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For Primary Care, More Patients Are Seeing Specialists

Even prenatal care visits to family doctors are declining, researchers find

TUESDAY, March 10 (HealthDay News) -- Specialists are increasingly providing routine and preventive services that have traditionally been handled by primary care doctors, a new study has found.

"In a nationally representative sample of more than 25,000 visits [in the United States], we have observed that about half of all visits for specialized care is for routine and preventive care, as reported by physicians themselves," said study author, Dr. Jose M. Valderas, a clinical lecturer at the University of Manchester in the United Kingdom.

The researchers looked at data on numerous specialties, including medical, surgical, obstetrics/gynecology and psychiatry. The only specialists specifically excluded from the study were anesthesiologists, pathologists and radiologists.

After reviewing two years of data on office visits from the National Ambulatory Medical Care Survey, the researchers found that 46 percent of visits to specialists were made by people who had already been seen by the specialist and were returning for routine follow-up or preventive care. Just under a third of the visits resulted from a referral, and three-fourths of all visits to specialists resulted in a return appointment with the same physician.

The findings were published in the March/April issue of the Annals of Family Medicine.

"The problem is that specialists don't necessarily know the standard of care" for primary care, explained Dr. Sam Awada, chief of family medicine at St. John Macomb-Oakland Hospital in Warren, Mich. "For example, I knew an oncologist who was taking care of a patient, and this lady got a foot problem. He gave her Motrin, but when it persisted, and she came to see me, I discovered she had a fracture, not a sprain. That's putting yourself in a quagmire unnecessarily. If I tried to manage someone's cardiac problem or their cancer, I'd be just as guilty. It should be an easy two-way street between family doctors and specialists."

Dr. Marc Siegel, an internist at New York University Langone Medical Center in New York City, said that he "would argue that if a specialist sees you for primary prevention, you're more likely to end up having a procedure."

"Although the nation is going in the direction of specialization, it's clearly not cost-effective," Siegel said.

Valderas said that "all care that does not need the specific involvement of a specialist could potentially and should be done by primary care physicians." Looking at health-care systems worldwide, he said, "health systems oriented towards primary care have consistently demonstrated better or comparable outcomes at lower costs."

Pregnant women appear to be among those seeing specialists more often for routine care.

In the same issue of the journal, another study found that family physicians are less likely to offer prenatal care to their expectant patients today than they were a decade ago.

It found that prenatal visits to family physicians declined from nearly 12 percent to just over 6 percent in a 10-year period. In non-urban areas, the drop was even more striking: from about 39 percent to 13 percent, the study found.

Expectant mothers who did visit their family physician for prenatal care were more likely to live in a non-metropolitan area, to be on Medicaid, and to be either younger (under 24) or older (over 30).

In rural areas, a lack of family physicians who don't offer prenatal care "could be a disaster," said Awada. Many family physician residency programs no longer focus on prenatal obstetrical care, he added.

A third study in the journal suggests that the consequences could be more far-reaching than just prenatal care. It found that, along with getting prenatal care, nearly one in five prenatal visits with a family physician also covered a medical issue not related to obstetrics.

More information

Whether you're seeing a primary care doctor or a specialist, the Agency for Healthcare Research and Quality has advice on choosing a doctor.

SOURCES: Jose M. Valderas, M.D., Ph.D., clinical lecturer, University of Manchester, United Kingdom; Sam Awada, M.D., chief, family medicine, St. John Macomb-Oakland Hospital, Warren, Mich.; Marc Siegel, M.D., internist, New York University Langone Medical Center, New York City; March/April 2009 Annals of Family Medicine

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