Abstract
PURPOSE
Most studies evaluating access to primary care have focused on changes in family physicians (FPs), with less exploration of patient differences over time. We examined both physicians and patients, including changes over time in the age and medical complexity of people seeing FPs.
METHODS
We conducted a population-based cohort study using administrative health data, including physician claims and hospital data, examining patients cared for by FPs providing comprehensive primary care from 2004 to 2020 in Alberta, Canada. We assessed changes in FPs and used validated algorithms to examine changes in comorbidity among adults cared for by those physicians.
RESULTS
There were notable changes in FPs over time including more physicians who were women (46.7% in 2020 vs 39% in 2004; P < .001) and trained in low/middle-income countries (17.2% vs 6.3%; P < .001). Patient age and number of comorbidities increased over time. The proportion aged 61-80 years increased from 16.1% in 2004 to 22.1% in 2020 (P < .001). Those with ≥5 comorbid conditions increased from 2.8% to 5.2% (P < .001). There were changes in physician practice over time including decreases in average days worked each year (167 in 2004, 156 in 2020; P = .007) and number of adult patients seen each day (23 vs 20; P < .001).
CONCLUSIONS
From 2004 to 2020, there were substantial changes in the characteristics and practices of FPs. In addition, there were notable trends in the characteristics of their patients, including an increasing proportion of older adults, often with more complex comorbidities.
Key words: primary care physicians, chronic disease, physician workforce
INTRODUCTION
Canada has a growing shortage of family physicians (FPs), with nearly 8.5 million Canadians (15%) without an FP.1 In Alberta, the number of family practices accepting new patients has decreased dramatically over the past few years, from nearly 900 in 2020 to 164 in 2024.2 This has led to challenges for many Canadians seeking primary care. Nearly 50% of older Canadians with acute illness wait >6 days to get an appointment with their FP, the worst among Commonwealth countries.3
There are many potential reasons for these challenges, but much of the focus has been on fewer FPs providing services.4 Possible explanations for the latter include older age at graduation, fewer residents choosing family medicine, earlier age at retirement, and inadequate investment in primary care. There has also been a decrease in working hours for all physicians over the past few decades5 and an increasing number of FPs who are taking on practice roles other than comprehensive primary care.6,7 Regardless of the underlying reasons, it is clear that the demographic characteristics and practice patterns of FPs have changed over time.8
What has received less attention is the increasing need for primary care services, in part owing to rapid population growth in Canada9 and the aging of baby boomers. Studies suggest that Canadians are also developing more comorbidities over time,10 but how this change is affecting primary care practice is uncertain.
We used administrative health data to examine changes over time in characteristics of adults cared for by FPs from 2004 to 2020. These characteristics include changes in age and number of comorbid chronic diseases including mental health and substance abuse disorders. We also report trends in FPs and practice patterns over time for adults aged >18 years.
METHODS
Context for Primary Care in Alberta, Canada
Approximately 85% of Albertans have access to an FP.11,12
Via primary care networks (PCNs), nearly 75% of Albertans with an FP have access to a primary care team.13,14 Alberta’s 39 PCNs are funded to support their physician members at a rate of $65 per paneled patient per year. Funds may be used for interdisciplinary staff such as nurses, dietitians, and social workers; for practice facilitation and member education; or for other programs, depending on patient and physician need.13 Funding remains insufficient to provide adequate coverage for team-based care (estimated at 0.4 full-time equivalent nonphysician staff per FP12), meaning that the model of care remains largely physician driven. In 2023, 91% of clinical payments to FPs were fee-for-service.15
Data Sources
We used the Interdisciplinary Chronic Disease Collaboration data repository, as described previously.16 The database captures demographic, laboratory, and administrative health data (including vital statistics, prescription drug data, physician claims, hospitalizations, emergency department and outpatient visits, and associated health care costs) for all individuals registered with Alberta Health (all residents of Alberta are eligible for insurance coverage; >99% participate).
