In the November 2016 issue of Canadian Family Physician, Dr Prince discusses the various pitfalls of recent requirements by several provincial medical colleges for family physicians to “ensure that medical care is continuously available to the patient in his or her medical practice.”1
As Dr Prince explains, there are many laudable reasons for expanding access to primary care, such as improved management of chronic conditions and increased patient satisfaction. However, as alluded to by Dr Prince, the specific strategy of expanding after-hours primary care service availability in an attempt to mitigate “unnecessary” emergency department (ED) visits or “avoidable” hospitalizations, or to improve ED overcrowding, is based more on intuitive appeal than empirical evidence. In fact, multiple studies and expert panels have found that those patients with minor, non-urgent conditions who present to the ED actually have a negligible effect on ED volumes and ED length of stay, and that expansion of after-hours access to primary care does not substantially lower ED volumes.2–6 Similarly, Canadian data have shown that those who present to the ED, rather than the primary care clinic, with an exacerbation of an ambulatory care–sensitive condition are in fact sicker than the average ED patient, are more likely to require hospitalization, and are thus likely using the ED appropriately.7 Emergency department overcrowding is in fact primarily due to hospital-wide issues relating to in-patient bed availability and consulting and diagnostic services.6,8,9 Previous investments in new primary care models aimed at expanding availability of primary care services have shown no effect on ED use.10 Nevertheless, the myth of the “primary-care-type” or “inappropriate” ED visit as a driver of ED overcrowding continues to persist.
Expanding primary care access is an important step in achieving improved disease prevention and management. However, we must weigh the increased financial and resource costs of providing expanded after-hours care against the demonstrated minimal gains of “avoidable” ED visits and hospitalizations.
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