Family physicians are playing and will play a key role in chronic disease prevention, identification and management since they are the frontlines and gateway to the healthcare system.  Family physicians are consulted by close to 80% of Canadians each year, the highest of any health professional group.¹ It is estimated that patients with chronic disease account for 51% of all visits to family physicians. ²

In the United States, data from the National Ambulatory Medical Care Survey has shown that most physician visits for common serious conditions are made to primary care physicians, 85% for chronic obstructive pulmonary disease, 82% for hypertension, 68% for diabetes, 58% for stroke, 57% for coronary artery disease, and 56% for asthma. ³ This will likely be higher for family physicians in Canada since there are many more specialists providing  primary care in the US.

Nearly everyone is going to suffer from chronic disease at some point in their lives.  Furthermore, people suffering from one chronic disease are at greater risk of developing other chronic diseases as well.  For example, 75% of patients with diabetes type 2 have other chronic health conditions, including heart disease and depression.⁴ In one study of 1000 patients presenting to 21 family physicians in the Saguenay region of Quebec  9 out of 10 adults had more than one chronic condition, and there was an increasing prevalence of two or more chronic conditions with increasing patient age. ⁵ This has been termed multi-morbidity and is particularly prevalent in geriatric patients.

Family doctors are in the best position to deal with chronic disease.  Their unique training, based on the Four Principles of Family Medicine, is well suited to this challenge.

First and foremost, they are skilled clinicians who remain up to date and capable of incorporating best evidence into clinical regimens as new information emerges.

The doctor-patient relationship is the hallmark of family medicine.  As family doctors follow their patients over time, a trusting relationship develops.  This relationship is key to engaging the patient in the management of own their disease(s) by incorporating self management plans into their daily lives, an essential element of the Chronic Care Model that encourages high quality chronic disease care.⁶ Furthermore, family physicians come to understand the illness experience of their patient with chronic disease.  Patient engagement in the disease process and management is enhanced when care is provided within the context of the illness experience for any individual patient.

Family physicians focus on prevention, which is the key to preventing chronic disease and further complications of chronic disease when this is already established.

Only family doctors have the dedication to continuity of care that enhances chronic disease management.  They see their patients in the office / clinic, at home, in the hospital, and in long term/chronic care settings.

Considering all the above features of family medicine as a discipline, there is very good reason that, in 2003, The First Ministers’ Accord on Health Care Renewal declared, “The core building blocks of an effective primary health care system are improved continuity and coordination of care, early detection and action, better information on needs and outcomes, and new stronger incentives to ensure that new approaches to care are swiftly adopted and here to stay.” ⁷

The First Ministers declaration describes family physicians to a “T”, in principles and in action.

For all the above reasons and more, the College of Family Physicians of Canada has proposed a goal that 95% of Canadians should have the majority of their care provided by a family physician by the year 2012. ⁸

Increasingly, the evidence supports the role of the family doctor in the management of chronic disease. Barbara Starfield’s work has shown that when patients have access to primary care physicians with whom they have enduring relationships and take responsibility to integrate care across their health concerns and over time, patients achieve better health outcomes and at lower costs. ⁹

A recent paper by Rick Glazier and colleagues at the Institute for Clinical Evaluative Sciences has shown that those patients in Ontario with chronic conditions who did not have a family doctor or made few physician visits and experienced low continuity of care, cost the system more in emergency department visits and hospitalizations.¹⁰ From this study, it is estimated that approximately 120,000 emergency room visits in Ontario, could be avoided each year if more Ontarians had a family doctor.

When we consider the “tsunami” of multi-morbidity that is facing us in Canada, there is one huge concern.  At the moment there is a tremendous shortage of family physicians, the key players facing this challenge.  Currently, it is estimated that there are 800,000 to 900,000 patients without a family physician in Ontario alone.

Various strategies are being proposed to deal with the family doctor shortage and the need for management of chronic disease.  Prominent among the strategies is the promotion of team-based care, which is taking shape in various forms across the country.¹¹ This makes inherent sense when faced with a shortage of family physicians.

In 2004, the federal government, the provinces and territories pledge to ensure that 50% of Canadians had access to multidisciplinary teams for primary health care by 2011.¹²

Collaborative teams where family physicians work with other health care professionals has received support from the College of Family Physicians of Canada.  It is estimated that overall, 32% of adult Canadians had access to more than one healthcare provider in 2008 and this percentage increased for those patients with chronic conditions and multi-morbidity.¹³ That being said, the most successful healthcare teams are those that are built around the family physician and family medicine services.  This fits with what Canadian patients want.  In a Decima survey conducted by the Ontario College of Family Physicians in 2008, 95% of respondents said they wanted a family physician to provide the majority of their care and coordinate the care of others.¹⁴

Team-based care for patients with chronic conditions has tremendous potential to enhance the quality of care of available, and ultimately, to increase access for other patients.  Allied health professionals, working in the team environment, can focus on problems within their scope of practice, which has the potential to free up family physicians to provide care to more patients.

