Abstract
PURPOSE Primary care access stands as a crucial indicator within health systems. However, there has been a noticeable lack of comprehensive research comparing different care models that facilitate primary care access when a patient’s regular physician is unavailable. This study aims to draw a contrast between health system utilization following a consultation with a patient’s designated family physician group (that is, an in-group physician who is not the patient’s primary physician) and an appointment with a walk-in clinic physician who operates outside the patient’s designated family physician group.
METHODS We executed a population-based, retrospective cohort study utilizing administrative data gathered from Ontario, Canada, encompassing all individuals formally enrolled with a family physician during the timeframe from April 1, 2019, to March 31, 2020. We compared the healthcare utilization of patients visiting within-group physicians to those attending walk-in clinic physicians, employing propensity score matching to minimize differences in patient characteristics. The key outcome measured was any visit to the emergency department within 7 days subsequent to the initial consultation.
RESULTS After matching, patients who consulted a within-group physician (N = 506,033) exhibited a 10% reduction in the likelihood of visiting the emergency department within a week post-visit compared to those who consulted a walk-in clinic physician (N = 506,033; 20,117 [4.0%] versus 22,320 [4.4%]; risk difference [RD] 0.4%; 95% CI 0.4-0.5; relative risk [RR] 0.90; 95% CI, 0.89-0.92). In cases where the visits occurred on weekends, this correlation was notably stronger (7,964 [3.7%] versus 10,055 [4.7%]; RD 1.0%; 95% CI 0.9-1.1; RR 0.79; 95% CI, 0.77-0.82). Patients accessing after-hours consultations with within-group physicians demonstrated increased likelihoods of engaging in either a virtual or in-person visit with the same group within the following week (virtual RR 1.86, in-person RR 1.87).
CONCLUSIONS Engaging with a within-group physician during after-hours might contribute to fewer subsequent emergency department visits when compared to consultations with walk-in clinic physicians. This outcome may stem from improved continuity of care and provides vital insights that can inform both primary care service models and relevant policy-making decisions.
Key words:
INTRODUCTION
Achieving a balance between timely access and continuity of care remains a formidable challenge within the realm of primary care. While an impressive 90% of the Ontario population claims to have a family physician or primary care provider,1 fewer than half manage to secure same- or next-day appointments.2 Walk-in clinics offer episodic care without requiring an appointment, catering to all patients regardless of their ties to a primary care physician.3–6 Patients attached to family physicians occasionally opt for walk-in clinics when their need for care arises outside normal office hours, particularly on evenings or weekends,7 or if they find accessing same- or next-day appointments with their regular physician to be challenging.8 Furthermore, many perceive walk-in clinics to be easier to access.3,9–11 Approximately 30% of Ontario residents seek care at walk-in clinics annually.12
To address the need for access while maintaining continuity of information and management, some healthcare funders have established requirements and incentives aimed at ensuring after-hours coverage within each primary care physician group.20,21 Our study aimed to evaluate two potential models for rapid access when a patient’s personal physician is unavailable. We posited that after-hours visits with a within-group physician would correlate with lower subsequent emergency department (ED) utilization compared to visits with a walk-in clinic physician.
METHODS
Setting
This investigation was anchored in a population-based, retrospective cohort study that utilized administrative claims data from Ontario, a province housing approximately 14.5 million residents and around 14,000 family physicians as of 2019.22 Ontario offers its permanent residents universal health coverage for medically essential physician and hospital services, absolving them of copayments or deductibles, and permits unrestricted choice of physician. The sole funding body is the Ontario government.
The majority (81%) of Ontarians are linked to care under a family physician via a patient enrollment model.23 This model consists of group practices that employ blended remuneration structures involving capitation alongside fee-for-service payments.24 Family physicians within primary care group practices primarily refer patients to specialists outside their practice as deemed necessary. Back in 2004, the Ontario government established after-hours premiums and minimum after-hours service requirements for physicians participating in patient enrollment models.25–27 Particularly in capitation-based settings (accounting for over 40% of practicing physicians),28 groups consisting of three or more physicians were mandated to provide a minimum of one three-hour coverage session each week during evenings or weekends.20,21 The required number of after-hours coverage blocks varied based on the group size and type. Additionally, physicians received incentives tied to access, which were diminished if enrolled patients sought care from external physicians (for example, at a walk-in clinic).29,30 Notably, walk-in clinics in Ontario typically operate independently of primary care clinics, and patients can select any walk-in clinic without the necessity for an appointment, all at no cost to them.
