IMPACT
What two years of training in Family Medicine do to medical practice in primary care.
Evidence from 600,000 patients followed for 6 years in primary care in Rio de Janeiro, attended by family physicians and by generalist physicians (physicians without family-medicine training).
The data presented here come from a cohort of 600,000 patients followed in primary care in Rio de Janeiro between 2013 and 2018. Patients were seen by two distinct groups of physicians: family physicians with 2 years of residency training in the specialty (200,000 patients) versus physicians without this training (400,000 patients). Working conditions and the demographic profile of the populations served were the same; the only difference was the physicians' training.
The numbers below reflect what happened in that cohort. Use the bar below to project what would happen to condition detection, to lab test ordering, to referrals to secondary care, and to hospital admissions if the proportion of family physicians were higher — or lower.
Family physicians detect more
28 conditions · BMC Family Practice (2021)
Family physicians were more likely to detect most of the 28 chronic conditions analysed. The effect is strongest for conditions that require active suspicion: drug addiction, alcohol abuse, peripheral artery disease, kidney failure.
| Event | RR (95% CI) | Observed | Δ | New |
|---|---|---|---|---|
| Hypertension | 1.15 (1.13 - 1.17) | 11,681 | 0 | 11,681 |
| Diabetes Mellitus | 1.07 (1.04 - 1.11) | 4,089 | 0 | 4,089 |
| Hypothyroidism | 1.51 (1.25 - 1.82) | 79 | 0 | 79 |
| HIV - AIDS | 1.19 (1.09 - 1.29) | 415 | 0 | 415 |
| Drug addiction | 1.98 (1.76 - 2.22) | 197 | 0 | 197 |
| Alcohol abuse | 1.72 (1.54 - 1.91) | 237 | 0 | 237 |
| Depression | 1.19 (1.14 - 1.26) | 1,119 | 0 | 1,119 |
| Psychosis | 1.20 (1.11 - 1.30) | 466 | 0 | 466 |
| Cardiac arrhythmias | 1.31 (1.19 - 1.45) | 412 | 0 | 412 |
| Peripheral artery disease | 2.41 (2.05 - 2.82) | 114 | 0 | 114 |
| Ischemic heart disease | 1.38 (1.27 - 1.49) | 499 | 0 | 499 |
| Heart failure | 1.69 (1.56 - 1.83) | 482 | 0 | 482 |
| Kidney failure | 1.82 (1.64 - 2.02) | 270 | 0 | 270 |
| Osteoarthritis | 1.11 (1.07 - 1.15) | 3,800 | 0 | 3,800 |
| Rheumatic disorders | 1.00 (0.92 - 1.10) | 503 | 0 | 503 |
| Neurological disorders | 1.29 (1.24 - 1.34) | 2,092 | 0 | 2,092 |
| Epilepsy | 0.86 (0.79 - 0.94) | 579 | 0 | 579 |
| Stroke | 1.44 (1.34 - 1.55) | 586 | 0 | 586 |
| Dementia | 1.28 (1.16 - 1.42) | 310 | 0 | 310 |
| COPD | 1.11 (1.02 - 1.21) | 532 | 0 | 532 |
| Asthma | 1.28 (1.21 - 1.36) | 782 | 0 | 782 |
| Chronic hepatitis | 1.31 (1.10 - 1.57) | 84 | 0 | 84 |
| Cirrhosis of the liver | 1.03 (0.90 - 1.18) | 212 | 0 | 212 |
| Cancer | 1.26 (1.17 - 1.36) | 627 | 0 | 627 |
| Neoplasia Men | 1.11 (0.92 - 1.33) | 92 | 0 | 92 |
| Neoplasia Women | 1.34 (1.11 - 1.62) | 81 | 0 | 81 |
| Breast cancer | 1.42 (1.21 - 1.67) | 122 | 0 | 122 |
| Metastatic cancer | 1.47 (0.96 - 2.26) | 16 | 0 | 16 |
Detecting diseases at the right moment means being able to start management at earlier stages of the disease, which allows us to modify its course, prevent unwanted outcomes, and keep complications and sequelae from being established.
