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

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Design: Observational cohort study using electronic health records. Setting: Rio de Janeiro, Brazil, public primary care system. Participants: 504940 patients, 633 generalists (physicians without RTFM) and 204 Family physicians (FP – doctors with two years of RTFM) from one health district between January 2015 and December 2018. Intervention: Two years of Residency Training in Family Medicine (RTFM) Main outcome measures: risk of patients being referred to secondary care for outpatient consultations and diagnostics tests; and having a follow-up medical consultation in primary care within three and six months after being referred. Results: We examined 2414508 medical consultations and 284754 referrals to secondary care. Family physicians (FPs) were less likely to request ambulatory care services (including surgical specialties), but were more likely to request Ophthalmology, Physiotherapy, Rehabilitation, and Surgical evaluations for their patients. Patients referred to secondary care by FPs were at a higher risk of having a follow-up visit in primary care for almost every service requested. If all medical consultations were performed by FPs, a 37.6% (95% CI 32.4% - 42.4%) increased demand for Rehabilitation services would be noticed. Oppositely, 1532 (95%CI 1458; 1602) fewer requests for Dermatology would happen every year. Conclusions: RTFM improves coordination and continuity of care by making FPs more competent to retain those health conditions that can be properly managed in primary care and making FPs more competent to detect health conditions that require specific biomedical technologies and skills, increasing the demand for those services. Besides, it increases the chances of patients having follow-up visits in primary care. Policymakers in low- and middle-income countries must consider investing in RTFM to make primary care systems more comprehensive, with better coordination and continuity of care. General Practice Epidemiology Primary Health Care Family Practice Health Workforce Developing Countries Article Summary Strengths and limitations of this study To our knowledge, our article is the first study to address the impact of residency training in Family Medicine on promoting continuity and coordination between primary and secondary levels of healthcare in low- and middle-income countries. We drew on data from electronic health records, which reflect real-world clinical practice in the public primary care system in Brazil, and using mixed-effects models allowed us to take into account the correlation among consultations from the same patient. Our analyses are limited to comparisons on patterns of referrals and follow-ups between Generalists and Family physicians and we cannot infer that patients are getting a better quality of care, having better quality of life or living longer. Having the full information about doctors’ individual and educational characteristics would have helped to better measure the role that residency training in Family Medicine plays in promoting the attributes of PHC. The evidence raised from primary care and Family Medicine in Brazil can be better translated to other low- and middle-income countries that are facing similar troubles training the healthcare workforce and developing comprehensive primary health care systems. Introduction For the last 40 years, improvements in Primary Health Care (PHC) were made worldwide due to the momentum created by the Alma-Ata declaration. 1 Many countries have achieved good results in creating and developing universal, accessible, and cost-effective PHC systems. 2,3 Today we have enough evidence supporting the notion that countries with strong PHC have better health indicators, 4 have reduced health inequalities, 5 and get better results while spending less money. 6 With a large universal public health care system 7 and a successful history of community-based PHC, 8 Brazil has been portrayed as an example to be followed by low- and middle-income countries (LMIC). The Family Health Strategy ( Estratégia de Saúde da Família – FHS) launched by the federal government in 1994, established a structure for PHC at the municipal level, providing financial resources for Family Health Teams (FHT) formed by one physician, one nurse, one nurse assistant and four to six Community Health Workers (CHW) to provide care for up to 4000 people living in a given catchment area. This initiative has substantially reduced infant and neonatal mortality, 9 hospital admissions related to ambulatory-care sensitive conditions, 10–13 and cardiovascular deaths. 14,15 Today 43,000 FHTs provide public-funded community-based PHC to 64% of the Brazilian population covered by the FHS. 16 However, many of these FHTs have only a nurse and CHW as health care providers and, when a doctor is available, it is very unlikely to be a trained Family Physician (FP). Despite recent policies that have tried to boost the creation and growth of residency programs in Family Medicine (FM) in Brazil, 17,18 only 4.4% of the residency seats are dedicated to FM. With only 5,500 FP in the country 19 (1.4% of all medical specialists), FM is still not seen by policymakers and health managers as a necessary medical specialty for doctors working in PHC. 20 Between 2008 and 2016, the Rio de Janeiro Municipal Health Department (RJ-MHD) expanded the FHS coverage from 3.5 to 70% in the city and allocated financial incentives for capacity building of human resources in FM. 21 A new FM residency training program was created and two established programs were expanded. 22,23 The rationale behind this initiative was that the investments made in residency training in FM (RTFM) would be translated into a more qualified provision of PHC with a wider scope of practice and better use of health resources. 