Detection and follow-up of chronic health conditions in Rio de Janeiro – the impact of residency training in family medicine

Capacity building of human resources for primary health care (PHC) is a sensitive issue in global health [1]. For many low- and middle-income countries [2] (LMIC) the inability to train health care providers is a critical structural problem [3, 4]. Family medicine (FM) is a key element that adds comprehensiveness to PHC [5, 6]. However, Residency Training in FM (RTFM) – the gold-standard for post-graduate training of medical health care providers in PHC – is usually not available or, at most, is undervalued and incipient in LMIC. Furthermore, the idea that PHC can easily be performed by any physician without specialized training is a common misconception among many policymakers in countries where selective PHC is the rule [7].

Family physicians (FPs) are trained to provide comprehensive patient-centered care [8, 9], managing the most prevalent health conditions in the community, and making good use of the resources available [10, 11]. In high-income countries (HIC) with strong PHC, FM is a well-established medical specialty and FPs comprise the majority of the medical workforce [12]. Nevertheless, leaders in FM and primary care providers routinely advocate for improvements [13], showing that strong PHC leads to better performance on health indicators while spending less money [14, 15]. Studies from LMIC showing the RTFM’s impact on the quality of care may encourage policymakers to invest in capacity building of human resources for PHC [16‐18].

Being able to diagnose prevalent chronic health conditions (CHCs), making rational use of laboratory tests and provide follow-up consultations are necessary competencies that any physician working in PHC must have [10, 19, 20]. This study tests the hypothesis that RTFM enables FPs to be more competent to detect CHC while requesting fewer laboratory exams and providing more follow-up visits for patients with CHC. It aims specifically to estimate the risks of patients (1) being diagnosed for a CHC; (2) having a laboratory test (LT) requested in one medical consultation; and (3) having a follow-up visit in PHC, according to the type of physician, i.e., FPs or physicians without RTFM (Generalists). Finally, (4) we aimed to determine the Population Attributable Fractions and estimate what would be the change in the amount of LTs requested and incident cases of CHC per year if all medical consultations were carried out by FPs.

Over a period of 6 years, 569.289 patients (335.346 women and 233.943 men) had 2.908.864 medical consultations performed by 964 different doctors (734 generalists and 231 FPs) in 30 PHC clinics and 196 FHTs. Doctors worked non-concurrently throughout the period of analysis and generalists accounted for 66.4% of the consultations in the sample, while FPs were responsible for 33.6%. There was a small but statistically significant (p-value for t-test < 0.05) difference in patients’ age and SDI distributions among Generalists’ and FPs’ populations. Patients from the wealthiest (SDI = 0.689) and the poorest areas (SDI = 0.416) were seen by both categories (Table 2).

Hypertension, T2DM, and Hypothyroidism, the three CHCs that were categorized using both ICD10 and clinical criteria, presented a similar pattern: using ICD10 codes, FPs were less likely to diagnose these conditions, while using clinical criteria, FPs were more likely to diagnose all of them.

FPs were more likely to diagnose the majority of the remaining 24 domains of CHC in the list. The exceptions were Epilepsy, presenting a lower risk of being diagnosed by FPs, while Rheumatic disorders, Cirrhosis of the liver and Neoplasia of male genital organs presented similar risk between generalists and FPs. Metastatic cancer presented a higher but not statistically significant risk of being diagnosed by FPs.

The risk of a patient having a follow-up visit was higher for FPs running the consultation. Even for those patients that have CHC that FPs were less likely to diagnose, patients have a higher chance of having a follow-up visit if their doctor is a FP. Around 7% of the patients coded as having Hypertension or T2DM would no longer be coded as such, decreasing by 1208, and 384 the number of incident cases per year, respectively. On the other hand, in all domains, except those that RR for medical categories were not statistically significant, an increasing number of incident cases would be seen. Hypertension and T2DM (according to clinical criteria), Heart failure, Stroke, Asthma, and Osteoarthritis would have the biggest increment in the number of incident cases, while Drug addiction, Alcohol abuse, Kidney failure, and Peripheral artery disease would have the biggest relative increase of new cases (Table 3).