Data Sources
Numerous datasets were linked using unique encoded identifiers and were analyzed at ICES, an independent nonprofit research institute. ICES possesses the legal standing under Ontario’s health information privacy legislation that allows for the collection and analysis of healthcare and demographic data for the enhancement and evaluation of health systems, without requiring patient consent. Detailed descriptions of the ICES databases employed in this research can be found in Supplemental Table 1.
We acquired additional data from the College of Physicians and Surgeons of Ontario (CPSO) annual license renewal survey31 through a data-sharing agreement. By utilizing physicians’ self-reported practice settings and their weekly hours dedicated to each setting, the CPSO provided indicative variables identifying whether a walk-in clinic or episodic care clinic, distinct from hospital environments, was where a physician predominantly operated.19 These mandatory questions ensured completeness, with no missing responses for any physician involved.
Study Population
The study population comprised all Ontario residents who were formally enrolled with a family physician as of April 2019,32 and had experienced at least one family physician interaction within the period spanning from April 1, 2019, to March 31, 2020 (for a visual representation of the study population flow, refer to Supplemental Figure 1).
Exposure
The primary exposure was determined during the first eligible visit (index visit) within the study timeframe, which categorized the type of family physician office engagement. The groups of exposure were delineated as follows.
Visit With a Within-Group Physician
All office visits with practitioners who belonged to the same group as the patient’s enrolling physician (yet not the patient’s individual family physician) during the study timeframe were included. Visits were restricted to after hours or weekends—periods when acute care demand is heightened and more comparable to care typically received at walk-in clinics (see Supplemental Table 2 for defined visit types).
Visit With a Walk-In Clinic Physician
Outcomes
The principal outcome was defined as any visit to the emergency department within 7 days following the index visit (including the day of the index visit). Secondary outcomes encompassed the time taken to visit the ED (up to 30 days); low-acuity ED visits (as per Canadian Triage and Acuity Scale levels 4 or 5) within 7 days; ED visits within 30 days; and the count of family physician visits, whether virtual or in-person, within 7 days of the index visit (excluding the index day itself).
Other Variables
Statistical Analysis
We characterized the cohort by means of means (SD), medians (interquartile range), and frequencies/counts. We compared visit characteristics among exposure groups using standardized mean differences (SMDs), regarding differences exceeding 10% (SMD 0.1) as potentially significant.36
For binary outcomes, we reported relative risk (RR) and risk difference (RD) with respective 95% confidence intervals (CI), which were estimated utilizing methods that accommodated the matched sample.40,41 For assessing the time correlating with ED visits, we reported the hazard ratio by employing a Cox proportional hazards model with a robust variance estimator to make allowances for clustering within matched pairs.42 Every analytical procedure was conducted using the SAS statistical software (version 9.4; SAS Institute).
Subgroup and Sensitivity Analyses
In examining age and rurality subgroups, we reported the RR regarding ED visit occurrences within 7 days post-index visit. To further evaluate outcomes following visits deemed most likely to be acute, we ran a subgroup analysis focused exclusively on weekend visits. For both population groups, this restricted analysis covered visits occurring on Saturdays or Sundays, without including the weekend visit characteristic in the propensity score model, as patients were exclusively hard matched on rurality.
Ethics Approval
This study received approval from the Women’s College Hospital Research Ethics Board (REB 2020-0095-E), which included a waiver for patient consent.
RESULTS
Patient Characteristics
From the total of 1,701,381 individuals in the cohort, we pinpointed 607,166 (35.7%) whose initial visit was with a within-group physician after hours or on a weekend, in contrast to 1,094,215 (64.3%) who consulted a walk-in clinic physician. The demographic profile reveals that patients seeing a within-group physician were older (mean [SD] = 40.7 [23.4] years versus 38.3 [20.7] years; SMD 0.11) and were less frequently residing in large urban settings (74.7% versus 88.5%; SMD 0.36) (Supplemental Table 4). Patients choosing a within-group physician recorded a higher number of family physician visits in the preceding two years (mean [SD] = 5.2 [5.7] versus 4.5 [5.6]; SMD 0.13) while exhibiting comparable levels of prior healthcare utilization and comorbidity counts (Aggregated Diagnosis Groups).