24 Measuring the impact that RTFM can make in promoting the attributes of PHC can be a hard task due to its characteristics, complexity and broad scope of practice, making it necessary to approach one aspect at a time. With FPs and Generalists (physicians without RTFM) working side by side for the last 10 years, the city of Rio de Janeiro can be a unique case study to address important research questions about the development of human resources for PHC in LMIC. 25 This study analyzes the impact of RTFM on two key attributes of PHC – continuity and coordination of care – by testing the hypothesis that trained FPs will be less likely to refer their patients to secondary care, but will be more likely to provide follow-up visits for patients once referred. It aims to compare FPs and Generalists performance by measuring (1) the risk of their patients being referred to SC for outpatient consultations and diagnostic tests; (2) the risk of those patients having a follow-up medical consultation in PHC within three and six months after being referred. Finally, it aims (3) to determine the population attributable fractions (PAFs) in a scenario in which all medical consultations and referrals were carried out by FPs. Methods STUDY DESIGN AND DATA SOURCE We conducted a retrospective longitudinal observational analysis of medical consultations in PHC and referrals to SC. This sample combines information from 504.940 patients (205.961 men and 298.508 women), 2.414.508 medical consultations, 284.754 referrals to SC, and 837 physicians working non-concurrently in one health district between January 2015 and December 2018. Patients’ consent was not necessary since only anonymized information was used during the study and the RJ-MHD, the actual caretaker of this information, gave the consent to use this dataset for this research. The study was approved by the RJ-MHD research ethics board and it is registered under the number 03795118.0.0000.5279. It was conducted in accordance with the 466/12 resolution from the Brazilian National Health Council 26 and the Declaration of Helsinki. EXPOSURE Physicians were divided into two categories: (1) Generalists - the reference category aggregating doctors without residency training in FM; and (2) Family physicians (FP) - graduated family physicians, FM preceptors and residents enrolled in the FM residency programs. Residents in FM were included in the same category as FP because they spend two years working 48 hours a week in a community-based primary care clinic under the full supervision of a senior FP (FM preceptor), sharing responsibilities for the same patients in one FHT. Every week they have learning sessions developed by the faculty members 23 using active learning methods 27,28 to address topics of FM and PHC, such as clinical reasoning, management of the most prevalent health conditions in PHC, communication skills, evidence based-medicine, PHC and health care systems, vulnerable populations, elderly care, multimorbidity, polypharmacy, among others. 29 They also have rotations in maternal care, pediatrics, internal medicine, and emergency care. These activities were designed in line with the National Committee for Medical Residencies (CNRM) 30 and with the Brazilian Society of Family and Community Medicine (SBMFC). 31 Information about other forms of post-graduate training were not available in the database and were not taken into account, nor the number of years in practice for any doctor. INDEPENDENT VARIABLES Every patient contributed to the models with individual information – (1) age (linear), (2) sex, and (3) the Charlson Comorbidity Index 32 – and contextual information – (4) the Social Development Index (SDI). The SDI is a linear scale combining information about sanitation, schooling, income, and housing conditions from every household in the FHT catchment area, representing the grade of social development of a neighborhood. 33 Hence, patients registered in the same FHT have the same SDI. It varies from 0 (least developed) to 1 (most developed). Charlson Comorbidity Index 32 was used to add information about patients’ morbidity burden to the models, assuming that those with more chronic conditions would be more likely to be referred to secondary care and have follow-up consultations after being referred. Time effects were regarded using dummy variables for months and years in all models. A dummy variable was used to include information identifying if the consultation was a prenatal care visit or not. All clinics in this sample have the same physical structure, offices equipped with computer, printer, medical equipment, room for small surgical procedures, the same arsenal of laboratory tests and medicines in the pharmacy, and the same type of human resources available: nurses, technicians, dentists, pharmacists, and managers. The availability of medical specialties in SC and diagnostics tests, and the referral procedures are the same for all doctors and clinics in the sample. The distribution of doctors among different clinics and FHT didn’t follow any criteria that could interfere in the relationship between the medical categories, the population assisted, and the study outcomes. OUTCOMES Referrals to SC were divided into three groups: (1) outpatient consultations for ambulatory care; (2) surgical evaluation; and (3) diagnostics tests. They were considered as a binary event (referred versus non-referred). To estimate the relative risks (RR) of having a follow-up visit in the PHC clinic after the referral, only patients who had been referred to the specific specialty under analysis were considered. Follow up visits were also considered binary events categorized as the patient having or not having one medical consultation (a) 90 days after the referral or (b) 180 days after the referral. The 32 most commonly requested medical specialties consultations and diagnostics tests in our dataset were used to perform this analysis. Comparing both the risk of a patient being referred to SC and the risk of having a follow-up visit by doctors with different types of training can bring us evidence about the effect that RTFM has on promoting both a more effective healthcare for the patient in primary care and a better continuity of care and coordination between primary and secondary levels of care. This notion is aligned with the definition of FM from the Brazilian, 31 Canadian 34 and European 35 curricula for FM, i.e., that experts in FM “are skilled clinicians that are capable of managing a full range of health conditions”, “make efficient use of health care resources through coordinating care” and “are responsible for the provision of longitudinal continuity of care as determined by the needs of the patient.” STATISTICAL ANALYSES Multilevel multivariate binomial regression models were used to estimate the RRs of patients being referred to SC in one medical consultation and patients having a follow-up visit in three and six months after being referred to SC, according to the medical category of the doctor in charge. A hierarchical data structure was created with consultations from the same patient clustered and ordered per each individual patient, taking into account the correlation among consultations from the same patient. Each outcome was analyzed individually. Mammography, Gynecology and Gynecologic Surgery entailed just women and high-risk prenatal care (HRPC) entailed only pregnant women. Models were adjusted for first level covariates (consultation), i.e., patient’s age, patient’s Charlson Comorbidity Index, prenatal care consultation, time, and medical category; and for second level covariates – SDI and patient’s sex. Variance partition coefficients were calculated for all adjusted models in order to explore the proportion of the variance attributed to the second level, i.e., the variance attributed to patients characteristics. 36 PAF for each requested service was calculated using the RR from the multivariate regression models to estimate the impact in the number of referrals requested per year in the same health care district if all medical consultations were performed by trained FPs. 37,38 Data processing and statistical analysis were performed using R version 3.6.2 and lme4 package. Results A similar proportion of women (2/3) and men (1/3) with a small difference for age and SDI distributions was seen by FPs and generalists. Each subgroup had patients from the most affluent (SDI = 0.689) and the least affluent areas (SDI = 0.416). Although doctors in the sample had not necessarily worked throughout the entire study period, the proportion in the sample represents the distribution of the categories among 30 clinics and 196 FHT (Table 1). Ambulatory care services were less likely to be requested by FPs, except for Ophthalmology, Physiotherapy, and Rehabilitation, which were requested more frequently by FPs (Table 2). Surgical specialties tended to be requested less often by FPs to ambulatory care in ENT, Orthopedics, General Surgery, Gynecology, Vascular Surgery, and Urology. When the referral was related to surgical evaluation in Plastic Surgery, Orthopedic Surgery or Eye Surgery, FPs tended to refer their patients more frequently. Diagnostic tests, such as Colonoscopy, Echocardiogram, EGD, and CPX tests were less frequently requested by FPs. Spirometry and Mammography were the only exceptions. Patients referred to SC by FPs were at a higher risk of having a follow-up visit in primary care after three and six months than those referred by Generalists for almost every service requested. HRPC was the only ambulatory care service that FPs and Generalists presented similar risk of a patient having a follow-up visit in the three and six-months period (Table 3). In a hypothetical scenario where all medical consultations were performed by FPs, all medical specialties would experience a decrease in demand for ambulatory care, with Angiology being, in relative terms, the most affected – PAF 55.6% (95%CI 51.3%; 58.9%) – and Dermatology and Orthopedics having the biggest absolute reduction, with 1532 (95%CI 1458; 1602) and 1696 (95%CI 1612; 1780) fewer requests every year. Contrarily, replacing Generalists by FPs would increase by 37.6% (95% CI 32.4%; 42.4%) the demand for Rehabilitation services and by 13.3% (95% CI 10.9%; 16.2%) the demand for Eye Surgery (Table 2). Surgical specialties such as Plastic Surgery and Orthopedic Surgery would have an increase in demand for consultations, while ENT and General Surgery would have a decrease in demand. For these two surgical specialties there would be 439 (95%CI 374; 506) and 111 (95%CI 48; 174) fewer requests every year, respectively. At the same time, the demand for most of the diagnostics tests would decrease, and 403 (95% CI 365; 441) fewer EGD tests and 277 (95% CI 232; 315) fewer Echocardiograms would be requested every year. Although the inclusion of the age, sex, SDI, time, and the CCI in the models slightly changed the effect sizes and confidence intervals of the main exposure, these variables were kept in the models that provided the RRs and PAFs reported here. Variance-inflation factors were always below 3 in all models. The partition coefficients of variance (VPC) showed that the proportion of variance attributed to the second level (patient characteristics) is more important for the occurrence of a referral than for the occurrence of a follow-up visit, with a consistent pattern for all types of services studied. The proportion of the variance attributed to the patient level for Pulmonology, Endocrinology and Spirometry, for example, are up to 53%, 40% and 