Definition of Comprehensive Care Primary Care Physicians
Starting with all physicians from April 1, 2004 to March 31, 2020, we first defined an active physician as any physician who billed ≥50 claims. We then defined FPs as those who submitted claims using the general practitioner (GP) code (which accurately identifies FPs) and who worked in an outpatient setting (Figure 1). We included physicians who submitted claims as an FP and as a specialist if they practiced in an office setting and the specialist claims fell into the following categories: addictions counsellor, anesthesiology, cardiac exercise stress testing, community medicine specialist, electrocardiogram interpretation, emergency medicine specialist, family therapist, generalist mental health physician, and obstetrics and gynecology. Family physicians who submitted claims as a specialist outside these categories were excluded.
Figure 1.
Flowchart for Family Physicians Providing Comprehensive Care at Some Point, 2004-2020
To define comprehensive care FPs, we followed the method of Schultz and Glazier.6 We first determined that a physician had worked ≥44 days during the year, with a day of work defined as ≥5 outpatient unique patient claims each day.6 Family physicians who did not meet this criterion were excluded from further analysis. We then identified FPs who were providing core primary care services, including general assessments, diabetes management, flu shots, and Papanicolaou (PAP) tests, as examples. To do this, we included FPs for whom ≥50% of their claims were for services defined as core primary care services and when those services fell into ≥7 (of 16 different) core primary care areas for each year. We excluded physicians who did not meet this definition of a comprehensive care FP.
We also assessed practice patterns for new FPs who entered the cohort and had no claims in the 3 years prior. We considered a physician to have left primary care if they submitted <50 outpatient claims as an FP in a year and did not submit >50 claims in any subsequent year.
Patient Cohort
We identified adults aged ≥18 years who saw ≥1 of the above-defined comprehensive FPs during each time period. Children aged <18 years were excluded.
Outcomes
We examined changes from 2004 to 2020 in the number of adults with comorbid conditions seen by FPs. We used validated algorithms to define patient comorbidities17 (Supplemental Table 1) including alcohol use disorder, asthma, atrial fibrillation, lymphoma, metastatic cancer, cancer, heart failure, chronic kidney disease, pain, chronic pulmonary disease, hepatitis B, cirrhosis, dementia, depression, diabetes, epilepsy, hypertension, hypothyroidism, inflammatory bowel disease, irritable bowel syndrome, multiple sclerosis, myocardial infarction, Parkinson disease, peptic ulcer disease, peripheral vascular disease, psoriasis, rheumatoid arthritis, schizophrenia, constipation, and stroke.
We determined the prevalence of noncommunicable cardiovascular-related chronic diseases over time, including myocardial infarction, chronic heart failure, peripheral vascular disease, stroke, diabetes, hypertension, and chronic kidney disease, because these often occur together, share similar risk factors, and are responsible for a substantial proportion of health care resource use. Given that we had laboratory data for all Albertans, we report the proportion of adults with diabetes and a hemoglobin A1C level >10% as well as the proportion of adults with advanced kidney disease (mean estimated glomerular filtration rate [eGFR] <30 mL/min/1.73 m2). Finally, we determined changes in the proportion and characteristics of FPs practicing comprehensive care and their patterns of clinical activity.
Covariates
We used data from the Interdisciplinary Chronic Disease Collaboration data repository to access patient demographic, diagnostic, and laboratory testing information.16 We defined rural areas as jurisdictions with fewer than 10,000 people.18
Physician gender, age, years in practice, specialty, and international medical graduate status were available in an anonymized fashion from the College of Physicians and Surgeons of Alberta. We collected information on geographic zone of practice (Alberta has 5 health zones including 3 rural zones) and the number of visits per day using Alberta Health physician claims data sets.