… and order fewer tests
30 lab tests · BMC Family Practice (2021)
Family physicians order fewer laboratory and imaging tests, making more rational use of these resources. The reductions are particularly significant for tests routinely ordered, such as hemogram, urea, uric acid, LDL cholesterol, and urinalysis.
| Event | RR (95% CI) | Observed | Δ | New |
|---|---|---|---|---|
| Hemogram | 0.53 (0.53 - 0.54) | 51,757 | 0 | 51,757 |
| Creatinine | 0.85 (0.84 - 0.86) | 43,746 | 0 | 43,746 |
| Urea | 0.29 (0.28 - 0.29) | 22,577 | 0 | 22,577 |
| Urinalysis | 0.67 (0.67 - 0.68) | 41,333 | 0 | 41,333 |
| Sodium | 0.42 (0.41 - 0.43) | 10,517 | 0 | 10,517 |
| Potassium | 0.73 (0.72 - 0.75) | 18,265 | 0 | 18,265 |
| Glucose | 0.46 (0.45 - 0.47) | 9,072 | 0 | 9,072 |
| A1C Hemoglobin | 0.64 (0.63 - 0.65) | 25,720 | 0 | 25,720 |
| PSA | 0.36 (0.34 - 0.37) | 4,365 | 0 | 4,365 |
| Total cholesterol | 0.81 (0.80 - 0.82) | 34,673 | 0 | 34,673 |
| HDL cholesterol | 0.94 (0.93 - 0.95) | 31,127 | 0 | 31,127 |
| LDL cholesterol | 0.41 (0.41 - 0.42) | 22,163 | 0 | 22,163 |
| Triglycerides | 0.82 (0.81 - 0.83) | 33,828 | 0 | 33,828 |
| Uric acid | 0.23 (0.22 - 0.23) | 15,603 | 0 | 15,603 |
| TSH | 0.71 (0.70 - 0.73) | 11,679 | 0 | 11,679 |
| AST | 0.48 (0.47 - 0.49) | 9,181 | 0 | 9,181 |
| ALT | 0.47 (0.46 - 0.48) | 9,363 | 0 | 9,363 |
| Alkaline phosphatase | 0.69 (0.67 - 0.71) | 3,505 | 0 | 3,505 |
| Gamma-GT | 0.64 (0.62 - 0.66) | 4,386 | 0 | 4,386 |
| Triiodothyronine | 0.08 (0.06 - 0.09) | 791 | 0 | 791 |
| Thyroxine | 0.13 (0.12 - 0.15) | 886 | 0 | 886 |
| Free Thyroxine | 0.56 (0.55 - 0.58) | 5,432 | 0 | 5,432 |
| Bilirubin | 0.78 (0.75 - 0.81) | 2,304 | 0 | 2,304 |
| ESR | 0.74 (0.71 - 0.77) | 1,957 | 0 | 1,957 |
| Ova & parasite | 0.09 (0.08 - 0.11) | 604 | 0 | 604 |
| Calcium | 0.44 (0.42 - 0.46) | 1,866 | 0 | 1,866 |
| LH | 0.56 (0.52 - 0.61) | 674 | 0 | 674 |
| FSH | 0.60 (0.56 - 0.64) | 863 | 0 | 863 |
| Rubella IgG | 0.48 (0.41 - 0.55) | 210 | 0 | 210 |
| Rubella IgM | 0.47 (0.40 - 0.54) | 216 | 0 | 216 |
Ordering fewer tests doesn't mean providing less care — it means making more judicious use of these resources. With better clinical judgment, family physicians detect more diseases while ordering fewer tests.
They refer with judgment
31 specialties · BMJ Open (2022)
The story here is more nuanced than in previous sections: family physicians don't simply refer less.
