Abstract
Objective To describe family physicians who primarily practise in a walk-in clinic setting and compare them with family physicians who provide longitudinal care.
Design A cross-sectional study that linked results from a 2019 physician survey to provincial administrative health care data in Ontario. The characteristics, practice patterns, and patients of physicians primarily working in a walk-in clinic setting were compared with those of family physicians providing longitudinal care.
Setting Ontario.
Participants Physicians who primarily worked in a walk-in clinic setting in 2019, as indicated by an annual physician survey.
Main outcome measures Physician demographic and practice characteristics, as well as their patients’ demographic and health care utilization characteristics, were reported according to whether the physician was a walk-in clinic physician or a family physician who provided longitudinal care.
Results Compared with the 9137 family physicians providing longitudinal care, the 597 physicians who self-identified as practising primarily in walk-in clinics were more frequently male (67% vs 49%) and more likely to speak a language other than English or French (43% vs 32%). Walk-in clinic physicians tended to have more encounters with patients who were younger (mean 37 vs 47 years), who had lower levels of prior health care utilization (15% vs 19% in highest band), who resided in large urban areas (87% vs 77%), and who lived in highly ethnically diverse neighbourhoods (45% vs 35%). Walk-in clinic physicians tended to have more encounters with unattached patients (33% vs 17%) and with patients attached to another physician outside their group (54% vs 18%).
Conclusion Physicians who primarily work in walk-in clinics saw many patients from historically underserved groups and many patients who were attached to another family physician.
One in 10 Canadians report they do not have a regular family physician or other primary care physician,1 and many who do struggle with being able to access their physician in a timely manner.2,3 Walk-in clinics provide care to patients with and without a regular physician and do not require a scheduled appointment or an ongoing relationship between patient and provider.4-6 An estimated one-third of the population visited a walk-in clinic annually before the COVID-19 pandemic.7 Yet, walk-in clinics have been criticized for reducing continuity of care, which is associated with better patient outcomes.8-12
Fewer family physicians are choosing to provide longitudinal primary care.13-16 In 2021, 1 in 5 family physicians in Toronto, Ont, were considering closing their practices in the next 5 years, and only 5% indicated they were actively seeking to grow their practices.17 Reasons for leaving practice included health concerns, financial pressure, burnout, retirement, and other work options in or outside medicine.18-20 As a result, access to longitudinal primary care is likely to worsen in the coming decade.21
For family physicians, walk-in clinics may offer a practice alternative. Yet, little is known about the characteristics of physicians who work primarily in a walk-in setting. Our primary study objective was to describe their characteristics, practice patterns, and patient populations, comparing these metrics with those of longitudinal family physicians. Given current crises in primary care access and health human resources, an additional objective was to translate walk-in clinic days worked to the number of patients who could become attached if this time were reallocated to supporting longitudinal primary care.
METHODS
Study design and setting
This was a cross-sectional study of Ontario family physicians. Ontario is Canada’s most populous province, and in 2019 had 14.5 million residents and approximately 14,000 practising family physicians.22 About 13% of the population (2 million people) do not have a regular family doctor.23,24
Primary care reforms over the past 15 years attached 81% of Ontarians to a family physician through a patient enrolment model.25 These models include an access-related bonus that is reduced by the total amount of fee-for-service charges made by enrolled patients attending outside clinics (eg, walk-in clinics).26-28
Data sources
Health administrative data sets were linked using unique encoded identifiers and analyzed at ICES (Appendix Table 1, available from CFPlus,* lists databases used). ICES is an independent, nonprofit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health care and demographic data, without consent, for health system evaluation and improvement.
Administrative health care data were linked (through a data-sharing agreement) to the results of the 2019 College of Physicians and Surgeons of Ontario (CPSO) annual licence renewal survey, a mandatory component of physician licence renewal in Ontario.29 A mandatory question asks physicians to list all their practice settings and the hours worked in each setting per week. The CPSO then derived the following variables from the self-reported data: whether a “walk-in clinic or episodic care clinic outside of a hospital” was a setting where a physician worked more than 0 hours per week, the greatest number of hours per week (of all listed settings), or most of their working time (50% or more of the member’s practice hours).
Physician population
We included all 2019 CPSO survey respondents with a specialty in family medicine or with no specialty reported, excluding those who could not be linked, not actively practising in 2019, or with a practice pattern consistent with a focused or specialist practice and those who worked fewer than 44 days per year.30
Physician comparison groups
We defined “walk-in clinic physicians” as those who spent the greatest number of hours worked and most of their time in this setting, and who had at least 1 day with 10 or more office encounters with patients who were not enrolled to them personally.