43%. At the same time, for the risks of follow-up visits for those patients referred to these three services, no more than 0.05%, 0.03% and 0.01% of the variance can be attributed to differences between patients. Discussion This research has taken a non-judgmental approach to the doctor-patient clinical encounter. It considers that every doctor in this sample has made the best possible decisions to provide the most appropriate health care to their patients and the comparisons between FPs and Generalists aim solely to analyze the patterns behind the numbers that represent the impact of having two extra years of training to work in primary care. Our study findings highlight a significant distinction in the types of consultation services that are more or less likely to be requested by FPs. When FPs were in charge of the consultation, the number of referrals in half of the ambulatory care specialties decreased by more than 50%. Services that did not require equipment or special skills other than clinical reasoning or general medical skills also had a significantly lower risk. On the other hand, Ophthalmology, Physiotherapy, and Rehabilitation – ambulatory care services that make use of special equipment and demand specific skills to be performed – were more often requested by FPs. (Table 2). Both Physiotherapy (reserved for minor musculoskeletal injuries) and Rehabilitation (motor, neurological, intellectual, and respiratory rehabilitation, as well as orthosis confection, prosthesis, and stoma care) are services that require specific biomedical technology and skilled professionals to be performed. These are usually available at the secondary level of the health care system. At the same time, Ophthalmology, Plastic surgery (exclusively reconstructive procedures), and Eye surgery followed the same pattern, and patients were more frequently referred by FPs. Part of the lower risk for requesting a referral to ambulatory care services among FPs can be explained by the learning opportunities that residents have during the two years of training. As part of the learning activities, 22 residents have case discussions with Dermatologists and Psychiatrists every other week at the clinic. They can book the patients they are facing difficulties to have a joint consultation with a specialist, sharing decisions about diagnostics and management, and discussing the resident’s educational needs, based on that case. 39 Biopsies and small procedures are mostly performed at the clinic as well. Due to its high prevalence, residents are trained in chronic pain management to deal with myofascial pain, to perform dry needling to relief trigger points, and simple physiotherapy exercises that can be performed by the patient alone or with the supervision of the physical educator at the local community gym available in every primary care clinic. Without the supervision of those specialists and the focused training in chronic pain management, FP would probably request referrals to Dermatology, Psychiatry, and Physiotherapy more frequently. However, the vast majority of the patients, including cases involving skin lesions and mental health issues, are regularly managed by the FHT with the help of a preceptor in FM. Cases that could also have been referred to a General Surgeon, such as lipomas, sebaceous cysts, and skin biopsies, or Vascular Surgery, such as chronic venous insufficiency, are included in the residents’ training, making them more competent to manage these conditions in PHC. On the other hand, Plastic surgery (exclusively reconstructive procedures) is another specialty that needs trained professionals to be performed and FPs are more likely to request it. Learning how to manage the most prevalent health conditions in PHC during RTFM can increase both the awareness about the conditions and the built-in capacity to manage them. The former makes FPs more prepared to recognize and diagnose the condition; the latter provides the necessary tools to treat it. This can explain why FPs are less inclined to request diagnostic tests for their patients. Diagnostic tests are part of the clinical reasoning process and if residents learn how to use them with an evidence-based approach, it is more likely that they will more cautiously select the patients that need them. This is not a new concern in PHC 40 and is aligned with the Choosing Wisely 41 and the Quaternary Prevention 42 initiatives, that exert a strong influence in the FM community by calling the attention of doctors and patients to the potential harms that unnecessary tests, treatments, and procedures can make. This requires a balanced approach to healthcare that takes into account issues around the underuse and the overuse of tests and/or treatments. Our study shows the distinction between services that patients are less likely from those they are more likely to be referred by FPs. This gives us a clue about what has been requested too much (Cardiology, Endocrinology, Allergology) and what has been requested too little (Eye surgery, Orthopedic surgery, Physiotherapy) in the public PHC system in Rio de Janeiro. In regard to the risk of occurrence of a follow-up visit being consistently higher among FPs, one could argue that the turnover and the shortage of doctors – two common issues in the Brazilian PHC – could have influenced the occurrence of this event. We cannot assure that retention in the same FHT was the same for every category. But if FPs were more inclined to stay working in the same FHT, we would not see a similar risk of follow-up for women referred to HRPC – RR 1.16; 95%CI 0.93-1.44 in three months and RR 0.92; 95%CI 0.71-1.19 in six months. Pregnant women have regular medical visits in PHC every month in the first semester, every two weeks in the last trimester, and every week in the last month. Of the 3547 women