Abstract
BackgroundSome jurisdictions restrict primary care physicians’ daily patient volume to safeguard quality of care for complex patients. Our objective was to determine whether people with dementia receive lower-quality care if their primary care physician sees many patients daily.MethodsPopulation-based retrospective cohort study using health administrative data from 100,256 community-living adults with dementia aged 66 years or older, and the 8,368 primary care physicians who cared for them in Ontario, Canada. Multivariable Poisson GEE regression models tested whether physicians’ daily patient volume was associated with the adjusted likelihood of people with dementia receiving vaccinations, prescriptions for cholinesterase inhibitors, benzodiazepines, and antipsychotics from their primary care physician.ResultsPeople with dementia whose primary care physicians saw ≥ 30 patients daily were 32% (95% CI: 23% to 41%, p < 0.0001) and 25% (95% CI: 17% to 33%, p < 0.0001) more likely to be prescribed benzodiazepines and antipsychotic medications, respectively, than patients of primary care physicians who saw < 20 patients daily. Patients were 3% (95% CI: 0.4% to 6%, p = 0.02) less likely to receive influenza vaccination and 8% (95% CI: 4% to 13%, p = 0.0001) more likely to be prescribed cholinesterase inhibitors if their primary care physician saw ≥ 30 versus < 20 patients daily.ConclusionsPeople with dementia were more likely to receive both potentially harmful and potentially beneficial medications, and slightly less likely to be vaccinated by high-volume primary care physicians.
Highlights
Some jurisdictions restrict primary care physicians’ daily patient volume to safeguard quality of care for complex patients
Up to 70% of older adults with dementia live in private community dwellings [2] and the majority of their care is provided by primary care physicians (PCPs) [3, 4]
In keeping with Burgess’ cognitive burden framework, we hypothesized that these time pressures and organizational routines associated with increased daily patient volume would compromise PCP’s ability to partake in the “controlled processing” necessary to optimize care in complex patients with dementia [12]
Summary
Some jurisdictions restrict primary care physicians’ daily patient volume to safeguard quality of care for complex patients. In keeping with Burgess’ cognitive burden framework, we hypothesized that these time pressures and organizational routines associated with increased daily patient volume would compromise PCP’s ability to partake in the “controlled processing” necessary to optimize care in complex patients with dementia [12] This deleterious effect of high daily patient volume on quality of primary care has been demonstrated in the management of other conditions: high-volume PCPs inappropriately prescribe antibiotics to treat viral infections at a higher rate than their low-volume counterparts; [13, 14] they provide lower-quality preventive care and medication management to people with asthma, angina, and diabetes than physicians who see fewer patients per day [6, 15, 16]. Even if high-volume PCPs were able to achieve controlled processing with reduced visit length, we posit that they would have less time to have the sometimes-difficult conversations around starting or stopping medications that target the neuropsychiatric symptoms of dementia [17]
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