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Primary care visits and health policy.

The article by Noralou Roos and colleagues (page 777) carries an important policy message and, in doing so, provides a mini “primer” on the importance of several characteristics of primary care. The authors analyse the determinants of frequency of visiting primary care physicians and its consistency over 2 years. They find that most people with a common primary care problem (hypertension) make the professionally recommended number of visits each year, but a substantial proportion make many more visits than this. That a high proportion of hypertensive patients make at least the recommended number of visits is testimony to the relative effectiveness of Canadian (at least Manitoban) health policy in assuring the quality of care, at least in comparison with the US. However, there is more to the story than this. The most important factors the authors found to be associated with visit frequency were, in order of importance, prior use (the frequency of visits in the previous year), the physicians’ practice style (measured by their patient recall pattern), comorbidity (the presence of 3 or more “serious medical problems” or a mental health problem), the continuity of care and the neighbourhood income level. Prior use of services is always the most potent determinant of subsequent use because it inherently controls for a whole host of characteristics that might be unknown or unmeasurable. These include various social and environmental determinants of utilization, differences in the need for preventive interventions and aspects of health status that are difficult to measure. The problem with using prior use as a predictor, especially when resource allocations are based on it, is that it is highly amenable to manipulation by practitioners, whose recommendations for follow-up appointments leads to about 40% of all visits. Comorbidity has also been shown to be an important factor in a study that used a more precise measure of comorbidity — the ACG (adjusted clinical groups) method. With this approach all diagnoses are used to derive a morbidity burden index for each individual in a population, according to the profile of types of illness experienced in a period (usually a year). Application of the ACG method reveals that consistently high users are people with combinations of different types of illness rather than those with any 1 or 2 types, regardless of the chronicity or severity of the illness. The more types of illness people have, especially if one of the illnesses is a psychosocial condition, the more likely they will be consistently high users of health care services. Continuity of care is another important determinant of use. Roos and colleagues report that patients with a better continuity of care with their practitioner made fewer visits. Evidence on the importance of continuity in primary care practice is accumulating rapidly. Although patients who identify with a particular place (e.g., a clinic) benefit more than those without a regular source of care, patients who see a particular physician over long periods benefit even more: this is because of better practitioner recognition of patient needs and problems, more accurate diagnoses, better concordance with treatment advice, fewer hospital admissions, lower costs of care overall and better achievement of patient-oriented preventive activities. The study by Roos and colleagues provides further evidence of the greater efficiency of services with more continuity of care. I was most interested to see that the patients in Roos and colleagues’ study who resided in lower-income neighbourhoods made more visits than those in higher-income areas. This observation is testimony to the effectiveness of policy Editorial