referred to that service (885 by FPs and 2662 by generalists), similar proportions had a follow-up visit within three (85.6% by FPS vs. 83.6% by generalists) and six months (89.5% by FPs vs. 90.2% by generalists). Comparing to Cardiology, where FPs were more likely to follow-up their patients in three months (RR 1.86; 95% CI 1.62-2.14) and in six months (RR 1.74; 95%CI 1.48-2.04), only 53.9% and 71.3% of those referred by Generalists had a follow-up visit in three and six months, while FPs have followed-up 68.3% and 81.3% of their referred patients, respectively. Table 2 highlights in absolute numbers how much change this intervention can make. Some results show a big difference in terms of distribution and provision of specialized care since some of the services would have their demand decreased by more than 50%. The investments made by the RJ-MHD to promote RTFM have already achieved some results, and its impact could be extended to the whole population if a feasible and sustainable expansion plan is put in place. This expansion should account for several variables that were not explored in this study and may rely not only on political will but on individual aspirations and preferences as well. The variance partition coefficients show us that the proportion of the variance attributed to the patient has major importance in the risk of a referral to SC being requested, but little influence on the occurrence of a follow-up visit. Although patients’ information has a major influence on the variance, FPs (a first level variable) reduce significantly the risk of a patient being referred. The little influence that patients’ information has on the occurrence of a follow-up visit demands additional studies exploring other aspects affecting it. If aspects related to the physician in charge (FP or generalist) can better explain part of the variance, it would provide another piece of evidence that RTFM improves coordination and, in this case, continuity of care. Finally, the impact of RTFM cannot be summarized exclusively in terms of referrals to SC. Residents in FM are not trained to perform one task, but to take care of people from cradle to grave. 43 During two years of RTFM they develop clinical, relational, scholar, and managerial competencies to provide the best patient-centered care in a community. 31,44,45 They are not trained exclusively to decide if a patient should or should not be referred to SC. This is just a detail of a much larger learning process whose effect goes beyond the RR measured in this study. That being said, it is reasonable to believe that RTFM must have an impact that goes beyond changing patterns of referrals to SC, affecting positively the quality of care delivered, and outcomes related to patients’ morbidity and mortality. Without a doubt, further research must be performed testing this hypothesis. Strengths and Limitations Evaluating PHC is a hard task and we tried to do it by aiming two specific aspects of PHC – professional training and referrals to SC. The first is a complex intervention and the second a surrogate outcome. Endpoint outcomes, such as hospital-admissions, quality of life, quality of care, patients’ satisfaction, survival, and absenteeism in the referral consultations should be studied in the future to draw a clearer dimension of the impact measured in this study. As mentioned before, having the full information about doctors’ individual and educational characteristics would have helped to better measure the role that training FM plays in the attributes of PHC. Apart from these limitations, empirical evidence about a real experience from a middle-income country can be better translated to similar countries that face the same difficulties to develop their PHC systems. 46 This kind of evidence can help to promote the development of FM in countries where PHC is still very incipient, 47 and FM is often not recognized as a medical specialty. 48,49 Conclusion Training doctors to develop the competencies needed to manage a broad scope of health conditions in PHC is one of the main goals of residency programs in FM. As a public health intervention, RTFM changes the pattern of referrals commonly seen in PHC when only Generalists take care of the population. In summary, it makes FPs more competent to retain those health conditions that can be properly managed in primary care and, at the same time, makes them more capable of detecting health issues that require specific biomedical technologies and skills, increasing the demand for those services. Besides, it increases the chances of a patient having a follow-up visit, improving coordination and continuity of care of their FHT. This is a real change not only in terms of comprehensiveness and coordination of care but also in costs paid by health systems, families, and society. Policymakers should look closely at the findings described in this article and consider carefully that investments in RTFM can make their PHC systems more comprehensive, with better coordination and continuity of care. Declarations ACKNOWLEDGMENTS We are very grateful to the colleagues at the Rio de Janeiro Municipal Health Department that gave us support for this research and provided the dataset we used to perform the study. We would also like to thank Dr. Armando Norman for his feedback on the writing and for his suggestions in the discussion section, especially regarding Quaternary Prevention. PATIENT AND PUBLIC INVOLVMENT Patients and/or the public WERE NOT involved in the design, or conduct, or reporting, or dissemination plans of this research. PATIENT CONSENT FOR PUBLICATION Not required. ETHICS APPROVAL The study was approved by the RJ-MHD research ethics board and it is registered under the number 03795118.0.0000.5279. It was conducted in accordance with the 466/12 resolution from the Brazilian National Health Council 26 and the Declaration of Helsinki. