. Golonka; Charles M. Cook; Robin L. Walker; Peter Faris; Shannon Spenceley; Richard Lewanczuk; Robert Wedel; Rebecca Love; Cheryl Andres; Susan D. Byers; Tim Collins; Scott Oddie

doi:10.9778/cmajo.20200014

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Figure 1:
Multilevel model focused on primary care physicians (PCPs), measuring weekly access each year of the study. Week of the access measure was nested in the year for each PCP (example shown for 1 physician), with adjustment for potential confounding patient and physician factors.
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Figure 2:
Scatterplot and linear regression of average weekly outcome measures within each third next available appointment exposure group. Note: CC = clinic continuity, DC = discontinuity, ED = emergency department, PC = provider continuity.

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Table 1:

Practice- and panel-level confounding variables

Practice	Panel
No. of physicians in the clinic (6), (38)	Physician panel size (39), (40)
Gender of physicians (41), (42)	Age of panel (39)
Location of clinic (43)	No. of patients on multiple panels (44)
No. of days worked per week (45)	Panel complexity^* (39), (46)
–	No. of female patients (39), (47)

↵* The Canadian Institute of Health Information’s Population Grouper was used to infer patient complexity. (48)

Table 2:

Descriptive statistics for confounding variables for each study year

Variable	Year; mean ± SD^*
Variable	2009	2010	2011	2012	2013	2014	2015	2016
No. of physicians with a panel	86	93	119	119	130	152	154	153
No. of physicians excluded (< 13 TNA measures within the year)	5	2	22	3	16	38	28	20
No. of physicians included in analysis	81	91	97	116	114	114	126	133
Confounding variables
Practice characteristics
No. of physicians	81	91	97	116	114	114	126	133
No. of clinics	17	18	19	24	23	21	22	23
Female physicians, no. (%)	21 (25.9)	27 (29.7)	30 (30.9)	33 (28.4)	37 (32.5)	32 (28.1)	39 (31.0)	40 (30.1)
Rural physicians, no. (%)	47 (58.0)	51 (56.0)	53 (54.6)	54 (46.6)	53 (46.5)	57 (50.0)	58 (46.0)	65 (48.9)
No. of days worked per week	4.0 ± 1.5	4.0 ± 1.5	3.9 ± 1.5	4.0 ± 1.5	4.0 ± 1.4	4.1 ± 1.3	4.0 ± 1.4	3.9 ± 1.4
No. of physicians per clinic	7.1 ± 3.4	7.3 ± 3.6	8.2 ± 4.5	8.7 ± 4.1	7.9 ± 3.9	9.5 ± 5.0	8.4 ± 3.5	7.9 ± 3.4
Panel characteristics
No. of panelled patients	110 868	114 531	108 244	151 866	157 631	158 974	164 965	169 563
Physician panel size	1458.8 ± 779	1286.9 ± 742	1127.5 ± 674	1368.2 ± 928	1382.7 ± 832	1406.8 ± 845	1330.4 ± 829	1367.4 ± 806
Age of patients, yr	39.6 ± 6.8	40.1 ± 7.2	40.4 ± 7.3	40.3 ± 6.8	40.1 ± 6.5	40.0 ± 6.1	39.1 ± 5.8	39.2 ± 6.0
Patients on multiple panels, %	13.9 ± 6.9	13.4 ± 7.7	14.1 ± 10.9	12.5 ± 7.1	14.0 ± 7.5	11.5 ± 5.9	12.0 ± 8.9	11.4 ± 8.3
Complex patients, %	5.2 ± 1.8	5.0 ± 1.7	5.6 ± 1.8	5.3 ± 1.7	4.8 ± 1.9	5.1 ± 1.7	5.3 ± 1.8	6.0 ± 2.0
Female patients, %	55.2 ± 13.5	55.5 ± 13.8	55.2 ± 14.4	55.3 ± 13.4	54.2 ± 13.2	53.5 ± 12.6	53.6 ± 12.4	53.1 ± 11.9
Patients aged > 60 yr, %	21.3 ± 9.7	22.4 ± 10.5	22.4 ± 10.8	23.5 ± 10.3	23.1 ± 10.0	22.7 ± 9.4	22.3 ± 8.8	22.9 ± 9.4

Note: SD = standard deviation, TNA = third next available appointment.
↵* Except where noted otherwise.