Analysis
We assessed the characteristics of FPs providing comprehensive care over time. Next, we examined trends in the age of adults seen, as well as the proportion with comorbid chronic diseases, including mental health disorders, and changes in prevalence of cardiovascular-related chronic disease. Because on average, 4% of physicians commence and leave primary care each year (meaning they would not practice for a full 12 months), we examined the practice patterns of FPs in 2-year time periods (April 1, 2004-March 31, 2006; April 1, 2011-March 31, 2013; April 1, 2018-March 31, 2020), estimating the number of visits per month for active physicians, then extrapolating to visits per year. In a similar manner, we determined the number of days FPs provided outpatient care each year (defined as days with outpatient claims for ≥5 different adults). To partially account for people working less than a full-time equivalent, we also reported days when FPs billed for ≥10 adults, referred to as service days.19
Ethics
This study was approved by University of Calgary’s Conjoint Health Research Ethics Board, with waiver of informed consent.
RESULTS
Family Physician Cohort
We identified 7,578 FPs working in Alberta and providing inpatient or outpatient care during the study period (Figure 1). Physicians working solely in hospitals represented 1.4%, 2.7%, and 4.7% of all FPs in the 2004, 2011, and 2018 time periods, respectively. After all exclusions, 5,243 FPs were providing comprehensive primary care over the entire time period. The number of comprehensive care physicians increased from 2,065 (71.3% of all FPs) in 2004 to 3,521 (74.0% of all FPs) in 2018 (Table 1) (P = .0085). Over time, more FPs were women (46.7% in 2020 compared with 39% in 2004; P < .001), and more had trained in low- or middle-income countries (17.2% in 2020 compared with 6.3% in 2004; P < .001).
Table 1.
Total Number of Family Physicians Providing Comprehensive Care, 2004-2006, 2011-2013, and 2018-2020
| Characteristic | April 1, 2004-March 31, 2006 | April 1, 2011-March 31, 2013 | April 1, 2018-March 31, 2020 | P value |
|---|---|---|---|---|
| Comprehensive family physicians (n = 2,065) | Comprehensive family physicians (n = 2,594) | Comprehensive family physicians (n = 3,521) | ||
| Age, y, mean (SD) | 46.8 (10.8) | 49.0 (11.9) | 47.9 (12.2) | < .001 |
| Gender, No. (%) | < .001 | |||
| Female | 806 (39.0) | 1,084 (41.8) | 1,645 (46.7) | |
| Male | 1,259 (61.0) | 1,510 (58.2) | 1,876 (53.3) | |
| Years of practice, mean (SD) | 20.5 (11.1) | 22.7 (12.2) | 21.3 (12.5) | |
| Location of training, No. (%) | < .001 | |||
| Canada | 1,345 (65.1) | 1,452 (56.0) | 1,819 (51.7) | |
| Other country with training equivalency | 484 (23.4) | 570 (22.0) | 657 (18.7) | |
| Other high- or upper middle–income country | 102 (4.9) | 250 (9.6) | 432 (12.3) | |
| Other lower middle– or low-income country | 130 (6.3) | 317 (12.2) | 606 (17.2) | |
| Unknown | 4 (0.2) | 5 (0.2) | 7 (0.2) | |
| Geographic zone of practice (Canada), No. (%) | < .001 | |||
| Calgary (predominantly urban) | 791 (38.3) | 1,045 (40.3) | 1,547 (43.9) | |
| Central | 651 (31.5) | 859 (33.1) | 1,144 (32.5) | |
| Edmonton (predominantly urban) | 246 (11.9) | 278 (10.7) | 319 (9.1) | |
| North | 211 (10.2) | 208 (8.0) | 232 (6.6) | |
| South | 158 (7.7) | 190 (7.3) | 255 (7.2) | |
| Unknown | 8 (0.4) | 14 (0.5) | 24 (0.7) | |
| Practicing in rural areas, No. (%)a | 454 (22.0) | 471 (18.2) | 554 (15.7) | < .001 |
Geographic areas are defined by Alberta Health Services. Rural includes areas with populations <10,000. These include towns, villages, hamlets, and agricultural areas.