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement No additional data are available as this work draws on de-identified data provided by patients as a part of their routine primary care. FUNDING The authors declare that there is no funding from any source supporting this research. CONFLICTS OF INTEREST The authors declare that there is no conflict of interest in publishing this article or in conducting this study. DATA STATEMENT All data used in this research represent patients, health care providers and medical consultations information that are under the protection of the Rio de Janeiro Municipal Health Department. These data can be obtained from the Rio de Janeiro Superintendence of Primary Care ( [email protected] ) under the authorization of the Rio de Janeiro Municipal Health Department Research Ethics Committee ( [email protected] ). AUTHOR STATEMENT This study was designed and conceived by AGJ, BB, GN, APDL. AGJ conducted the first data analysis and wrote the first draft of this manuscript. AGJ and APDL performed the multilevel analysis. AGJ, BB, GN and APDL discussed the results from the multilevel analysis and decided together what were the most relevant information to be reported at the manuscript. BB, GN and APDL reviewed and made comments on the manuscript. AGJ, BB, GN and APDL wrote and have agreed to submit the final version of the manuscript References WHO-Unicef. Declaration of Alma-Ata. Int Conf Prim Heal Care . 1978. Watkins DA, Yamey G, Schäferhoff M, et al. The Lancet Commissions Alma-Ata at 40 years : reflections from the Lancet Commission on Investing in Health. Lancet . 2018;392(10156):1434-1460. doi:10.1016/S0140-6736(18)32389-4 Rohde J, Cousens S, Chopra M, et al. 30 years after Alma-Ata: has primary health care worked in countries? Lancet . 2008;372(9642):950-961. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61405-1/fulltext. Starfield B. Primary Care and Health: A Cross-National Comparison. 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Interface Commun Heal Educ . 2017;21:1301-1313. doi:10.1590/1807-57622016.0511 Oliveira FP de, Araújo C de A, Torres OM, Figueiredo AM de, Souza PA, Oliveira FA de. The More Doctors Program and the rearrangement of medical residency education focused on Family and Community Medicine. Interface - Comun Saúde, Educ . 2019;23(1):1-16. http://www.scielo.br/pdf/icse/v23s1/1807-5762-icse-23-s1-e180008.pdf. Mário Scheffer. DEMOGRAFIA MÉDICA NO BRASIL 2018 . São Paulo; 2018. Anderson MIP, Rodrigues RD. Formação de especialistas em Medicina de Família e Comunidade no Brasil: dilemas e perspectivas. Rev Bras Med Fam e Comunidade . 2011;6(18):19-20. Soranz D, Pinto LF, Penna GO. Themes and Reform of Primary Health Care (RCAPS) in the city of Rio de Janeiro , Brazil article. Cien Saude Colet . 2016:1327-1338. doi:10.1590/1413-81232015215.01022016 Justino ALA, Oliver LL, Melo TP de. Implementation of the Residency Program in Family and Community Medicine of the Rio de Janeiro Municipal Health Department , Brazil article. 2016:1471-1480. doi:10.1590/1413-81232015215.04342016 Izecksohn MMV, Teixeira Junior JE, Stelet BP, Jantsch AG. Preceptorship in Family and Community Medicine: challenges and achievements in a Primary Health Care in progress. Cien Saude Colet . 2016:737-746. doi:10.1590/1413-81232017223.332372016 Prado Junior JC. Desafios para a expansão de programas de residência em Medicina de Família e Comunidade: a experiência carioca. Rev Bras Med Família e Comunidade . 2015;10(34):1-9. Frenk J, Chen L, Bhutta ZA, et al. Health professionals for a new century: transforming education to strengthen health systems in an interdependent world. Lancet . 2010;376:1923-1958. doi:10.1016/S0140-6736(10)61854-5 Novoa PCR. What changes in Research Ethics in Brazil: Resolution no. 466/12 of the National Health Council. Einstein (São Paulo) . 2000;12(1). doi:10.1590/S1679-45082014ED3077 Hung W, Jonassen DH, Liu R. Problem-Based Learning. Handb Res Educ Commun Technol . 2008:485-506. doi:10.1016/j.kjms.2010.11.005 Wood DF. ABC of learning and teaching in medicine: Problem based learning. Bmj . 2003;326(October 2007):328-330. doi:10.1136/bmj.326.7384.328 Programa de Residência em Medicina de Família e Comunidade da Secretaria Municipal de Saúde do Rio de Janeiro. Multiplica: Método de Ensino Para Programas de Residência Em Medicina de Família e Comunidade . 1 ed. Rio de Janeiro: SBMFC; 2016. http://portalmultiplica.org/. Ministério da Educação. Comissão Nacional de Residência Médica. http://portal.mec.gov.br/residencias-em-saude/residencia-medica. Published 2020. SBMFC. Currículo Baseado em Competências para Medicina de Família e Comunidade. Currículo Baseado em Competências para Medicina de Família e Comunidade. http://www.sbmfc.org.br/wp-content/uploads/media/Curriculo Baseado em Competencias(1).pdf. Published 2015. Accessed February 27, 2020. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol . 1994. doi:10.1016/0895-4356(94)90129-5 Cavallieri F, Lopes GP. Índice de Desenvolvimento Social - IDS: Comparando as Realidades Microurbanas Da Cidade Do Rio de Janeiro . Rio de Janeiro; 2008. http://portalgeo.rio.rj.gov.br/estudoscariocas/download/2394_Índice de Desenvolvimento Social_IDS.pdf. Shaws E, Oandasan I, Fowler N. CanMEDS-FM 2017: A competency framework for family physicians across the continuum. The College of Family Physicians of Canada - Le Collège des Médecins de Famille du Canada. https://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/Health_Professionals/CanMEDS-Family-Medicine-2017-ENG.pdf. Published 2017. Accessed February 27, 2020. EURACT Council. THE EUROPEAN DEFINITION OF GENERAL PRACTICE/FAMILY MEDICINE. https://www.woncaeurope.org/sites/default/files/documents/Definition EURACTshort version revised 2011.pdf. Published 2011. Accessed January 1, 2020. Goldstein H, Browne W, Rasbash J. Partitioning variation in multilevel models. Underst Stat . 