Trends in patient attachment to an aging primary care workforce: a population-based serial cross-sectional study in Ontario, Canada

Abstract

Background: Population aging is a global phenomenon. Resultant healthcare workforce shortages are anticipated. To ensure access to comprehensive primary care, which correlates with improved health outcomes, equity, and costs, data to inform workforce planning are urgently needed. Objectives: To explore temporal trends in early career, mid-career, and near-retirement comprehensive primary care physician characteristics, the medical and social needs of their patients, and the workforce's capacity to absorb patients of near-retirement physicians. Gender-based workforce trends and trends around alternative practice models were also explored. Design: A serial cross-sectional population-based study using health administrative data. Setting: Ontario, Canada, where most comprehensive primary care is delivered by family physicians (FPs) under universal insurance. Participants: All insured Ontario residents at three time points: 2008 (12,936,360), 2013 (13,447,365), and 2019 (14,388,566) and all Ontario physicians who billed primary care services (2008: 11,566; 2013: 12,693; 2019: 15,054). Exposure(s): Changes in the comprehensive FP workforce over three time periods. Main Outcome(s) and Measure(s): The number and proportion of patients attached to near-retirement comprehensive FPs; the number and proportion of near-retirement comprehensive FPs; the characteristics of patients and their comprehensive FPs. Results: Patient attachment to comprehensive FPs increased over time. The overall FP workforce grew, but the proportion practicing comprehensiveness declined from 77.2% (2008) to 70.7% (2019), with shifts into other/focused scopes of practice across all physician career stages. Over time, an increasing proportion of the comprehensive FP workforce was near retirement age. Correspondingly, an increasing proportion of patients were attached to near-retirement comprehensive FPs. By 2019, 13.9% of comprehensive FPs were 65 years or older, corresponding to 1,695,126 (14.8%) patients. Mean patient age increased, and near-retirement comprehensive FPs served markedly increasing numbers of medically and socially complex patients. Conclusions and Relevance: Primary care is foundational to high-performing health systems, but the sector faces capacity challenges as both patients and physicians age and fewer physicians choose to practice comprehensiveness. Nearly 15% (1.7 million) of Ontarians with a comprehensive FP may lose their physician to retirement by 2025. To serve a growing and increasingly complex patient population, innovative solutions that extend beyond simply growing the FP workforce are needed.

Competing Interest Statement

The authors have declared no competing interest.

Funding Statement

This study was supported by the INSPIRE PHC (Innovations Strengthening Primary Health Care Through Research) Research Program, which is funded through the Health Systems Research Program of the Ontario Ministry of Health (MOH) and the Ontario Ministry of Long-term Care (MLTC). It was also supported by ICES, which is funded by an annual grant from the Ontario MOH and MLTC. The opinions, results and conclusions reported in this paper are those of the authors and are independent from the funding sources. No endorsement by ICES, Ontario Health, or the Ontario MOHLTC is intended or should be inferred. Parts of this material are based on data and/or information compiled and provided by the Canadian Institute for Health Information (CIHI) and Cancer Care Ontario (CCO). The analyses, conclusions, opinions and statements expressed herein are solely those of the authors and do not reflect those of the data sources; no endorsement is intended or should be inferred. Dr. Premji is also supported by the PhD Family Medicine program at the University of Western Ontario, and by the Junior Clinical Research Chair in Family Medicine at the Department of Family Medicine, University of Ottawa.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

Yes

The details of the IRB/oversight body that provided approval or exemption for the research described are given below:

The use of data in this study was authorized under section 45 of Ontario's Personal Health Information Protection Act (PHIPA) and did not require review by a research ethics board or informed consent.

I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

Yes

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Data Availability

The data sets from this study are held securely in coded form at ICES. Data-sharing agreements prohibit ICES from making the data sets publicly available, but access may be granted to those who meet pre-specified criteria for confidential access, available at www.ices.on.ca/DAS. The complete data set creation plan, and underlying analytic code are available from the authors upon request, understanding that the programs may rely upon coding templates or macros unique to ICES.

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