Patients seen by FPs present a lower risk of having any of the 30 LTs requested during one consultation, with a RR lower than 50% for Glucose, Ova & parasite, Urea, Sodium, T3, T4, PSA Rubella IgG and IgM, Uric acid, Calcium, AST, ALT and LDL cholesterol (Table 4).

In a scenario where all medical consultations would be performed by FPs, T3, T4, Ova & parasite, Uric acid, PSA, Urea and LDL cholesterol would have their demand reduced by more than 50%. In absolute numbers, Hemograms, Urea, Uric acid, LDL cholesterol and Urinalysis would experience the greater impact, with almost 20.000 Hemograms and more than 10.000 Urea, Uric acid, and LDL cholesterol tests avoided per year (Table 5)

Figure 1 presents a summary picture of patients with at least one CHC seen in PHC by FPs and Generalists throughout the analysis. Each dot represents, for each category in a month, the average amount of LTs ordered (size) and the average amount of CHC that patients have (y-axis). They don’t represent reasons for encounter, but the number of morbidities that patients have listed in their records. For Hypertension, T2DM, and Hypothyroidism only patients that met clinical criteria were considered. Over the years, the amount of CHC increase for both groups of patients, but that increment is bigger for FPs’ patients, that also have fewer LTs requested.

The hypothesis tested here show that RTFM, when compared to having no training in FM, can make doctors more likely to diagnose a large set of CHC, provide more follow-up visits to their patients and request fewer LTs in primary care. Moreover, it seems that RTFM makes doctors more accurate when diagnosing Hypertension, T2DM and Hypothyroidism, the three domains analyzed using ICD10 codes and clinical criteria.

These findings support the definition of FPs as skilled clinicians able to cover the “full range of health conditions” and to use “the prevalence and incidence of an illness in the community” during their decision-making processes [10, 11, 20]. This is important evidence showing that FM is a key element to bring comprehensiveness to PHC. Being more capable of detecting a large set of CHC together with the increased offer of follow-up visits to patients with CHCs means not only that more patients will have their health issue identified but that they will also have more medical visits to manage their CHC, which is key for the success of the treatment.

Furthermore, the higher risk of patients being diagnosed for a CHC by FPs can be representing the detection of conditions when symptoms are mild or non-specific, in the early stages [9, 42]. If patients with undifferentiated symptoms leave the consultation room without a diagnosis – or a clear diagnostic plan – they will potentially go to another health service to find a solution to their problem. Their diagnosis will be delayed, and it will probably be made when the symptoms become more pronounced. For conditions such as Cancer, HIV, Cardiac arrhythmias, and Kidney failure this delay can make a difference between a successful treatment and an avoidable death. The changes in the absolute numbers in Table 3 does not mean that those patients are not being diagnosed, but they are either trying to solve their problems somewhere else or having their diagnosis delayed.

The disparity of RRs observed in the three domains analyzed using ICD10 codes and clinical criteria – Hypertension, T2DM and Hypothyroidism – also brings to discussion the matter of payment-for-performance schemes, overdiagnosis and accuracy.

Hypertension and T2DM are CHCs that are targeted by the payment-for-performance municipal schemes since the PHC reform took place [27]. One performance measurement is the number of patients coded for Hypertension or T2DM reaching levels of blood pressure below 140/90 mmHg or 6.5% for A1C hemoglobin. If patients with prediabetes or prehypertension are coded as T2DM and Hypertension, their control target would be already reached, making these patients accounted as successfully treated. Another reason for that difference could be the focus that the federal government gives to cardiovascular diseases, via selective programs for screening and management of Hypertension and T2DM. With financial and political incentives for FHTs to pay extra attention to these conditions, it is not unusual for FHTs to reserve specific days or shifts of the week in their schedule exclusively for patients with Hypertension and/or T2DM, restricting access for patients with other health conditions [43, 44].