1(4):223-231. doi:https://doi.org/10.1207/S15328031US0104_02 Mansournia MA, Altman DG. Population attributable fraction. BMJ . 2018;757(February):2-3. doi:10.1136/bmj.k757 World Health Organization. Population Attributable Fraction (PAF). Health statistics and information systems. https://www.who.int/healthinfo/global_burden_disease/metrics_paf/en/. Published 2020. Accessed April 25, 2020. Eve R. PUNs and DENs: Discovering Learning Needs in General Practice . 1st editio. CRC Press; 2001. Wilkin D, Smith AG. Variation in general practitioners’ referral rates to consultants. J R Coll Gen Prctitioners . 1987;(August):0-3. Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA. ‘Choosing Wisely’: a growing international campaign. BMJ . 2014;(December):1-9. doi:10.1136/bmjqs-2014-003821 Jamoulle M. Quaternary prevention, an answer of family doctors to overmedicalization. Int J Heal Policy Manag . 2015;4(2):61-64. doi:10.15171/ijhpm.2015.24 Freeman TR. McWhinney’s Textbook of Family Medicine .; 2016. doi:10.1093/med/9780199370689.001.0001 EURACT. The EURACT Educational Agenda Of General Pratctice/Family Medicine .; 2005. Stewart M, Brown JB, Weston W, McWhinney IR, McWilliam CL, Freeman T. Patient-Centered Medicine: Transforming the Clinical Method . 3rd Ed. Radcliffe Medical Press; 2014. Dye C, Boerma T, Evans D, et al. The World Health Report 2013: Research for Universal Health Coverage .; 2014. Arya N, Gibson C, Ponka D, et al. Family medicine around the world: overview by region. Can Fam Physician . 2017;63(June 2017):436-441. Ponka D. The Besrour Papers: Seeking evidence for family medicine. Afr J Prim Heal Care Fam Med . 2017:1-2. doi:10.4102/phcfm.v9i1.1559 Ponka D, Rouleau K, Arya N, et al. Developing the evidentiary basis for family medicine in the global context. Can Fam physician Médecin Fam Can . 2015;61(7):596-600. Tables Table 1: Number of medical consultations and patients’ characteristics according to each medical category in the study sample. Rio de Janeiro, Brazil, 2015 – 2018. Medical category Number of doctors – N (%) Consultations – N (%) Referrals per 100 consultations SDI -mean (SD) Patients age (%) Patients according to sex – N (%) 18 & 45 Women men Generalists 633 (75.6) 1.629.235 (67.5) 12.7 0.573 (0.03) 21.3 31.8 46.9 1.067.212 (65.6) 562.023 (34.4) Family physicians 204 (24.4) 785.273 (32.5) 9.9 0.585 (0.03) 18.5 34.5 47.0 517.813 (65.9) 267.460 (34.1) Table 2: Relative risk of a patient being referred to SC in one medical consultation in PHC according to the medical category of the doctor in charge – Generalists (reference) and Family physicians. Rio de Janeiro, Brazil, 2015 – 2018. Medical Specialty Family physicians Average number of referrals per year Population attributable fraction % (95% CI) Change (and 95% CI) in the number of referrals per year if all doctors were family physicians Ambulatory care Cardiology 0.4 (0.38-0.43) 2008 -50.3 (-47.2; -52.4) -1010 (-948; -1052) Neurology 0.5 (0.47-0.53) 1835 -40.3 (-37.4; -43.2) -740 (-686; -793) Psychiatry 0.45 (0.4-0.5) 897 -45.2 (-40.3; -50.3) -405 (-361; -451) Dermatology 0.49 (0.47-0.51) 4144 -41.3 (-39.3; -43.2) -1711 (-1629; -1790) Pulmonology 0.54 (0.48-0.6) 903 -36.5 (-31; -42.2) -330 (-280; -381) Infectious Diseases 0.74 (0.63-0.87) 290 -19.2 (-9.2; -28.4) -56 (-27; -82) Urology 0.57 (0.54-0.61) 1762 -33.7 (-30.1; -36.5) -594 (-530; -643) Allergology 0.54 (0.47-0.6) 480 -36.5 (-31; -43.2) -175 (-149; -207) Nephrology 0.63 (0.57-0.7) 603 -28.4 (-22.4; -33.7) -171 (-135; -203) Endocrinology 0.42 (0.38-0.46) 1021 -48.2 (-44.2; -52.4) -492 (-451; -535) Gastroenterology 0.38 (0.34-0.42) 867 -52.4 (-48.2; -56.7) -454 (-418; -492) Angiology 0.35 (0.32-0.39) 1030 -55.6 (-51.3; -58.9) -573 (-528; -607) Rheumatology 0.47 (0.42-0.52) 830 -43.2 (-38.4; -48.2) -359 (-319; -400) Physiotherapy 1.17 (1.11-1.23) 2390 10.9 (7.2; 14.4) 261 (172; 344) Rehabilitation 1.68 (1.57-1.79) 1173 37.6 (32.4; 42.4) 441 (380; 497) Ophthalmology 1.09 (1.06-1.12) 8713 5.9 (4; 7.8) 514 (349; 680) ENT 0.71 (0.67-0.75) 2269 -21.6 (-18.4; -24.9) -490 (-417; -565) Orthopedics 0.52 (0.5-0.54) 4934 -38.4 (-36.5; -40.3) -1895 (-1801; -1988) Gynecology 0.86 (0.79-0.94) 738 -9.9 (-4.1; -15.2) -73 (-30; -112) HRPC 0.66 (0.6-0.72) 991 -25.8 (-20.8; -31) -256 (-206; -307) Surgical evaluation Eye Surgery 1.21 (1.17-1.26) 4458 13.3 (10.9; 16.2) 593 (486; 722) Gynecologic Surgery 0.87 (0.81-0.95) 989 -9.2 (-3.4; -13.7) -91 (-34; -135) Orthopedic Surgery 1.22 (1.02-1.47) 147 13.9 (1.3; 27.5) 20 (2; 40) General Surgery 0.91 (0.86-0.96) 1968 -6.3 (-2.7; -9.9) -124 (-53; -195) Plastic Surgery 1.19 (1.1-1.29) 859 12.1 (6.5; 17.9) 104 (56; 154) Vascular Surgery 0.87 (0.77-0.99) 359 -9.2 (-0.7; -16.8) -33 (-3; -60) Diagnostic tests Echocardiogram 0.66 (0.62-0.71) 1201 -25.8 (-21.6; -29.3) -310 (-259; -352) Spirometry‡ 0.96 (0.85-1.09) 385 -2.7 (-10.6; 5.9) -10 (-41; 23) Colonoscopy 0.76 (0.68-0.85) 510 -17.6 (-10.6; -24.1) -90 (-54; -123) EGD 0.49 (0.45-0.53) 1090 -41.3 (-37.4; -45.2) -450 (-408; -493) CPX test 0.72 (0.64-0.81) 431 -20.8 (-13.7; -27.5) -90 (-59; -119) Mammography‡ 0.98 (0.93-1.03) 2424 -1.4 (-4.8; 2) -34 (-116; 48) ‡: Non-statistically significant in the multivariate binomial models. All models had a p-value lower than 0.001, except those marked as ‡ All models were adjusted for first level covariates (consultation), i.e., patient’s age, patient’s Charlson Comorbidity Index, prenatal care consultation, time, and medical category; and for second level covariates – SDI and patient’s sex. Gynecology, Gynecologic Surgery and Mammography considered only women as population at risk. Table 3: Relative risk of a patient having a follow-up visit in PHC within three and six