A growing proportion of older adults do not have a 'usual' clinician, survey finds
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Fewer adults with multimorbidity had a “usual” clinician from whom they regularly sought care in 2016 compared with 2010, according to survey results published in JAMA Network Open.
Moreover, the data showed that adults whose usual clinician was a specialist instead of a primary care clinician were 5.6 percentage points less likely to receive the influenza vaccine.
“Our results suggest the importance of providing usual care — ideally primary care — for older adults with multimorbidity,” Ishani Ganguli, MD, MPH, an assistant professor of medicine at Brigham and Women’s Hospital, and colleagues wrote. “In addition to the preventive health benefits ... specialist usual clinicians had primary focus in just 24% to 25% of their patients’ chronic conditions, suggesting potential gaps in care that were not captured by the outcomes we examined.”
Ganguli and colleagues analyzed Medicare Current Beneficiary Survey data from 2010, 2013 and 2016 on community-dwelling Medicare Advantage and traditional Medicare beneficiaries with at least two chronic conditions. The analysis included 25,490 unweighted respondent-years, representing 90,324,639 respondent-years nationally. Among them, 58.4% belonged to women. The mean age of all respondents was 77.5 years.
Trends in usual clinician use
From 2010 to 2016, the proportion of adults reporting a usual clinician decreased from 94.2% to 91% (P < .001), according to Ganguli and colleagues. During the study period, women were more likely than men to report having a usual clinician (adjusted marginal difference [AMD] = 2.5 percentage points; 95% CI, 1.5-3.5). Individuals with an income of $50,000 or more were also more likely to report having a usual clinician (AMD = 2.2; 95% CI, 1.1-3.4) compared with those who had an income of less than $15,000. Black beneficiaries were less likely to report a usual clinician compared with white beneficiaries (AMD = 2.8; 95% CI, 4.3 to 1.3). Similarly, those with traditional Medicare compared with Medicare Advantage were less likely to report a usual clinician, the researchers reported (AMD = 3.2; 95% CI, 4.1 to 2.3).
“We found that over time, fewer older adults with multiple chronic conditions report having a usual clinician,” Ganguli told Healio Primary Care.
Specialist vs. primary care clinicians
Among the 23,279 respondents with usual clinicians, those who reported seeing a specialist decreased from 5.3% to 4.1% (P < .001). Respondents were more likely to report specialists as their usual clinicians if they had traditional Medicare (AMD = 2.3; 95% CI, 1.6-2.9), were Black or non-white Hispanic (Black vs. white: AMD = 1.5; 95% CI, 0.2-2.8; non-white Hispanic vs. white: AMD = 3.8; 95% CI, 1.9-5.7) or lived in the Northeast compared with the Midwest (AMD = 3.6; 95% CI, 2.1-5.2).
Overall, respondents with usual clinicians were more likely to receive preventive services like cholesterol screening (AMD = 6.7; 95% CI, 5.4-8.1) and the influenza vaccine (AMD = 11.6; 95% CI, 9.2-14.0), the researchers observed. While the influenza vaccination rate was lower among adults with a specialist usual clinician (73.8% vs. 68%), there were similar rates of BP assessments (98.8% vs. 99.3%), cholesterol screening (96.8% vs. 96.3%) and diabetes screening (52.8% vs. 54.7%) among those with a specialist or primary care usual clinician.
The researchers noted that the reduction in usual care access “may have persisted and even accelerated to date, given COVID-19 pandemic-era financial struggles and likely closures among primary care practices.”
“Bolstering equitable access to usual care, and especially primary care, requires a multipronged approach, including primary care workforce expansion and redistribution to areas of need, insurance design to encourage regular primary care engagement, and technology-enabled efficiencies in care delivery,” Ganguli and colleagues wrote.