Of care continuity and brick walls

In a recent brilliant guest editorial in the Annals of Family Medicine, Dr Otto Maarsingh of the Netherlands asked the Pink Floyd–inspired question, “The wall of evidence for continuity of care: how many more bricks do we need?”¹ He went on to provide overwhelming supporting evidence for the many ways continuity of care with a primary care provider like a family physician benefits patients, physicians, and health care systems. These include reduced mortality rates; fewer emergency department visits and hospitalizations; lower health care costs; improved uptake of preventive care and medication adherence; and better physician-patient relationships leading to greater satisfaction for both.¹

The additional brick in the wall for the benefits of care continuity to which Dr Maarsingh referred is an excellent study from Alberta published in that same issue by Dr Terrence McDonald and colleagues.² Using linked administrative health data from 2015 to 2018, they showed, “The best health care outcomes (measured by ED [emergency department] visits and hospitalizations) are associated with consistently seeing one’s own primary family physician or seeing a clinic partner when that physician is unavailable.”² The researchers acknowledged the effect of what they called partial continuity is interesting and complex and warrants further study.

Yet despite many benefits of continuity of care, research in the United Kingdom and United States reveals that over the past decade, continuity of care in primary care has declined.^3,4 With the current crisis in family medicine and primary care in Canada, where roughly 1 in 5 Canadians do not have access to a primary care provider they see regularly, the situation is certain to be similar.

The rapid expansion of virtual care necessary during the COVID-19 pandemic has the potential to enhance continuity (eg, by improving patient access and attachment to primary care providers, especially in rural and underserved areas) or undermine it. Virtual care through walk-in clinics, for example, could worsen the problem of people seeking one-off, transactional care, reducing longitudinal and continuous care.

Concerns about the impact of virtual care and the need to define and measure patient-provider attachment were drivers behind an excellent scoping review by Drs Monica Aggarwal and Richard Glazier in this month’s issue of Canadian Family Physician (page 634).⁵

Walk-in clinics have long been viewed as undermining continuity in primary care and, as noted above, such concerns could be amplified in the age of virtual care. This issue of Canadian Family Physician contains a cross-sectional study by Dr Lauren Lapointe-Shaw and colleagues (page e156)⁶ that uses an annual physician survey linked to provincial administrative health care data from Ontario that compares characteristics, practice patterns, and patients of physicians primarily working in a walk-in clinic setting with those of family physicians providing longitudinal care.

The results are rich, fascinating, and hard to sum up in just a few words here. Among the most important findings are that physicians who work primarily in walk-in clinics saw many patients from historically underserved groups, as well as many patients who were unattached to another family physician.⁶ I leave you to read the study and draw your own conclusions about the risks and benefits of walk-in clinics.

I shall end this editorial where I began, quoting Dr Maarsingh: “[T]he constantly growing wall of evidence for continuity cannot be ignored, leading to the question: how many more bricks before we—patients, physicians, health insurers, and policy makers—fully commit to promoting continuity in primary care?”¹

• Copyright © 2024 the College of Family Physicians of Canada