Factors Associated With Loss of Usual Source of Care Among Older Adults

Stephanie K. Nothelle, MD; Cynthia Boyd, MD, MPH; Orla Sheehan, MD, PhD; Jennifer L. Wolff, PhD

Disclosures

Ann Fam Med. 2018;16(6):538-545. 

In This Article

Discussion

This is the first national study to examine factors associated with loss of USC among older adults, a fast-growing segment of the population.[1] Our results suggest that clinical as well as social factors are important in an older adult's ability to maintain a stable relationship with a provider over time.

Previous studies on loss of USC created composite outcomes which include both gaining and losing a USC.[22,23] It seems plausible, however, that the factors associated with losing a USC might differ from those associated with gaining a USC. As most older adults in the United States have a USC, more individuals are at risk of loss than gain of USC in this population. Thus, we sought to examine factors involved in the pathway associated with losses of USC.

Some of the factors which were found to be significantly associated with losing a USC such as male sex, Hispanic ethnicity,[19] and depressive symptoms[20] have been associated with lack of a USC in cross-sectional studies. Similarly, lack of transportation has been identified as a barrier to accessing care among older[32,33] and younger adults in cross sectional studies.[34] Our findings extend this work by indicating that demographic and health factors are longitudinally associated with USC loss. This contribution is valuable because we examined individuals who were engaged in care but then lose a USC, while cross-sectional studies also capture those who continuously have no USC. The latter group may have chosen to not engage in care, rather than encountering an obstacle that made maintaining this relationship difficult.

Lack of insurance coverage has been repeatedly associated with decreased report of USC,[5,18,22,35,36] including changes in USC due to changes in insurance coverage.[22,36] The association between moving to a new address and increased odds of losing a USC makes intuitive sense; it may take some time after moving to a new area to find a new source of primary care. There is relatively little data on this topic, however, outside of the pediatric literature.[37] The association between a higher number of chronic conditions or having fallen and lower odds of losing a USC are consistent with the notion that persons with multiple chronic conditions and functional impairment are more likely to utilize health care, potentially spurred by the symptoms associated with these conditions.[38,39] In contrast, presence of depressive symptoms may decrease motivation to access care, potentially explaining the increased odds of losing a USC observed for those with depressive symptoms.

Many of the factors that were significantly associated with loss of a USC in the adjusted model, including number of chronic conditions, falls, depressive symptoms, and insurance status, were not significant in the unadjusted analysis of baseline characteristics (Table 1 and Table 2). The response to interview questions associated with these variables may have changed with time and thus, a characteristic like falls or insurance status at the baseline interview may not be reflective of the response associated with losing a USC years later.

The association between living in a residential care or nursing facility and losing a USC warrants further investigation. Participants in the nursing facility who were previously in the community may have responded that they do not have a USC as the question asks about a doctor the participant "goes to" while nursing facilities usually provide on-site physician visits. Residential facilities, however, unlike nursing facilities, do not face federal requirements regarding routine visits from a physician,[40] so continuing primary care for those in a residential facility largely resembles that of community dwelling older adults.[41] The majority of those who report losing a USC and reside in a residential care facility were living in a residential facility in the prior round (data not shown), suggesting that perhaps with time, it has become difficult to travel to office visits or their primary clinician no longer follows patients in such facilities.[41]

Some participants who transitioned to a nursing or residential facility were excluded from the analysis due to failure to complete a participant interview (n = 172) (Figure 1). The aOR associated with nursing home residence had a particularly high point estimate (aOR 6.47) and was associated with a wide CI (4.46–10.85) reflective of the fact that such a transition is a relatively rare event. Removing this population from our analysis did not significantly change our findings (Supplemental Table 2, available at http://www.annfammed.org/content/16/6/538/suppl/DC1/).

Several limitations of this study should be considered. First, self-report of USC is a proxy for, rather than true measurement of, an individual's actual access to primary care. USC is a widely used and important surrogate for access to care, however, and has been tied to a number of important outcomes. There was notable attrition of participants over the 5 years of follow-up (n = 2,500) (Figure 1). We conducted analyses of baseline characteristics of those who were and were not lost to follow-up during the study. Characteristics associated with loss to follow-up were largely similar to characteristics associated with loss of USC, meaning our results may underestimate the frequency of loss of USC and the strength of the association between some variables and loss of USC, such as race and ethnicity (Supplemental Table 3, available at http://www.annfammed.org/content/16/6/538/suppl/DC1/). Additionally, although we used multiple rounds of data, participants were interviewed yearly which limited our ability to capture the fluidity of loss in USC status; meaning our results may be better described as loss and failure to regain a USC in a timely manner than as loss of a USC. However, the annual interview construct does allow for plausible shifts in response to changes in enrollment in health insurance. Finally, our study is limited to assessing factors associated with an initial loss of USC rather than transitions between USC statuses.

Our study illustrates the importance of considering how changes in access to health insurance, transportation, or residence can have important implications for older adults' ability to maintain a USC. Future work is needed to assess how changes in these factors affect older adults' ability to experience a continuous source of care and the impact of that continuity on functional decline and hospital admissions.

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