Furthermore, those who opted for a within-group physician were more aligned with team-based primary care models when compared to those visiting a walk-in clinic physician (35.3% versus 16.5%; SMD 0.44). Patients from within the group typically received care from physicians associated with smaller practices (mean [SD] = 43 [69] physicians versus 64 [109] physicians; SMD 0.24) and lived geographically closer to their enrolling physician’s practice, on average residing 10 km closer (mean [SD] = 10.6 (31.0) km versus 20.6 (57.3) km; SMD 0.22).
From the cohort, 83% of patients receiving care from a within-group physician were successfully matched. After this process, there remained 506,033 patients across both groups. No measured characteristic varied by more than 10% (SMD 0.1), other than the factor of visits occurring on weekends (34.1% versus 28.1%; SMD 0.13) (Table 1). A detailed list of the top 20 visit diagnoses is available in Supplemental Table 5.
Table 1.
Characteristics of Patients in Matched Cohort (April 1, 2019-March 31, 2020)
Outcomes
Within the 7-day post-index visit window, patients who consulted a within-group physician during after-hours or weekends were found to be 10% less likely to visit an ED compared with those attending a walk-in clinic physician (RD 0.4 [95% CI, 0.4-0.5]; RR 0.90 [95% CI, 0.89-0.92]) (Table 2). These patients also exhibited a significantly reduced hazard for ED visits (hazard ratio 0.94 [95% CI, 0.93-0.95]), indicated by early divergence in time-to-event curves that suggest the majority of risk differences manifest soon after the initial visit (see Supplemental Figure 2a for Kaplan-Meier curves).
Table 2.
Propensity Score–Matched Outcomes
Furthermore, individuals who had consultations with a within-group physician were more likely to schedule either in-person or virtual follow-up visits with their own family physician or a physician from within the same group in the week following the index visit compared to those visiting a walk-in clinic, although the differences in risk differences were modest.
The reduction in 7-day emergency department visits for those who consulted a within-group physician was chiefly attributed to individuals residing in large urban areas (RR 0.86 [95% CI, 0.84-0.88]) and children/adolescents (aged Supplemental Table 6). Conversely, individuals living in rural regions who opted for care from a within-group physician experienced an increased likelihood of visiting the ED within the next week (RR 1.26 [95% CI, 1.13-1.41]).
Weekend-Only Visits
Among the 545,352 individuals identified in the weekend-only visit cohort, 279,119 (51.2%) had their index visit with a within-group physician, while 266,233 (48.8%) had visited a walk-in clinic physician. The differences in characteristics reflected similar patterns to the overall cohort analysis (Supplemental Table 7).
Post-matching, 213,190 patients were left in each group—76% of patients experiencing a visit with a within-group physician were successfully matched (Supplemental Table 8). The two groups were well-aligned concerning both patient characteristics and the top 20 visit diagnoses (Supplemental Table 9). Results following the index visit mirrored those noted in the primary analysis, albeit with even greater differences observed (Supplemental Table 10). Patients visiting a within-group physician were found to be 21% less likely to attend the ED within the subsequent seven days compared to those consulting a walk-in clinic physician (RD, 1.0% [95% CI, 0.9-1.1]; RR, 0.79 [95% CI, 0.77-0.82]) (Supplemental Figure 2b). Additionally, those who consulted a within-group physician were more likely to have an upcoming in-person or virtual appointment with their enrolling physician or group within 7 days.
DISCUSSION
This matched cohort study spanning the population level revealed that patients aligned with a family physician who consulted a colleague from their familial physician’s group after hours were 10% less likely (0.4% lower absolute risk) to seek ED care within one week in contrast to those who opted for walk-in clinic services. This marginal risk difference emerged predominantly within the initial few days post-visit and was particularly significant among patients living in densely populated urban areas. Patients who consulted a within-group physician also exhibited a greater propensity to follow up with their regular family physician or a within-group physician in the following week.
A 2005 study based in Ontario discovered that walk-in clinic visits were correlated with higher rates of 3-day healthcare reutilization for minor conditions compared to visits to family physicians, an outcome potentially influenced by variances in patient satisfaction.47 Research conducted in the U.S. indicated that walk-in clinics (specifically retail clinics devoid of longitudinal primary care) for low-acuity conditions resulted in escalated healthcare utilization and associated costs.48 Those findings reinforced the notion that increasing the availability of walk-in clinics did not diminish the frequency of low-acuity ED visits.49 Furthermore, in a recent exploration of virtual family physician visits, we noted lower incidences of ED visits following within-group virtual consultations compared to those following virtual consultations with external physicians,50 indicating that continuity in care can play an integral role in minimizing repeat healthcare utilization across both virtual and in-person care contexts.