Payment-for-performance initiatives are designed to improve the quality of care, but if it comes with an increased risk of overdiagnosis [45], the potential damage that can result from that (overtreatment, unnecessary procedures, and stigmatization) can be more harmful than beneficial [46]. Furthermore, a higher number of Hypertension and T2DM cases should be followed by a proportionally increased number of actual cardiovascular diseases (Heart failure, Ischemic heart disease, Stroke, Cardiac arrhythmias, and Peripheral artery disease), but that is not the case.

One could argue that those patients were not subject to overdiagnosis, but were actual cases that were properly managed and, therefore, have the development of cardiovascular diseases prevented. That could be true for cardiovascular diseases, however, the increased risk that FP’s patients have to be diagnosed for HIV, Dementia, Drug addiction, Psychosis, Kidney failure, Cardiac arrhythmias, and Cancer suggests the opposite. These are conditions that need not only good clinical knowledge and skills to be suspected and diagnosed but competencies and attitudes that RTFM programs are meant to develop [10, 19, 20, 47].

The higher risk of detection of HIV among FPs illustrates this situation. Rapid tests for HIV and syphilis are available in every public PHC clinic in Rio de Janeiro. Doctors, nurses, and nurse technicians are trained by the RJ-MHD to perform this point-of-care test. They learn the procedure but raising suspicion and offering the test to a patient demands attitudes that are beyond the knowledge and skills needed to perform the test.

Overdiagnosis can be also the case for Epilepsy, a CHC referring to recurrent seizures, but patients with isolated seizures or even febrile seizures are commonly labeled as epileptic.

Mental health conditions (Depression, Psychosis, Drug addiction and Alcohol abuse) being more likely to be diagnosed by FPs also show how RTFM can make doctors more sensitive to perceiving conditions that are commonly neglected in the community, which require an active attitude to be suspected, investigated and diagnosed. In other words, if the professional just waits for the patient to declare having problems with alcohol or drugs, very few patients will be diagnosed and will have an opportunity for treatment [48].

It is worth noting the contrast between the amount of LTs requested and the number of CHCs diagnosed, e.g., FPs request 64% less PSA than Generalists, but the detection of Cancer in male genital organs (93% are Prostate Cancer) is similar. The number of glucose and A1C hemoglobin exams is 30 to 50% higher among Generalists, but the number of patients diagnosed by clinical criteria for T2DM and the risk of follow-up consultations favors FPs. This information corroborates the definition of a FP as a “skilled clinician” that makes “effective and efficient use of diagnostic and therapeutic interventions” [19, 20]. LTs that would usually be requested for patients with liver damage, i.e., Gamma GT, AST, ALT, and Alkaline phosphatase illustrates the situation very well. They are more often requested by Generalists but conditions that would necessarily need those exams, such as Alcohol abuse and Chronic hepatitis, are more likely to be diagnosed by FPs. Conditions that would also require those exams, such as Cholangitis and Cirrhosis of the liver, could be partially accountable for that difference, but they would hardly explain the whole gap.

Finally, continuity of care can also play an important role in increasing the risk of detection of CHC among FPs. Since FPs provide more follow-up consultations, their patients will have more opportunities to be diagnosed for a second or third CHC, a common event in patients with multimorbidity [49]. Cardiac arrhythmias, Kidney failure and Peripheral artery disease, conditions that are consequences of having a prior diagnose of T2DM or Hypertension, exemplify this phenomenon.

Being a competent clinician, able to cover the full range of health conditions and making effective use of diagnostic and therapeutic interventions are competencies that FPs must have to work in PHC, and RTFM seems to be effective in promoting them among physicians in Rio de Janeiro. Furthermore, the development of these competencies helps to expand access to health care, making PHC more comprehensive, effective, and socially accountable. Policymakers in LMIC must consider that PHC systems will not move from selective interventions to become truly comprehensive and effective without investments in capacity building of human resources. Regarding the medical workforce, this transformation will not happen without investments in RTFM.