Age and Number of Comorbidities Increased Over Time Among Adults Seen by Family Physicians
There were changes in patient age distribution over time, most notably for those aged 61-80 years, where the proportion increased from 16.1% in 2004 to 22.1% in 2020 (P < .001) (Figure 2, Table 2). More people seeing FPs had comorbid conditions over time, most notably adult patients with ≥3 comorbidities (11.0%, 13.9%, and 17.0% in 2004, 2011, and 2018, respectively) and ≥5 comorbidities (2.8%, 4.0%, and 5.2% in 2004, 2011, and 2018, respectively) (Figure 2, Table 2). There was no meaningful change in the proportion of adults with diabetes and a hemoglobin A1C level >10%, but there was a doubling in the proportion of people with a hemoglobin A1C level >10% among the entire FP roster, indicating more complexity within FP rosters (Table 2).
Figure 2.
Changes in Number of Comorbid Conditions Over Time Among Adults, Stratified by Agea
a Comorbidities: alcohol use disorder, asthma, atrial fibrillation, lymphoma, metastatic cancer, cancer, heart failure, chronic kidney disease, pain, chronic pulmonary disease, hepatitis B, cirrhosis, dementia, depression, diabetes, epilepsy, hypertension, hypothyroidism, inflammatory bowel disease, irritable bowel syndrome, multiple sclerosis, myocardial infarction, Parkinson disease, peptic ulcer disease, peripheral vascular disease, psoriasis, rheumatoid arthritis, schizophrenia, constipation, stroke.
Table 2.
Characteristics of Adults Seeing Comprehensive Care Family Physicians, 2004-2006, 2011-2013, and 2018-2020
| April 1, 2004-March 31, 2006 | April 1, 2011-March 31, 2013 | April 1, 2018-March 31, 2020 | P value | |
|---|---|---|---|---|
| Total Alberta population aged >18 years at start of time period | 2,584,225 | 3,056,462 | 3,406,451 | |
| Total seen by a comprehensive care family physician | 2,230,436 | 2,658,769 | 3,070,338 | |
| Age, y, mean (SD) | 45.4 (17.7) | 46.5 (17.9) | 47.8 (18.1) | < .001 |
| Age, y, No. (%) | ||||
| ≤40 | 945,347 (42.4) | 1,095,297 (41.2) | 1,212,737 (39.5) | < .001 |
| 41-60 | 832,252 (37.3) | 957,691 (36.0) | 1,033,800 (33.7) | |
| 61-80 | 358,633 (16.1) | 483,235 (18.2) | 677,996 (22.1) | |
| ≥81 | 94,204 (4.2) | 122,546 (4.6) | 145,805 (4.7) | |
| Sex, No. (%) | < .001 | |||
| Female | 1,196,513 (53.6) | 1,416,524 (53.3) | 1,617,466 (52.7) | |
| Male | 1,033,923 (46.4) | 1,242,242 (46.7) | 1,452,864 (47.3) | |
| Other | 0 (0) | 3 (<0.01) | 8 (<0.01) | |
| Neighborhood income quintile, No. (%) | < .001 | |||
| Lowest | 457,667 (20.5) | 604,769 (22.7) | 584,191 (19.0) | |
| Second lowest | 478,716 (21.5) | 570,069 (21.4) | 584,568 (19.0) | |
| Third lowest | 440,991 (19.8) | 494,340 (18.6) | 553,481 (18.0) | |
| Fourth lowest | 430,809 (19.3) | 460,507 (17.3) | 541,068 (17.6) | |
| Highest | 406,716 (18.2) | 463,262 (17.4) | 539,380 (17.6) | |
| Undefined | 15,537 (0.7) | 63,208 (2.4) | 267,650 (8.7) | |
| Zone (based on residence postal code), No. (%) | < .001 | |||
| Calgary (predominantly urban) | 827,021 (37.1) | 1,014,605 (38.2) | 1,205,239 (39.3) | |
| Central | 275,862 (12.4) | 312,859 (11.8) | 335,089 (10.9) | |
| Edmonton (predominantly urban) | 707,402 (31.7) | 862,139 (32.4) | 1,015,044 (33.1) | |
| North | 238,718 (10.7) | 264,609 (10.0) | 292,027 (9.5) | |
| South | 180,154 (8.1) | 201,569 (7.6) | 218,875 (7.1) | |