There are many examples available of how allied health professionals can assist family physicians in providing care to patients with chronic disease.  These would include: medication reviews by pharmacists, anticoagulation monitoring and management by pharmacists and nurses, diet and nutrition counseling by dietitians and / or nurses, and a focus on preventive care practices by nursing staff. These are only a few examples of innovative solutions to providing care that can be developed by teams working effectively together.

Recent initiatives in Ontario, called Shared Care Collaboratives, jointly supported by the Ontario Medical Association and the Ministry of Health and Long-Term Care have proven successful.  These Collaboratives involved family physicians in Fee-for-Service group practice models working together with allied health professionals such as nurses, dietitians, and social workers. One such model, with which I am familiar, achieved very impressive results measured in terms of  HbA1C improvements for diabetic patients, and colorectal cancer screening rates for patients in general.  In addition, there was tremendous patient and physician satisfaction with the care provided.¹⁵

Another component of a strategy to improve chronic disease management by family physicians is that of information technology.  Canada lags behind other countries in the utilization of information technology in healthcare. Since the majority of care for chronic disease management will be provided in the family physicians office, a key component of any information technology strategy should be electronic medical records for every family physician that have interconnectivity capabilities with the rest of the system.  Some jurisdictions are choosing to support chronic disease management through chronic disease registries such as the Diabetes Registry in Ontario.  This registry will be populated from electronic medical records, laboratory data from around the province, and information provided by patients themselves through a web portal.  Such registries have the potential to engage patients more effectively in their own self management, which is laudatory, but their creation must not detract from the overall drive to provide family physicians with the information technology resources that they need to manage chronic disease in their own practice settings.

In summary, the Canadian health-care system faces a huge challenge with the “tsunami” of baby boomers acquiring chronic disease and multi-morbidities.  Family physicians are the key to managing chronic diseases because of their particular skills and attitudes, their focus on the doctor-patient relationship and their ability to provide continuity in a variety of health care settings.  Available evidence supports the family physician as the key player in any chronic disease management strategy.  Family physicians working together collaboratively with other health professionals in team-based care can effectively deliver chronic disease management. It is important that the appropriate resources be provided to support family physicians in this endeavor, including allied health professionals such as nurses, nurse practitioners, dietitians, social workers, and pharmacists, among others. It is important that these resources also include the appropriate information technology, electronic medical records, chronic disease registries, and the ability to share information electronically amongst the individual patient’s circle of care.

references

1. Fact Sheet, Section of General and Family Practice, Ontario Medical Association, 2009.
2. Health Council of Canada. (2007 December). Why health Care Renewal Matters: Learning from Canadians with Chronic Health Conditions. Toronto: Health Council.
3. Green LA. Is primary care worthy of physicians? In: Showstack J, Rothman AA, Hassmiller SB, eds. The Future of Primary Care. San Francisco, Calif: Jossey-Bass; 2004:143-160
4. Health Council of Canada. (2007 March). Why Health Care Renewal Matters: Lessons from Diabetes. Toronto; Health Council
5. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L. Prevalence of multimorbidity among adults seen in family practice. Ann Fam Med 2005;3:223-228.
6. Martin CM. Chronic Disease and Illness Care. Canadian Family Physician 2007;53:2086-2091.
7. Canada. First Ministers’ Meeting. (2003) First Ministers’ Accord on Health Care Renewal. Ottawa: Health Canada. www.hc-sc.gc.ca
8. CFPC Health Policy Report Card. 2007. College of Family Physicians of Canada. www.cfpc.ca
9. Starfield B, Shi L, Macinko J. Contributions of primary care to health systems and health. Milbank Q 2005;83:457-502
10. Glazier R, Moineddin R, Agha M, Zagorski B, Hall R, Manuel D, Sibley L, Kopp A. The impact of not having a family physician among people with chronic conditions. I.C.E.S. Report, July 2008; www.ices.on.ca
11. Health Council of Canada. Teams In Action: Primary Health Care Teams for Canadians. April 2009;
12. Canada. First Ministers’ Meeting. (2004) A 10-Year Plan to Strengthen Health Care. Ottawa: Health Canada. www.hc-sc.gc.ca
13. Statistics Canada. (2009). 2008 Canadian Survey of Experiences with Primary Health Care
14. Decima Survey 2008. Ontario College of Family Physicians. Toronto. www.ocfp.ca
15. Faulds C. 2009. Personal communication

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