The comparison group included longitudinal family physicians who were not included in the above definition and who practised comprehensive primary care, as defined by a standard ICES algorithm (Appendix Table 2, available from CFPlus*).30 Of note, some longitudinal family physicians may also occasionally provide walk-in services to their own patients, patients of other physicians, or unattached patients.
Physician characteristics
Physician and practice characteristics, including years in practice, gender, and patient enrolment model type, were included (all variables are listed in Appendix Table 2). Physician-level continuity was defined as the proportion of all their enrolled or virtually rostered patients with whom they had encounters in 2019. Virtual rostering assigns patients who are not formally enrolled to the family physician with the most claims for primary care services in the previous year (Appendix Table 2).25
Patient characteristics at encounters
We examined patient characteristics at each office encounter from January to December 2019, excluding walk-in clinic physician encounters with their own enrolled patients. This included level of material deprivation, dependency, instability, and ethnic concentration in patients’ residential neighbourhoods, divided into quintiles, as provided by the Ontario Marginalization Index (all variables are listed in Appendix Table 2).31,32 We also included whether they were new insurance registrants in the past 10 years (a proxy for recent immigration to the province) and a count of comorbidities and previous health care utilization based on Aggregated Diagnosis Groups and Resource Utilization Bands, both derived from the Johns Hopkins ACG System, version 10.33 Finally, we described the physician-patient relationship at each encounter (ie, whether patients were formally enrolled to the physician, their group, or another group, or not enrolled to any physician) and the most frequent diagnoses.
Analysis
We first described physicians and their encounters and plotted their main practice locations on a map of Ontario. As suggested by our patient partners, we overlaid a map of the density of unenrolled patients in 2019.
We compared the characteristics of walk-in and longitudinal FPs, and their encounters, using standardized mean differences (SMDs), with differences greater than 10% (0.1) being considered meaningful.34
We estimated how many more Ontarians could be enrolled to a family physician if each walk-in clinic workday were reallocated to support a primary care enrolment model (methods are described in Appendix Table 3, available from CFPlus*). The purpose of this was neither to simulate nor inform any particular intervention, but rather to appreciate the size of the walk-in clinic physician workforce, in the context of an Ontario population with more than 2 million unattached patients.23 Analysis was executed using SAS software, version 9.4. Figures were generated using Tableau software, version 2022.3.7. We followed STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) reporting guidelines.35
Ethics approval
This study was approved by the Women’s College Hospital Research Ethics Board (REB 2020-0095-E) with a waiver of patient consent.
Patient partner participation
Three patient partners who have been longitudinally involved in the project team’s work on walk-in clinics36 contributed to the analytic plan and to the interpretation of the results.
RESULTS
A total of 16,337 FPs completed the survey in 2019. After exclusions (Figure 1), 597 (5.7%) of the 10,443 included family physicians were classified as walk-in clinic physicians. Another 9137 (87.5%) were longitudinal FPs, of whom 1085 (11.9%) reported spending some time in a walk-in setting. Physicians who primarily worked in walk-in clinics had lower physician-level continuity than longitudinal FPs (0.1 vs 0.6, SMD=1.98).
Flowchart of family physicians included in the study: Physicians who met the definition for comprehensive practice and practised in a walk-in clinic setting some of the time, but did not meet the definition for walk-in clinic physicians, were included in the longitudinal family physician group.
Physician characteristics
Compared with longitudinal FPs, more walk-in clinic physicians were male (Table 1), offered services in a language other than English or French, and were more likely to practise in large urban areas. Walk-in physicians’ primary practice addresses were clustered in major urban areas, covering only some of the areas with the highest proportions of unattached patients (Figure 2).
Characteristics of walk-in clinic vs longitudinal family physicians in 2019
Proportion of patients without a family physician (per 1000 patients) overlaid with walk-in clinic physician primary practice locations in Ontario: Circle size reflects the number of walk-in clinic physicians with a primary practice location within an FSA (first 3 digits of postal code). Colour of FSA reflects the proportion of patients without a family physician (non-enrolled) per 1000 patients on a scale from 0 to 300; 11 physicians were missing an FSA and 2 physicians had a primary practice location outside Ontario (not plotted). Total N=584 physicians.
Of the walk-in clinic physicians who had enrolled patients (38.5%), most worked in enhanced fee-for-service models (87.8%). Walk-in clinic physicians received a mean of 89.2% of their income from fee-for-service billings, compared with 44.1% for longitudinal FPs (SMD=1.55).
Compared with longitudinal FPs, walk-in clinic physicians worked a similar number of days in an office setting but had 1.7 times as many office encounters and saw almost 3 times as many patients.