Family physicians don't simply refer less; they refer more judiciously. For conditions that require specialized resources — rehabilitation, physiotherapy, eye surgery — they refer patients more readily, expanding access for those who truly need it. For clinical conditions that can be managed in primary care — dermatology, ambulatory orthopaedics, cardiology, pulmonology, endocrinology — they refer far less, keeping care at the first level. The net effect is increased capacity of the health system.
| Event | RR (95% CI) | Observed | Δ | New |
|---|---|---|---|---|
| Cardiology | 0.40 (0.38 - 0.43) | 2,008 | 0 | 2,008 |
| Neurology | 0.50 (0.47 - 0.53) | 1,835 | 0 | 1,835 |
| Psychiatry | 0.45 (0.40 - 0.50) | 897 | 0 | 897 |
| Dermatology | 0.49 (0.47 - 0.51) | 4,144 | 0 | 4,144 |
| Pulmonology | 0.54 (0.48 - 0.60) | 903 | 0 | 903 |
| Infectious diseases | 0.74 (0.63 - 0.87) | 290 | 0 | 290 |
| Urology | 0.57 (0.54 - 0.61) | 1,762 | 0 | 1,762 |
| Allergology | 0.54 (0.47 - 0.60) | 480 | 0 | 480 |
| Nephrology | 0.63 (0.57 - 0.70) | 603 | 0 | 603 |
| Endocrinology | 0.42 (0.38 - 0.46) | 1,021 | 0 | 1,021 |
| Gastroenterology | 0.38 (0.34 - 0.42) | 867 | 0 | 867 |
| Angiology | 0.35 (0.32 - 0.39) | 1,030 | 0 | 1,030 |
| Rheumatology | 0.47 (0.42 - 0.52) | 830 | 0 | 830 |
| Physiotherapy | 1.17 (1.11 - 1.23) | 2,390 | 0 | 2,390 |
| Rehabilitation | 1.68 (1.57 - 1.79) | 1,173 | 0 | 1,173 |
| Ophthalmology | 1.09 (1.06 - 1.12) | 8,713 | 0 | 8,713 |
| ENT | 0.71 (0.67 - 0.75) | 2,269 | 0 | 2,269 |
| Orthopaedics | 0.52 (0.50 - 0.54) | 4,934 | 0 | 4,934 |
| Gynaecology | 0.86 (0.79 - 0.94) | 738 | 0 | 738 |
| HRPC | 0.66 (0.60 - 0.72) | 991 | 0 | 991 |
| Eye surgery | 1.21 (1.17 - 1.26) | 4,458 | 0 | 4,458 |
| Gynaecological surgery | 0.87 (0.81 - 0.95) | 989 | 0 | 989 |
| Orthopaedic surgery | 1.22 (1.02 - 1.47) | 147 | 0 | 147 |
| General surgery | 0.91 (0.86 - 0.96) | 1,968 | 0 | 1,968 |
| Plastic surgery | 1.19 (1.10 - 1.29) | 859 | 0 | 859 |
| Vascular surgery | 0.87 (0.77 - 0.99) | 359 | 0 | 359 |
| Echocardiogram | 0.66 (0.62 - 0.71) | 1,201 | 0 | 1,201 |
| Spirometry | 0.96 (0.85 - 1.09) | 385 | 0 | 385 |
| Colonoscopy | 0.76 (0.68 - 0.85) | 510 | 0 | 510 |
| EGD | 0.49 (0.45 - 0.53) | 1,090 | 0 | 1,090 |
| CPX test | 0.72 (0.64 - 0.81) | 431 | 0 | 431 |
Reducing referrals doesn't congest primary care; it decompresses secondary care, ensuring that the patient's care happens where it should be.
