Engagement in primary health care among marginalized people who use drugs in Ottawa, Canada

Claire E Kendall,Brad Renaud,Mark Tyndall,Jessy Donelle,Lisa M Boucher,Pam Oickle,Sean Leblanc,Nicola Diliso,Dave Pineau,Rob Boyd,Alana Martin,Zack Marshall,Ahmed M Bayoumi

doi:10.1186/s12913-020-05670-z

Abstract

BackgroundThere may be less primary health care engagement among people who use drugs (PWUD) than among the general population, even though the former have greater comorbidity and more frequent use of emergency department care. We investigated factors associated with primary care engagement among PWUD.MethodsThe Participatory Research in Ottawa: Understanding Drugs (PROUD) cohort study meaningfully engaged and trained people with lived experience to recruit and survey marginalized PWUD between March–December 2013. We linked this survey data to provincial-level administrative databases held at ICES. We categorized engagement in primary care over the 2 years prior to survey completion as: not engaged (< 3 outpatient visits to the same family physician) versus engaged in care (3+ visits to the same family physician). We used multivariable logistic regression to determine factors associated with engagement in primary care.ResultsCharacteristics of 663 participants included a median age of 43 years, 76% men, and 67% living in the two lowest income quintile neighborhoods. Despite high comorbidity and a median of 4 (interquartile range 0–10) primary care visits in the year prior to survey completion, only 372 (56.1%) were engaged in primary care. Engagement was most strongly associated with the following factors: receiving provincial benefits, including disability payments (adjusted odds ratio [AOR] 4.14 (95% confidence interval [CI] 2.30 to 7.43)) or income assistance (AOR 3.69 (95% CI 2.00 to 6.81)), having ever taken methadone (AOR 3.82 (95% CI 2.28 to 6.41)), mental health comorbidity (AOR 3.43 (95% CI 2.19 to 5.38)), and having stable housing (AOR 2.09 (95% CI 1.29 to 3.38)).ConclusionsDespite high comorbidity, engagement in primary care among PWUD was low. Our findings suggest that social care (housing, disability, and income support) and mental health care are associated with improved primary care continuity; integration of these care systems with primary care and opioid substitution therapy may lessen the significant morbidity and acute care use among PWUD.

Highlights

There may be less primary health care engagement among people who use drugs (PWUD) than among the general population, even though the former have greater comorbidity and more frequent use of emergency department care
We found that primary care engagement was more likely among PWUD who received provincial benefits, had stable housing, had mental health comorbidity, and reported ever being on methadone
Expanding on Kerr et al.’s [10] finding that 78% of PWUD self-reported visits to primary care in the past year, we found that only 56% of this population had regular engagement with any one family physician

Summary

Introduction

Common comorbidities among PWUD include mental health conditions, HIV and hepatitis C [2, 5, 6] Despite this high burden of illness, the large majority of people who use drugs have unmet health needs [7,8,9]. We have found that for PWUD, compared to not having a regular family physician, having a regular family physician reduces the odds of having multiple emergency department visits by 50% [2] This is consistent with a broad literature evidence base demonstrating patient-reported health outcomes and health system improvements associated with having a regular source of primary care, especially for complex populations [17,18,19]

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