Encounter-level characteristics
Walk-in clinic physicians provided 13% of all their office encounters to patients enrolled to them or their group (longitudinal=64.7%, SMD=1.25), 33.0% of encounters to patients who were not formally enrolled to any family physician (longitudinal=17.0%, SMD=0.38), and 54.0% of encounters to patients who were enrolled to another physician outside their group (longitudinal=18.3%, SMD=0.80; Table 2).
Encounter-level patient enrolment characteristics of walk-in clinic vs longitudinal family physicians in 2019
Acute conditions such as the common cold, acute bronchitis, and acute sinusitis were more commonly diagnosed at encounters with walk-in clinic physicians; chronic conditions such as hypertension and diabetes were more commonly listed diagnoses for encounters with longitudinal FPs (Table 3).
Top 10 OHIP diagnoses billed by walk-in clinic physicians (walk-in encounters*) vs longitudinal family physicians (all office encounters) in 2019
Walk-in encounter patients were, on average, 10 years younger than those of longitudinal FPs (Table 4). Walk-in clinic physicians had more encounters with patients who were recent registrants, from large urban areas, and from neighbourhoods with high ethnic diversity. Walk-in clinic physicians had fewer encounters with patients who had high previous health care utilization or who resided in neighbourhoods with high dependency scores.
Encounter-level patient characteristics of walk-in clinic physicians (non-enrolled patients only) vs longitudinal family physicians (all patients) in 2019
Walk-in clinic physician workforce
We estimated that the walk-in clinic work hours provided by the 597 walk-in physicians included in our sample (median 3 days of walk-in work per physician-week, interquartile range [IQR]=2 to 4, mean [SD]=3.1 [1.5]) were equivalent to the physician time needed to support the enrolment of a median 468,456 (IQR=314,247 to 712,308) additional patients to longitudinal primary care.
DISCUSSION
We found that 6% of family physicians licensed in Ontario in 2019 worked mainly in walk-in clinics. These physicians saw more patients daily and frequently treated unattached patients and those attached to an outside family physician. They were also more often male, multilingual, and practised in multiple locations. Compared with longitudinal FPs, their patients were typically younger, less frequent health care users, from urban and ethnically diverse areas, or recent immigrants. This subset of family doctors worked an average of 3 days per week in walk-in clinics, equivalent to the physician time needed to enrol about 470,000 patients to a longitudinal FP.
Past studies of walk-in clinic physicians in Canada are more than a decade old. Previously, physicians working in walk-in clinics in Ontario and British Columbia were more often female.6,37 However, a study of 2015-2017 family medicine graduates found that more women preferred longitudinal primary care; this is potentially consistent with the finding of more men working in walk-in clinics in 2019.38
We found that, compared with longitudinal FPs, walk-in clinic physicians served more ethnically diverse populations. Recent immigrants have lower rates of attachment,26 cancer screening,39-41 and care for chronic diseases.42-46 Whereas US retail clinics typically serve higher-income areas with lower levels of those classified as a minority,47-51 walk-in clinics have acted as health care hubs for immigrant communities in Scandinavia.52,53 We found that a higher proportion of walk-in physicians offer services in a language other than English or French. They may be the children of immigrants, or immigrants themselves, in which case they could be in a better position to communicate with and understand the needs of patients new to Canada.54,55 Nonetheless, immigrants should be offered the opportunity to also engage in longitudinal primary care to better meet their preventive and chronic care needs.
Timely access to episodic care remains foundational to a high-performing health care system. Ideally, this would be achieved in a setting that ensures continuity with longitudinal care. More than half of walk-in clinic physician encounters were with patients who were attached to an outside physician. In a survey study, 50% of patients indicated poor access to their regular family physician as the reason for visiting a walk-in clinic, although geographic proximity and general convenience were also commonly cited reasons.56 Although access challenges2 continue to drive demand for walk-in clinics in Canada, other countries such as Norway, the Netherlands, Sweden, and Finland have few to no walk-in clinics.57-60 In these countries, there is greater accountability for same-day and after-hours access for urgent primary care issues, obviating the need for separate walk-in clinics.61-66
In translating total walk-in clinic workdays to the number of additional patients who could be enrolled, our aim was to contextualize the size of the walk-in physician workforce. The combined walk-in clinic workdays reflect a workforce similar to that which would be needed to enrol one-quarter of all unattached patients in Ontario. However, any potential intervention could more realistically aim for 10% or less of walk-in days reallocated, and should account for what is currently a mismatch between the geographic locations of walk-in physicians’ practices and of many unattached patients.