They reduce admissions
14 ambulatory-care sensitive conditions · PLOS Glob Public Health (2023)
Patients followed by family physicians had a lower risk of hospitalization for the ambulatory-care sensitive conditions analysed (Brazilian ACSC list). The effect was observed both for acute conditions (pneumonia, skin infections, conditions related to pregnancy, childbirth, and the postpartum period) and for chronic conditions that, when well managed, can reduce the risk of exacerbation and hospital admission — asthma, heart failure, and angina pectoris are some examples.
| Event | RR (95% CI) | Observed | Δ | New |
|---|---|---|---|---|
| Hypertension | 0.83 (0.61; 1.15) | 128 | 0 | 128 |
| Diabetes mellitus | 0.76 (0.56; 1.04) | 160 | 0 | 160 |
| Stroke | 0.74 (0.58; 0.95) | 244 | 0 | 244 |
| Angina pectoris | 0.62 (0.51; 0.75) | 271 | 0 | 271 |
| Heart failure | 0.52 (0.40; 0.67) | 230 | 0 | 230 |
| Epilepsy | 0.79 (0.57; 1.11) | 86 | 0 | 86 |
| Asthma | 0.35 (0.21; 0.57) | 54 | 0 | 54 |
| Pregnancy related | 0.78 (0.60; 1.01) | 136 | 0 | 136 |
| Gastroenteritis | 0.45 (0.25; 0.79) | 45 | 0 | 45 |
| Pneumonia in children | 0.57 (0.42; 0.77) | 114 | 0 | 114 |
| Pneumonia in adults | 0.36 (0.24; 0.56) | 116 | 0 | 116 |
| Skin infection | 0.82 (0.69; 0.97) | 331 | 0 | 331 |
| Ear, nose & throat | 1.06 (0.64; 1.77) | 28 | 0 | 28 |
| Pelvic inflammatory disease | 0.59 (0.38; 0.93) | 41 | 0 | 41 |
Every admission avoided represents not only savings for the system, but less suffering and better quality of life. A patient whose asthma is well controlled is one fewer patient in the emergency room.
Diagnosis is only one step
3 separate analyses
Diagnosing, ordering tests, or making a referral is just one step of care. Continuing care over time with the same physician is both a challenge and a duty of primary care. After making a new diagnosis, after referring a patient to secondary care, and after a hospital admission, family physicians provide more follow-up visits in each of these three situations. This shows how training in this specialty prepares physicians to deliver continuity of care to their patients.
Continuity of care after diagnosis
Diagnosing a health condition is only one step of what we do in Primary Health Care. Continuing the care of this patient over time — managing the problem jointly with the patient and using pharmacological and non-pharmacological measures to change the course of the disease, provide symptom relief, or mitigate potential consequences — accounts for a large part of family physicians' routine work.
In addition to diagnosing more chronic health problems, family physicians provide more follow-up visits after making the diagnosis. The table below shows the "risk" of a follow-up visit within 30 days after being diagnosed, compared with being diagnosed by a generalist without family-medicine training.
In other words, family physicians not only diagnose more conditions, but also provide more follow-up visits.
| Condition | Follow-up (RR, 95% CI) |
|---|---|
| Hypertension | 1.54 (1.41–1.68) |
| Diabetes Mellitus | 1.43 (1.32–1.55) |
| Hypothyroidism | 2.25 (1.86–2.72) |
| AIDS | 1.72 (1.55–1.91) |
| Drug addiction | 2.64 (2.22–3.14) |
| Alcohol abuse | 2.53 (2.13–2.99) |
| Depression | 1.89 (1.70–2.11) |
| Psychosis & Schizophrenia | 1.77 (1.58–1.98) |
| Cardiac arrhythmias | 1.93 (1.70–2.19) |
| Peripheral artery disease | 2.80 (2.26–3.47) |
| Ischemic heart disease | 2.01 (1.77–2.27) |
| Heart failure | 2.66 (2.34–3.01) |
| Kidney failure | 2.44 (2.08–2.87) |
| Osteoarthritis | 1.77 (1.57–1.98) |
| Rheumatic disorders | 1.74 (1.56–1.93) |
| Neurological disorders | 1.94 (1.75–2.15) |
| Epilepsy | 1.37 (1.24–1.51) |
| Stroke | 1.73 (1.55–1.94) |
| Dementias | 1.78 (1.56–2.05) |
| COPD | 1.56 (1.41–1.72) |
| Asthma | 1.71 (1.51–1.93) |
| Chronic Hepatitis | 1.85 (1.59–2.15) |
| Cirrhosis of the liver | 1.99 (1.77–2.24) |
| Neoplasias (general) | 1.78 (1.43–2.20) |
| Neoplasias (Men) | 2.14 (1.75–2.62) |
| Neoplasia (Women) | 2.08 (1.77–2.46) |
| Breast cancer | 1.69 (1.06–2.70) |
| Metastatic cancer | 1.18 (1.10–1.27) |
Continuity of care after referral
Referring patients to secondary care is an important step in many therapeutic journeys. However, family physicians should be able to address most care needs at the first level, where they practice. Referrals should be done judiciously and for specific purposes — never to transfer ongoing care.
