Terminations in Primary Care: a Retrospective Observational Study of 16 Primary Care Clinics

Background The relationship between clinician and patient is the cornerstone of primary care. Breakdown and termination of this relationship are understudied yet important, undesirable outcomes. Objective To better understand the nature and extent of provider and clinic termination of the primary care relationship. Design Retrospective observational case-control study. Subjects Adult patients in Eastern Massachusetts who received primary care at hospital- and community-based clinics and health centers participating in a practice-based research network between January 2013 and June 2017. Main Measures Formal termination by primary care physician (PCP), reasons for termination, independent predictors of termination based on mixed-effects logistic regression, and documentation of a new PCP after termination. Key Results We identified 158,192 patients who received primary care from 182 PCPs across 16 clinics. We found 536 cases of formal termination. Clinics ranged from 4 to 119 terminations per 10,000 patients (intraclass correlation coefficient [ICC]=0.21; 95% CI: 0.18–0.24). Patient age, race/ethnicity, educational attainment, relationship status, employment status, and insurance type were independent predictors of termination (e.g., compared to patients employed full-time, patients unemployed due to disability were more likely to be terminated [adjusted OR:9.26; 95% CI: 6.74–12.74]). The most common cause for termination (38%) was appointment “no-shows” with some PCPs/clinics found to enforce a policy of dismissal following three no-shows. At the time of chart review, 201 patients (38%) had no documentation of a new PCP. Among patients who re-established care within the network, 134 (25%) had a primary care visit within 6 months of termination. Conclusions Detailed chart review found that, unlike previous survey-based studies, dismissal was often for missed appointments based on enforcement of no-show policies. Many sociodemographic factors were associated with termination. Variability among clinics highlights the need for further research to better understand circumstances surrounding terminations, with the principal goals of improving patient-provider relationships and providing equitable care.