| Missing | 1,279 (0.1) | 2,988 (0.1) | 4,064 (0.1) | |
| Overall comorbidities, No. (%)a | < .001 | |||
| 0 | 1,130,661 (50.7) | 1,303,244 (49.0) | 1,365,520 (44.5) | |
| 1 | 583,641 (26.2) | 650,162 (24.5) | 758,353 (24.7) | |
| 2 | 269,413 (12.1) | 335,800 (12.6) | 424,881 (13.8) | |
| 3-4 | 183,549 (8.2) | 262,487 (9.9) | 361,917 (11.8) | |
| ≥5 | 63,172 (2.8) | 107,076 (4.0) | 159,667 (5.2) | |
| With a chronic cardiovascular condition, No. (%)b | 553,148 (24.8) | 780,719 (29.4) | 1,009,527 (32.9) | < .001 |
| With ≥3 cardiovascular-related conditions, No. (%)b | 56,390 (2.5) | 97,453 (3.7) | 145,288 (4.7) | < .001 |
| With mental health or substance use disorder, No. (%)c | 283,191 (12.7) | 388,399 (14.6) | 476,471 (15.5) | < .001 |
| Percentage of visits to family physicians for adults with ≥3 cardiovascular-related conditions, % (SD)b | 7.1 (25.6) | 11.5 (31.9) | 13.9 (34.6) | < .001 |
| With HbA1C >10%, among patients with diabetes, No. (%) | 6,358 (5.8) | 12,101 (5.9) | 15,620 (5.9) | < .001 |
| With HbA1C >10%, among total patient roster, No. (%) | 6,358 (0.3) | 12,101 (0.5) | 15,620 (0.5) | < .001 |
| With advanced kidney disease (mean eGFR <30 mL/min/1.73 m2), among total patient roster, No. (%) | 11,673 (0.5) | 12,413 (0.5) | 16,444 (0.5) | < .001 |
eGFR = estimated glomerular filtration rate, HbA1c = hemoglobin A1c.
Comorbidities: alcohol use disorder, asthma, atrial fibrillation, lymphoma, metastatic cancer, cancer, heart failure, chronic kidney disease, pain, chronic pulmonary disease, hepatitis B, cirrhosis, dementia, depression, diabetes, epilepsy, hypertension, hypothyroidism, inflammatory bowel disease, irritable bowel syndrome, multiple sclerosis, myocardial infarction, Parkinson disease, peptic ulcer disease, peripheral vascular disease, psoriasis, rheumatoid arthritis, schizophrenia, constipation, stroke.
Chronic cardiovascular-related conditions include chronic kidney disease, myocardial infarction, chronic heart failure, peripheral vascular disease, stroke, diabetes, and hypertension.
Depression, schizophrenia, or alcohol use disorder.
The proportion of adults with ≥3 cardiovascular-related comorbid conditions doubled from 2004 to 2020 from 2.5% to 4.7% (P < .001) (Table 2). In 2020, 1 in 7 visits for adults to FPs was for adults with ≥3 cardiovascular-related conditions, compared with 1 in 14 visits in 2004. The proportion of adult patients with mental health or substance use disorder increased from 12.7% to 15.5% from 2004 to 2020 (P < .001) (Table 2).
Age- and sex-adjusted analyses confirmed that these changes in comorbid chronic diseases over time were largely independent of changes in demographic characteristics (Supplemental Figures 1 and 2), particularly for people with multiple chronic conditions and for older age groups.
Notable Changes in Physician Practice Patterns Over Time
Table 3 summarizes changes in clinical activity for FPs providing comprehensive care. There was a small decrease in the average number of days per year that physicians provided outpatient care for ≥5 adults (167 days in 2004 to 156 in 2020; P = .007) and in the number of service days for which physicians saw ≥10 adult outpatients (162 days in 2004 to 154 in 2020; P < .001). The average number of adults seen each day decreased from 23 (median = 22; 25%-75% percentile = 17-29) to 20 (median = 18; 25%-75% percentile = 13-24; P < .001).