The table below shows that patients referred to secondary care by family physicians have a higher chance of being seen again in primary care by the same physician within the following 3 and 6 months — compared with patients referred by generalists.
| Medical specialty / test | 3 months (ratio, 95% CI) | 6 months (ratio, 95% CI) |
|---|---|---|
| Ambulatory care | ||
| Cardiology | 1.86 (1.62 – 2.14) | 1.74 (1.48 – 2.04) |
| Neurology | 1.78 (1.56 – 2.03) | 1.74 (1.49 – 2.02) |
| Psychiatry | 2.15 (1.75 – 2.64) | 2.05 (1.62 – 2.61) |
| Dermatology | 1.42 (1.30 – 1.55) | 1.45 (1.32 – 1.60) |
| Pulmonology | 1.73 (1.41 – 2.11) | 1.76 (1.39 – 2.23) |
| Infectious diseases | 2.02 (1.47 – 2.77) | 1.55 (1.11 – 2.17) |
| Urology | 1.74 (1.54 – 1.98) | 1.79 (1.55 – 2.06) |
| Allergology | 1.89 (1.47 – 2.41) | 1.97 (1.50 – 2.58) |
| Nephrology | 2.17 (1.74 – 2.71) | 1.89 (1.45 – 2.46) |
| Endocrinology | 1.74 (1.44 – 2.11) | 1.47 (1.19 – 1.82) |
| Gastroenterology | 1.77 (1.42 – 2.20) | 1.92 (1.48 – 2.50) |
| Angiology | 1.40 (1.15 – 1.70) | 1.40 (1.12 – 1.75) |
| Rheumatology | 1.86 (1.52 – 2.28) | 1.58 (1.25 – 1.98) |
| Physiotherapy | 1.73 (1.58 – 1.90) | 1.72 (1.54 – 1.92) |
| Rehabilitation | 1.73 (1.52 – 1.97) | 1.55 (1.34 – 1.80) |
| Ophthalmology | 1.62 (1.54 – 1.70) | 1.57 (1.49 – 1.66) |
| ENT | 1.70 (1.53 – 1.89) | 1.52 (1.36 – 1.71) |
| Orthopaedics | 1.83 (1.69 – 1.97) | 1.63 (1.50 – 1.78) |
| Gynaecology | 1.88 (1.57 – 2.25) | 1.78 (1.45 – 2.18) |
| High-risk prenatal care | 1.16 (0.93 – 1.44) | 0.92 (0.71 – 1.19) |
| Surgical evaluation | ||
| Eye surgery | 1.62 (1.51 – 1.74) | 1.45 (1.34 – 1.58) |
| Gynaecological surgery | 1.65 (1.42 – 1.93) | 1.55 (1.30 – 1.84) |
| Orthopaedic surgery | 1.48 (1.01 – 2.16) | 1.22 (0.81 – 1.82) |
| General surgery | 1.74 (1.56 – 1.93) | 1.64 (1.45 – 1.84) |
| Plastic surgery | 1.51 (1.30 – 1.77) | 1.43 (1.21 – 1.68) |
| Vascular surgery | 1.24 (0.96 – 1.60) | 1.51 (1.14 – 2.01) |
| Diagnostic tests | ||
| Echocardiogram | 1.91 (1.64 – 2.23) | 1.53 (1.28 – 1.84) |
| Spirometry | 1.48 (1.15 – 1.90) | 1.65 (1.22 – 2.23) |
| Colonoscopy | 1.72 (1.38 – 2.15) | 1.43 (1.12 – 1.85) |
| EGD | 2.04 (1.71 – 2.43) | 2.17 (1.75 – 2.68) |
| CPX test | 2.02 (1.58 – 2.58) | 1.70 (1.27 – 2.28) |
| Mammography | 2.03 (1.84 – 2.24) | 1.93 (1.72 – 2.17) |
Continuity of care after hospital discharge
For follow-up visits after hospital discharge, the picture repeats. Confidence intervals are wider here — a function of the smaller number of events (admissions are far rarer than diagnoses or referrals). Even so, patients hospitalized for angina pectoris, heart failure, stroke, pneumonia, and skin infections had a much higher chance of receiving follow-up visits after discharge when their physician is a family physician.
