In our rush to offer “McMedicine,” do we even know what patients really want?
Did you know that less than 10 percent of primary care visits are urgent in nature?
Primary care covers a wide range of acute and non-acute issues, including preventive care and chronic disease management. And yet, same-day or next-day access features prominently in performance reports about primary care. It’s a key patient survey metric highlighted by the Commonwealth Fund Study, where it’s used to compare our health system’s performance with that of other countries. It’s also a key feature of the Ontario government’s recently passed Patients First legislation.
But access to primary care is a multi-dimensional concept. It includes considerations like geography, urgency, and continuity. How far must a patient travel to access care? Would they prefer to delay a non-urgent appointment in order to see their own doctor? I recently collaborated on an Ontario study of patients’ access to their primary care practice that looked not just at the wait time for an appointment, but 10 other aspects of access, including ease of getting to the practice, availability of after-hours services, and access to allied health professionals like nurses and social workers.
The unsurprising finding was that, similar to the Commonwealth Fund Study’s results and the Ontario Ministry of Health and Long-term Care’s reports, most patients (68 percent) waited more than a day for their appointment.
What did surprise us, though, was that most patients (96 percent) said it was easy to get their appointment, and most (87 percent) said they got their appointment for when they wanted it. Patients felt quite positive about their access overall, with 74 percent responding favourably across all 11 dimensions, a finding that challenges the common narrative that access to primary care in Ontario is poor.
In the Health Care Experiences Survey that the MOHLTC uses, we see a similar pattern: Although the same day/next day access is low (43 percent), patient-reported timeliness of access (the data for which is available upon request from the ministry) is much higher at 70 percent. There’s obviously room for improvement in timeliness here, but the situation seems far less dire than what the results for same day/next day access alone would suggest.
So, big deal, one might say. What’s the problem with featuring same day/next day appointments as a prominent quality indicator even if it may not be perfect? Well, there are many problems with focusing on this measure.
1. We promote convenience over continuity
As I wrote previously on Healthy Debate, we are already seeing a concerning shift in health care toward what some have termed “McMedicine.” Patients are offered virtual physician consultations while they’re at the pharmacy. There’s a walk-in clinic smack dab in the middle of the local Walmart. Cellphone apps promise assessments and diagnoses via text message.
Developing policy that explicitly prioritizes same day/next day access, despite the lack of evidence that this improves outcomes, further ingrains convenience medicine into our culture. This comes at the cost of a quality indicator that is much more important: Relational continuity, which means seeing the same provider for most of one’s primary care. Relational continuity is associated with important outcomes both for patients and the health system (costs, integration, communication), and it gets disrupted when policies prioritize same day/next day. Recognizing the importance of continuity, Health Quality Ontario, which reports annually on primary care performance in the province, included it as a quality indicator for the first time in 2017.
2. We perpetuate myths about emergency department use
An idea persists in Canadian health care that emergency department (ED) backlogs are due to low-urgency visits that could be seen in primary care if only those patients could get same-day access to their family doctor.
Not only is this unfounded, it risks preventing us from finding solutions to the actual issues underlying ED overcrowding: Overflowing inpatient wards, too few long-term care beds, an inadequate supply of home care services, the lack of community-based after-hours diagnostic services like imaging and bloodwork, and the unique setting of rural medicine, where family doctors are often responsible for providing ED services.
3. We risk overwhelming an already strained primary care sector
Primary care does not operate within a vacuum. Access is influenced by many external factors over which primary care providers often have little or no control. For example, lengthy wait times can drive repeated contact with primary care by patients who should have long ago received specialty care, or by patients whose medical issues—and in turn, treatment plans—remain unclear until they can finally get that biopsy or MRI. As family doctors, we’ve all seen patients who wait up to 18 months for their knee surgery and require our help to manage their pain in the meantime. We’ve all seen complex mental health patients who face excessive waits for psychiatric care—even after a hospitalization or a suicide attempt—and similarly require our help in the meantime.
Add to this issues like aging and increasingly complex patients, and a fragmented, inefficient health infrastructure, and we start to see how unrealistic it is to focus on one sector when it comes to improving primary care access.
So what can we do to better measure access to primary care?
First of all, we need policymakers to focus on gathering data that capture the complexity of access and prioritize timeliness. In our study, patients were asked questions like: “Can you see other doctors in this practice if your doctor is not available?” “Are the opening hours too restrictive?” and “Were you able to arrange an appointment for as soon as you wanted to?” When analyzing data, we need to be mindful of the ways in which patients may have interpreted the questions. For example, in the Commonwealth Fund Study and the ministry’s survey, the wording of the same day/next day questions might actually be capturing both urgent and non-urgent visits.*
Second, we should collect data from multiple sources. Most access studies (including ours) have limitations such as low sample sizes, sampling bias, and recall bias. Even one of the best resourced studies out there, the Commonwealth Fund Study, has a response rate of only 21 percent, and likely misses vulnerable or unique populations such as low-income patients, Indigenous populations, rural patients, and new immigrants and refugees. To more accurately gauge access, we need to collect data at the patient level, the physician level, and the practice level. Family physicians should receive funding and other supportive infrastructure to do this in as unobtrusive a manner as possible.
Third, we need to approach access as a philosophy rather than taking a prescriptive, one-size-fits-all approach. If our patient calls needing a same-day appointment, we should do what we can to accommodate them, but what that looks like will vary from setting to setting, with consideration for issues like rural family doctors’ commitments to servicing their EDs and hospitals. Practices can look to “open access” or “carve-out” scheduling, offer telephone follow-ups, emails and team-based approaches, all of which have been demonstrated to reduce wait times for primary care appointments.
And finally, to meaningfully address access to primary care, we need to look at the “whole system.” Innovative solutions to wait-lists, referral systems, and communications with patients and specialists, would help alleviate some of the pressures that have direct, negative effects on access to primary care.
Focusing on the “same day/next day” metric not only risks missing opportunities to truly improve access, but also risks undermining other important dimensions of quality, causing real harm to our patients and to our health care system as a whole.
*Commonwealth Fund Study: “The last time you were sick or needed medical attention…”
Ontario Ministry of Health and Long-term Care’s Health Care Experiences Survey: “The last time you were sick or concerned that you had a health problem…”
Kamila Premji is a practising family physician in Ottawa and a Ph.D. candidate at Western University’s Centre for Studies in Family Medicine.