Table 3.
Clinical Activity of Comprehensive Care Family Physicians for Adults, 2004-2006, 2011-2013, and 2018-2020
| April 1, 2004-March 31, 2006 | April 1, 2011-March 31, 2013 | April 1, 2018-March 31, 2020 | P value | |
|---|---|---|---|---|
| Comprehensive family physicians (n = 2,065) | Comprehensive family physicians (n = 2,594) | Comprehensive family physicians (n = 3,521) | ||
| Overall activity | ||||
| Number of days worked per year including inpatient and outpatient claims, mean (SD) | 182.3 (54.6) | 167.3 (54.8) | 162.8 (57.2) | .018 |
| Number of days worked per year based on outpatient claims, mean (SD) | 166.9 (54.1) | 156.9 (54.2) | 156.0 (56.9) | .007 |
| Number of days worked per year, normalized to full days per year, based on outpatient claims, mean (SD)a | 173.0 (52.1) | 163.6 (53.9) | 161.3 (55.4) | .009 |
| Number of service days per year based on outpatient claims, mean (SD)b | 161.7 (59.3) | 156.5 (70.6) | 153.9 (66.6) | < .001 |
| Number of unique patients seen per day per physician based on outpatient claims, mean (SD) | 23.0 (9.5) | 22.4 (16.0) | 19.9 (9.1) | < .001 |
| Activity spent caring for patients with chronic diseases | ||||
| Number of unique outpatients with ≥5 comorbid chronic diseases seen per day based on outpatient claims, mean (SD) | 1.7 (1.5) | 2.3 (2.1) | 2.3 (2.2) | < .001 |
| Number of visits per year per physician for each patient with ≥5 comorbid chronic diseases, mean (SD) | 4.9 (2.9) | 4.8 (2.8) | 4.9 (2.8) | .009 |
To account for physicians who start practice after April 1 of each fiscal year, this normalizes days worked to a full year.
We defined a service day as a family physician billing for ≥10 adults associated with a fee of at least $25 on 1 calendar day.19
Changes in Number of Patient Visits Over Time
Over this 16-year period, there was a 38% increase in Alberta’s population and a 41.4% increase in the number of FPs providing comprehensive care (Supplemental Figure 3). For Albertan adults seeing comprehensive primary care physicians, there were 17,959 visits per 10,000 adults between April 1, 2004 and March 31, 2005 compared with 20,769 visits per 10,000 adults between April 1, 2019 and March 31, 2020.
Changes in New Family Physicians in Each Time Period
Consistent with changes in the overall group of family physicians, the proportion of new FPs who were women increased from 46% to 59% over time (Supplemental Table 2). A smaller proportion of new physicians began practice in rural areas in 2020 (18%) than in 2004 (27%). There was a similar percentage decrease in the number of visits per day compared with the overall group of family physicians (Supplemental Table 3).
DISCUSSION
Among patients seen by FPs in Alberta from 2004 to 2020, we identified a substantial increase in the prevalence of chronic diseases and specifically in cardiovascular-related conditions such as myocardial infarction, chronic heart failure, peripheral vascular disease, stroke, diabetes, chronic kidney disease, and hypertension. The increase was most notable for people with multiple chronic conditions. These changes have led to a doubling in the proportion of FP visits for adults with ≥3 cardiovascular-related diseases over this period. We also noted that the clinical practices of FPs comprised a relatively high and growing proportion of Albertans aged >60 years and adults with mental health and substance abuse disorders.
Our finding that the burden of comorbid conditions, and in particular multimorbidity, has increased among adult Canadians over time is consistent with the results of other studies using administrative health data in Canada10 and also with the results of national longitudinal surveys using self-report data, suggesting our results are not due to changes in administrative coding of health data.20 Like other studies, we found that the increases were most substantial for people with ≥5 comorbid conditions.21 To our knowledge, the present study is the first to focus on patients seen by FPs.