In the realm of primary care, persistent tensions exist between the dual objectives of timely access and care continuity.51 Continuity of relationships has consistently been linked to improved health outcomes and diminished healthcare expenditures14,52–54 while also being an aspect valued by patients themselves.55,56 Nevertheless, many patients may encounter pressures that compel them to prioritize timely care whenever they perceive their health issue requires immediate attention. Moreover, factors like convenience and geographical proximity to care facilities significantly influence patient choices.7,8,27 Family physicians are encouraged to enhance their availability to deliver both continuity and prompt service. However, the reality is that primary care physicians are not obligated to provide 24/7 services, and many opt for part-time work arrangements.57 Therefore, timely access to care within a familiar group is likely seen as a preferable alternative when access to one’s own physician isn’t feasible. Consequently, findings from this study lend support to this dual approach.58 Notably, many physician groups utilize shared electronic medical records, which further ensures continuity of information and management for patients seeking care outside regular hours. Nonetheless, awareness regarding after-hours care options within patient groups remains limited, as evidenced by a 2012-2019 survey in which approximately 60% of Ontarians reported being unaware of the after-hours services provided by their family physician’s clinic.8,60 Hence, raising awareness regarding after-hours service availability is critical to achieving the intended outcomes of policies surrounding healthcare coverage.
Limitations
Conclusions
In summary, we discovered that compared to visits with walk-in clinic physicians, after-hours consultations with physicians affiliated with one’s own family practice group were correlated with a slight reduction in the risk of subsequent ED visits in the following week. Further investigation is warranted to unravel the underlying factors contributing to this observation, particularly how informational or management continuity may mitigate health system utilization.
Acknowledgments
We extend our gratitude to patient partners Krysta Nesbitt and Patrick Roncal for their invaluable contributions to the development of the analytic framework and the interpretation of results. Patient partners received an hourly honorarium for participating in the review of research materials and attending project meetings.
Data utilized in this document was adapted from the Statistics Canada Postal Code Conversion File, founded on data licensed from Canada Post Corporation, and/or the Ontario Ministry of Health Postal Code Conversion File, which contains data sourced under license from Canada Post and Statistics Canada authorities. Portions of this research are based on data and/or information compiled and provided by the College of Physicians and Surgeons of Ontario (CPSO), the Canadian Institute for Health Information, Ontario Health, and the Ontario Ministry of Health. The data provided by the CPSO were acquired through an established data-sharing agreement with ICES. The analyses, conclusions, opinions, and statements articulated herein are those of the authors exclusively, without reflecting the views of the funding or data sources; no endorsements are intended or should be inferred.
Footnotes
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Conflicts of interest: authors report none.
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Data-Sharing Statement: The dataset employed in this study is secured in coded form at ICES. Due to legal binding agreements between ICES and data providers (such as healthcare organizations and governmental entities), ICES is unable to publicly furnish the dataset; however, access may be granted to individuals meeting predetermined criteria for confidential access, available at www.ices.on.ca/DAS (das{at}ices.on.ca). The detailed dataset creation plan and analytical code are available upon request, noting that the computer programs may depend on coding templates or unique macros specific to ICES and might either be inaccessible or require modification for use.
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Funding support: This study received support from ICES, which is funded by an annual grant from the Ontario Ministry of Health and the Ministry of Long-Term Care. The study also benefited from grant funding awarded to L.L-S. and N.M.I. by the Canadian Institutes of Health Research (grant #175285).
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Supplemental materials
- Received for publication May 1, 2024.
- Revision received August 9, 2024.
- Accepted for publication August 14, 2024.
- © 2024 Annals of Family Medicine, Inc.
What factors contribute to lower emergency department visits when patients utilize after-hours services from their primary care physicians?
The data that support the findings of this study are available from the corresponding author upon reasonable request. Restrictions apply to the availability of these data, which were used under license for this study. Data are not publicly available due to privacy or ethical restrictions.
this study illustrates that patients who seek care from physicians within their family practice group during after-hours are less likely to visit the emergency department shortly thereafter compared to those who visit walk-in clinics. This underscores the importance of continuity of care and highlights the need for increased awareness regarding after-hours services provided by family practices. Future research should continue to explore how these dynamics play out in different healthcare contexts and further investigate the implications for healthcare system utilization.
