Accessibility of adolescent care in the context of primary care reforms: a retrospective population-based cohort study in Québec, Canada

Introduction: Family medicine groups (FMGs) were implemented in Québec over a decade ago as a new model of multidisciplinary primary care intended to improve the medical home. Primary care is crucial for adolescents, since unhealthy behaviours such as smoking, alcohol abuse, and physical inactivity that arise during this period translate into risk factors for chronic diseases in adulthood. Proper access to primary care may help adolescents maintain health, modify unhealthy behaviors, and receive timely treatments. In Québec, adolescents primarily receive primary care from family physicians (FMG and non-FMG) or pediatricians. No published studies have investigated the impact of the new reform models on adolescent access to care.Objectives: To assess the extent to which FMGs are associated with increased access to care and decreased health inequalities for adolescents. Methods: Population-based retrospective cohort study linking province-wide health administrative data in Québec for adolescents between 2010-2013 (n=574,964). Multivariate regression analyses were performed to test associations between 4 primary care models (FMGs, family physicians not part of FMGs, pediatricians, or no primary care) and two outcomes: emergency department (ED) visits (main outcome; proxy for primary care accessibility) and primary care visits (secondary outcome). Models were adjusted for confounders: age, sex, co-morbidities, rurality, socioeconomic status (SES), and previous ED visits. Reasons for ED visits was examined through the ICD-9CA diagnostic codes on physician claims. Secondary analysis assessed for effect modification, testing the interaction between SES and primary care model.Results: The distribution of adolescents across primary care models was the following: 19.7% in FMGs, 13.7% in pediatric care, 10.1% in non-FMGs, and 56.5% in no primary care. Compared to adolescents receiving care from FMGs, fewer ED visits were made when receiving care from pediatricians (incidence rate ratio [IRR] 0.90, 95% CI 0.87-0.93) or with no primary care (IRR 0.89, 95% CI 0.87-0.91). No significant differences in rates of ED use were found between FMGs and non-FMGs (IRR 0.98, 95% CI 0.95-1.02). Adolescents in pediatric (RR 1.29, 95% CI 1.28-1.31) and non-FMG models (RR 1.12, 95% CI 1.11-1.13) were more likely to receive a primary care visit than those in FMGs. The interaction term between SES and primary care model was only significant for the secondary outcome. Non-FMGs had the greatest gap in access to primary care visits between the lowest and the highest SES groups, whereas the pediatric and FMG models had comparable gradients. Conclusion: The majority of adolescents did not utilize primary care and FMGs were not associated with improved access for adolescents. Although FMGs did not significantly impact health inequalities for ED visits, FMGs reduced inequality in primary care visits between the lowest and highest SES groups compared to non-FMGs. Among adults, FMGs have been linked to minor improvements in access. Our findings suggest the same benefit does not extend to the adolescent population. The current study identifies gaps in adolescent primary care – future studies should ascertain and address the barriers and enablers of primary care accessibility.

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