Table 3:

Means of the outcome variables for each year of the study period

Outcome variable	Year; mean ± SD
Outcome variable	2009	2010	2011	2012	2013	2014	2015	2016
Provider continuity	58.7 ± 21.9	60.6 ± 23.7	60.9 ± 24.2	62.3 ± 23.8	62.3 ± 22.6	64.2 ± 22.1	64.1 ± 22.3	63.6 ± 22.5
Clinic continuity	76.7 ± 11.8	79.5 ± 12.3	80.2 ± 11.5	80.1 ± 12.7	79.1 ± 12.4	81.0 ± 10.4	81.1 ± 10.5	79.6 ± 11.5
Discontinuity ≤ 50 km	14.6 ± 10.0	12.7 ± 9.2	11.6 ± 9.0	11.4 ± 9.3	11.1 ± 9.1	9.6 ± 7.6	10.2 ± 8.0	10.6 ± 8.5
All-cause emergency department visits ≤ 50 km per 1000	1.14 ± 0.6	1.06 ± 0.6	1.04 ± 0.6	1.06 ± 0.6	0.95 ± 0.5	0.98 ± 0.6	1.01 ± 0.7	1.03 ± 0.6

Note: SD = standard deviation.

Table 4:

Confounding variables within the third next available appointment exposure groups

Variable	TNA exposure group; mean ± SD^*
Variable	Improved n = 96	Stable n = 669	Worsened n = 107
Practice characteristics
Female physicians, no. (%)	38 (39.6)	186 (27.8)	37 (34.6)
Rural physicians, no. (%)	49 (51.0)	338 (50.5)	51 (47.7)
No. of days worked per week	4.1 ± 1.4	4.0 ± 1.4	4.0 ± 1.4
No. of physicians per clinic	8.8 ± 4.3	8.0 ± 4.0	8.0 ± 3.9
Panel characteristics
Physician panel size	1412.8 ± 934.4	1388.1 ± 791.7	1363.3 ± 938.2
Age of panel, yr	39.2 ± 5.3	40.0 ± 6.6	39.2 ± 6.9
Patients on multiple panels, %	13.3 ± 7.8	13.1 ± 8.4	12.4 ± 8.4
Complex patients, %	5.6 ± 2.4	5.3 ± 2.0	5.4 ± 1.8
Female patients, %	57.4 ± 12.8	54.2 ± 13.5	55.7 ± 13.7
Starting TNA value	11.7 ± 10.7	4.4 ± 5.0	4.1 ± 4.1

Note: SD = standard deviation, TNA = third next available appointment.
↵* Except where noted otherwise.

Table 5:

Multilevel model of the effect on third next available appointment exposure groups

Outcome variable	β coefficient (95% CI)^*
Provider continuity
TNA improved	0.15 (0.10 to 0.19)
TNA worsened	−0.10 (−0.15 to −0.05)
TNA stable	0.02 (0.00 to 0.04)
TNA improved v. stable	0.13 (0.08 to 0.18)
TNA worsened v. stable	−0.12 (−0.17 to −0.07)
Clinic continuity
TNA improved	0.03 (0.002 to 0.07)
TNA worsened	−0.02 (−0.05 to 0.02)
TNA stable	0.01 (−0.003 to 0.02)
TNA improved v. stable	0.02 (−0.01 to 0.06)
TNA worsened v. stable	−0.03 (−0.06 to 0.01)
Discontinuity ≤ 50 km
TNA improved	−0.06 (−0.08 to −0.03)
TNA worsened	−0.01 (−0.03 to 0.02)
TNA stable	−0.02 (−0.03 to −0.01)
TNA improved v. stable	−0.04 (−0.06 to −0.01)
TNA worsened v. stable	0.01 (−0.02 to 0.04)
Emergency department visits ≤ 50 km per 1000
TNA improved	−0.0032 (−0.0044 to −0.0020)
TNA worsened	−0.0005 (−0.0017 to 0.0008)
TNA stable	−0.0017 (−0.0021 to −0.0012)
TNA improved v. stable	−0.0015 (−0.0028 to −0.0003)
TNA worsened v. stable	0.0012 (−0.001 to 0.0025)

Note: CI = confidence interval, TNA = third next available appointment.
↵* Shows the mean changes in the continuity measure per week within each of the groups.