| Condition | Two months (95% CI) | Four months (95% CI) | Six months (95% CI) |
|---|---|---|---|
| Hypertension | 1.19 (0.55–2.55) | 1.11 (0.49–2.48) | 1.22 (0.50–2.93) |
| Diabetes mellitus | 1.30 (0.66–2.54) | 1.26 (0.58–2.72) | 1.54 (0.69–3.45) |
| Stroke | 1.43 (0.84–2.43) | 2.20 (1.21–3.99)* | 1.80 (0.97–3.32) |
| Angina pectoris | 2.10 (1.33–3.31)* | 1.78 (1.11–2.87)* | 1.94 (1.15–3.28)* |
| Heart failure | 3.09 (1.63–5.88)* | 3.50 (1.80–6.82)* | 3.33 (1.67–6.62)* |
| Pneumonia (children) | 1.84 (0.95–3.56) | 2.92 (1.40–6.07)* | 3.18 (1.49–6.78)* |
| Pneumonia (adults) | 3.93 (1.32–11.68)* | 2.60 (0.84–8.01) | 2.08 (0.66–6.57) |
| Skin infection | 1.62 (1.12–2.36)* | 1.39 (0.95–2.02) | 1.30 (0.88–1.93) |
* 95% CI does not include 1.0 (statistically significant).
Risk ratios were estimated using multilevel binomial models adjusted for age, sex, Charlson comorbidity index, neighbourhood social development index, and time. Each visit was treated as a binary event nested within the patient, and within the physician or family health team, depending on the outcome.
The absolute numbers projected by the bar above use the World Health Organization's Population Attributable Fraction (PAF) formula, applied to the observed baseline for each event.
Limitations: the data reflect the specific context of Rio de Janeiro between 2013–2018, with the particular structure of the city's public primary care system. Immediate generalization to other contexts requires caution. Local variations in structure, resources, and medical training affect the transferability of the findings.
- RBMFC 2020 — Pesquisa científica, atenção primária e medicina de família: três ingredientes essenciais para melhorar a qualidade dos cuidados de saúde. Rev Bras Med Fam Comunidade. Rio de Janeiro, 2020 Jan-Dec; 15(42):24661.
- BMC Family Practice 2021 — Jantsch, A.G., Burström, B., Nilsson, G. et al. Detection and follow-up of chronic health conditions in Rio de Janeiro – the impact of residency training in family medicine. BMC Fam Pract 22, 223 (2021).
- BMJ Open 2022 — Jantsch AG, Burström B, Nilsson GH, et al. Residency training in family medicine and its impact on coordination and continuity of care: an analysis of referrals to secondary care in Rio de Janeiro. BMJ Open 2022;12:e051515.
- PLOS Global Public Health 2023 — Jantsch AG, Burström B, Nilsson GH, Ponce de Leon A (2023) The impact of residency training in family medicine on hospital admissions due to Ambulatory-care Sensitive Conditions in Rio de Janeiro. PLOS Glob Public Health 3(10): e0000547.
- Full thesis (UERJ) — The impact of residency training in family medicine in promoting the attributes of primary care in Rio de Janeiro / O impacto da residência em medicina de família na promoção dos atributos da atenção primária no Rio de Janeiro.
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