In qualitative research from 20 years ago, family physicians reported walk-in clinics as necessary to fill the gap between primary care and emergency services.67 Several recent physician workforce trends have the potential to increase that gap by decreasing access to longitudinal primary care. Fewer new family medicine graduates are choosing to pursue longitudinal family practice,13,14 and more are leaving practice.17 In a qualitative study of walk-in clinic physicians’ perspectives, scheduling flexibility, a desire to practise episodic care, the demand for walk-in care, and the fee-for-service payment model motivated the choice to practise in a walk-in setting.68 Paradoxically, physician workforce diversion to walk-in clinics and other alternatives may further reduce access to longitudinal primary care, ensuring that demand for walk-in clinics remains high.
Limitations
Our study has several limitations. First, we relied on self-report to identify walk-in clinic physicians in Ontario. Physicians may underreport full-time walk-in clinic status and, as a result, our sample of walk-in clinic physicians is likely to be more specific than sensitive. Second, longitudinal physicians included some who reported working in a walk-in clinic setting part-time. We focused on those who primarily practised in walk-in clinic settings to increase confidence that encounters with unenrolled patients were indeed walk-in clinic encounters. Walk-in style practice exists on a spectrum, and any misclassification of physicians in either direction would have biased our findings toward the null. Third, the physician primary practice address may not always correspond to a walk-in clinic location. Fourth, some communities and care teams were not included in our study as they do not appear in claims-based data. This includes Indigenous communities,69 as well as community health centres, which provide care to less than 2% of the population.17 Finally, changes in walk-in clinic physician services since 2019 could not be determined, but access to longitudinal, comprehensive primary care has worsened since the pandemic.70,71 Future research is needed to examine practice patterns postpandemic, as there have likely been shifts resulting from the rise of virtual care, including virtual walk-in clinics,36,72 as well as ongoing shifts in practice preferences of newly graduating family physicians.15
Conclusion
Physicians who primarily work in walk-in clinics fill gaps in the system by seeing unattached and underserved patients, albeit in an episodic model that is not designed to support preventive care or the ongoing management of chronic disease. More than half of walk-in clinic physicians’ encounters were with patients who were enrolled in another practice, suggesting that access barriers could explain some of this walk-in clinic use.
Acknowledgment
This study was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. This study also received funding from a Canadian Institutes of Health Research project grant awarded to Drs Lauren Lapointe-Shaw and Noah M. Ivers (grant #175285). We thank Alexander Kopp for contributions to the study design and data analysis. We also thank our patient partners Cherryl Bird, Krysta Nesbitt, and Patrick Roncal for their contributions to the analytic plan and results interpretation. Alexander Kopp was not compensated for this work. Patient partners were provided with an hourly honorarium for reviewing study materials and attending project meetings. This document used data adapted from the Statistics Canada Postal Code Conversion File, which is based on data licensed from Canada Post Corporation, and data adapted from the Ontario Ministry of Health Postal Code Conversion File, which contains data copied under licence from Canada Post Corporation and Statistics Canada. Parts of this material are based on data and information compiled and provided by the College of Physicians and Surgeons of Ontario (CPSO), Canadian Institute for Health Information, Ontario Health, and the Ontario Ministry of Health. The data provided by the CPSO was acquired through a data-sharing agreement between ICES and the CPSO. We thank the Toronto Community Health Profiles Partnership for providing access to the Ontario Marginalization Index. The analyses, conclusions, opinions, and statements expressed herein are solely those of the authors and do not reflect those of the funding or data sources; no endorsement is intended or should be inferred. The data set from this study is held securely in coded form at ICES. While legal data sharing agreements between ICES and data providers (eg, health care organizations and government) prohibit ICES from making the data set publicly available, access may be granted to those who meet prespecified criteria for confidential access, available at https://www.ices.on.ca/DAS (email: das{at}ices.on.ca). The full data set creation plan and underlying analytic code are available from the authors upon request, understanding that the computer programs may rely upon coding templates or macros that are unique to ICES and are therefore either inaccessible or may require modification.
Footnotes
↵* The Appendix is available from https://www.cfp.ca. Go to the full text of the article online and click on the CFPlus tab.
Contributors
Dr Lauren Lapointe-Shaw, Dr Christine Salahub, Dr Peter C. Austin, Dr Sundeep Banwatt, Dr R. Sacha Bhatia, Dr Laura Desveaux, Dr Tara Kiran, Dr Aisha Lofters, Dr Malcolm Maclure, Dr Danielle Martin, Dr Rita K. McCracken, J. Michael Paterson, Dr Jennifer Shuldiner, Dr Mina Tadrous, and Dr Noah M. Ivers contributed substantially to the study concept and design. Dr Li Bai contributed to the acquisition of data. All authors contributed to the analysis and interpretation of data. Drs Lapointe-Shaw and Salahub wrote the first draft of the manuscript. All authors revised the draft critically for important intellectual content, gave final approval of the version to be published, and agreed to act as guarantors of the work.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
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