Whereas the proportion of FPs providing comprehensive care was relatively stable over time, we found changes in the characteristics of FPs as a whole, including a greater proportion of women and those trained in low- and lower middle–income countries. The nature of their clinical activity changed as well, with small decreases in the average number of days providing outpatient care each year and the number of outpatient visits per day from 2004 to 2020. Considered together, this meant that the average number of unique adults seen per year by FPs between April 1, 2019 and March 31, 2020 decreased by 15% compared with the time period between April 1, 2004 and March 31, 2005.
Given that the present study focused only on adults, we did not report trends in FP panel sizes. However, other studies have noted that over the past 20 years, the number of patients on an FP’s roster has decreased approximately 17%, and the number of appointments each offers has decreased by 25%, from approximately 5,500 to 4,150 visits each year.22
The decreased number of patients seen per day, and possibly smaller roster sizes, might be due to several factors including the substantial changes we noted in age distribution and complexity of FP patients over time. It is also possible that FPs might be combining traditional primary care with focused practices (eg, surgical assistants, hospitalists, urgent care) and are therefore spending fewer days providing comprehensive outpatient care.5,7,8,22,23 Surveys also suggest a substantial increase in burnout24 and administrative burden,25 which could both have resulted in decreased capacity for patient care. Finally, there has been an overall decrease in hours worked for all types of physicians over the past few decades.5
Our analysis has several limitations that should be considered. We were unable to identify whether FPs are providing walk-in care for unattached patients or longitudinal care. We used visits per day as a proxy of clinical activity, which is not necessarily a good proxy for efficient care. Some physicians might choose to see patients 4 times to manage a condition, whereas others might accomplish the same benefit in a single comprehensive visit. Our findings therefore are not an indication of work hours. We did not include children aged <18 years, meaning that these analyses do not reflect the full spectrum of primary care workload, although trends over time are still informative. We did not account for the varied practice of rural FPs. We excluded FPs engaged in primarily focused practice, some of whom might still be providing comprehensive primary care for a small panel of patients not accounted for in this analysis. Finally, it is possible that some of the changes in comorbidity relate to changes in administrative coding over time, or increased case finding over time, though our changes are consistent with self-reported data from national health surveys.20
This work has policy implications and should inform workforce planning by provincial health ministries. Our analyses show that the substantial changes in age and complexity of patients seen in primary care, and changes in how FPs are practicing, are contributing to the current capacity crisis in primary care. With expected population growth and aging, access to primary care is likely to worsen.
If physicians continue to practice using the current physician-centric model, many more FPs will need to be recruited and/or trained. There are many tactics that can be considered including making primary care a more attractive option for learners, recruiting and training more international medical graduates as FPs, and recruiting and training more nurse practitioners. Systems could also expand primary care teams, allowing FPs to care for larger patient panels and enhance chronic disease management supports.26,27 These options are not mutually exclusive, and each would require time to execute. For all of these options, payment models for FPs must incentivize and enable the team-based care that will be required to support larger panels. Additional resources will also be needed to train additional FPs and/or nurse practitioners as well as other members of primary care teams.
CONCLUSION
Family physicians are now providing care for patients who are older and have more comorbid conditions than those seen 20 years ago. Compared with patients without complexity, more complex patients require more visits per year and more time per visit. Whereas the total number of FPs has increased over time, the population has also increased substantially, and FPs are seeing fewer outpatients each year. These factors all warrant consideration in future primary care workforce planning.
Supplementary Material
Footnotes
Conflicts of interest: authors report none.
Funding support: This work was supported by a Canadian Institutes of Health Research (CIHR) Foundation Award. Neither CIHR nor Alberta Health had any role in designing the study; collecting, analyzing, or interpreting data; or writing or submitting the manuscript.
Disclaimer: This study is based in part on data provided by Alberta Health. The interpretation and conclusions contained herein are those of the researchers and do not necessarily represent the views of the Government of Alberta. Neither the Government of Alberta nor Alberta Health express any opinion in relation to this study.
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