The association of primary care continuity with avoidable emergency department visits and hospitalizations for older adults living in Québec: An inverse probability of treatment weighting analysis

Background: Avoidable hospitalizations, which refer to hospitalizations for a condition that could have been prevented with appropriate and effective primary care, disproportionally occur among older adults. Indeed, about half of avoidable hospitalizations occur among older adults and this number could be on the rise given Canada’s population aging. The high prevalence of avoidable hospitalizations may signify issues in treating older adults in the primary healthcare system. One avenue to prevent avoidable hospitalizations is primary care continuity which enables better management of long-term conditions and allows for earlier detection and treatment of acute events and in turn, prevents avoidable hospitalizations. Scant studies have accurately accounted for confounding when studying the impact of primary care continuity on avoidable outcomes. In addition, the association between primary care continuity and avoidable hospitalizations has been seldom explored in Québec. This study aims to measure the association between primary care continuity and avoidable emergency department visits and avoidable hospitalizations among older adults. Design: Retrospective cohort (2005-2016), with inverse probability of treatment weighting using propensity scores. Data: The Care Trajectories-Enriched Data (TorSaDE) cohort, which links patient-reported socio-demographic information from survey data (Canadian Community Health Survey) with Québec provincial health administrative data (Régie de l’assurance maladie du Québec (RAMQ)). Inclusion: Participants (n= 15,256) were 65+ years old and had ≥ 2 primary care visits in the year prior to survey completion. Participants were followed for 1 year, or until death. Exposure: High or low relational primary care continuity as defined by the validated Usual Provider of Care Index (UPC) and measured during the year prior to CCHS completion. Outcome: Measured during 1 year after CCHS completion. Primary: high or low avoidable emergency department visits and hospitalizations as defined by a validated list of ambulatory care-sensitive conditions. Secondary: High or low all-cause emergency department visits or hospitalizations. Results: Among the 15,256 respondents, the mean age was 74.41 years (Standard deviation (SD)=6.95) and 59.2% were female. The average number of visits per year with a general physician were 4.36 (SD=3.17) and the average UPC score was 0.87(SD=0.20). Among the respondents, 65% had high primary care continuity; this subgroup was characterized by a higher prevalence of men and residents in rural areas and of lower household income and greater medical need. The weighted sample was balanced by covariates and thus there were only negligible differences between the control and treatment group. There was a total of 10251 all-cause emergency department visits, 5135 all-cause hospitalization visits, 1186 Ambulatory Care Sensitive Condition (ACSC) emergency department visits, and 542 ACSC hospitalizations. Thus, approximately 12 % of all emergency department visits and 11% of all hospitalizations were potentially avoidable. 5198 (34%) and 3412 (22%) of respondents experienced at least one emergency department visit or hospitalization respectively. 864 (5.7%) respondents experienced at least one ACSC emergency department visits while 308 (2.0%) experienced at least one ACSC hospitalization. High primary care continuity was associated with lower odds of all-cause hospitalization 0.935(95% confidence interval, CI [0.875-0.999] p <0.05) but not all-cause emergency 0.976 (95% CI [0.921-1.035] p= 0.422). High primary care continuity was associated with a higher odds of avoidable emergency department visits but not associated with avoidable hospitalizations. The odds ratios were 1.131 (95% CI [1.002-1.276] p<0.05) and 1.127(95%CI [0.923-1.376] respectively.Conclusion: High primary care continuity may be an avenue for reducing hospitalizations for older adults in Québec, but more research is needed to understand its influence on avoidable outcomes

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