months after being referred to secondary care by Generalists (reference) or Family physicians. Rio de Janeiro, Brazil, 2015 – 2018. Medical Specialty 3 months 6 months 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) Orthopedics 1.83 (1.69; 1.97) 1.63 (1.50; 1.78) Gynecology 1.88 (1.57; 2.25) 1.78 (1.45; 2.18) HRPC‡ 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) Gynecologic Surgery 1.65 (1.42; 1.93) 1.55 (1.30; 1.84) Orthopedic 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) ‡: Non-statistically significant in the multivariate binomial models. All models had a p-value lower than 0.001, except those marked as ‡ All models were adjusted for first level covariates (consultation), i.e., patient’s age, patient’s Charlson Comorbidity Index, prenatal care consultation, time, and medical category; and for second level covariates – SDI and patient’s sex. Gynecology, Gynecologic Surgery and Mammography considered only women as population at risk. Cite Share Download PDF Status: Published Journal Publication published 01 Feb, 2022 Read the published version in BMJ Open → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-350593","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":17766695,"identity":"3834b843-0d11-4d20-a822-b317ff48508e","order_by":0,"name":"Adelson Guaraci Jantsch","email":"","orcid":"https://orcid.org/0000-0002-3012-5619","institution":"Universidade do Estado do Rio de Janeiro","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Adelson","middleName":"Guaraci","lastName":"Jantsch","suffix":""},{"id":17766696,"identity":"d81ca45f-75de-429b-990a-fe19ce77354a","order_by":1,"name":"Bo Burström","email":"","orcid":"","institution":"Department of Global Public Health at the Karolinska Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Bo","middleName":"","lastName":"Burström","suffix":""},{"id":17766697,"identity":"c6a89901-eb8d-4df5-a835-f8f75eae626d","order_by":2,"name":"Gunnar Nilsson","email":"","orcid":"https://orcid.org/0000-0001-7811-7602","institution":"Department of Neurobiology, Care Sciences and Society at the Karolinska Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gunnar","middleName":"","lastName":"Nilsson","suffix":""},{"id":17766698,"identity":"53740a5a-8c09-4a31-b21b-5a81796c4021","order_by":3,"name":"Antônio Ponce de Leon","email":"data:image/png;base64,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","orcid":"https://orcid.org/0000-0002-0704-5215","institution":"Department of Global Public Health at the Karolinska Institute","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Antônio","middleName":"Ponce","lastName":"de Leon","suffix":""}],"badges":[],"createdAt":"2021-03-21 15:44:59","currentVersionCode":1,"declarations":{"humanSubjects":true,"vertebrateSubjects":false,"conflictsOfInterestStatement":true,"humanSubjectEthicalGuidelines":true,"humanSubjectConsent":true,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false,"coiExplicitlySet":false},"doi":"10.21203/rs.3.rs-350593/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-350593/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1136/bmjopen-2021-051515","type":"published","date":"2022-02-01T18:23:24+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":18251488,"identity":"dc97e028-5194-48fc-968f-6dce4c04531f","added_by":"auto","created_at":"2022-02-15 18:23:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":236266,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-350593/v1/af39ddda-0b76-420a-8a1f-d3a4df742ca0.pdf"}],"financialInterests":"","formattedTitle":"\u003cp\u003eResidency training in family medicine and its impact on coordination and continuity of care: an analysis of referrals to secondary care in Rio de Janeiro\u003c/p\u003e","fulltext":[{"header":"Article Summary","content":"\u003cp\u003eStrengths and limitations of this study\u003c/p\u003e\n\u003cul\u003e\n\u003cli\u003eTo our knowledge, our article is the first study to address the impact of residency training in Family Medicine on promoting continuity and coordination between primary and secondary levels of healthcare in low- and middle-income countries.\u003c/li\u003e\n\u003cli\u003eWe drew on data from electronic health records, which reflect real-world clinical practice in the public primary care system in Brazil, and using mixed-effects models allowed us to take into account the correlation among consultations from the same patient.\u003c/li\u003e\n\u003cli\u003eOur analyses are limited to comparisons on patterns of referrals and follow-ups between Generalists and Family physicians and we cannot infer that patients are getting a better quality of care, having better quality of life or living longer.\u003c/li\u003e\n\u003cli\u003eHaving the full information about doctors\u0026rsquo; individual and educational characteristics would have helped to better measure the role that residency training in Family Medicine plays in promoting the attributes of PHC.\u003c/li\u003e\n\u003cli\u003eThe evidence raised from primary care and Family Medicine in Brazil can be better translated to other low- and middle-income countries that are facing similar troubles training the healthcare workforce and developing comprehensive primary health care systems.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eFor the last 40 years, improvements in Primary Health Care (PHC) were made worldwide due to the momentum created by the Alma-Ata declaration.\u003csup\u003e1\u003c/sup\u003e Many countries have achieved good results in creating and developing universal, accessible, and cost-effective PHC systems.\u003csup\u003e2,3\u003c/sup\u003e Today we have enough evidence supporting the notion that countries with strong PHC have better health indicators,\u003csup\u003e4\u003c/sup\u003e have reduced health inequalities,\u003csup\u003e5\u003c/sup\u003e and get better results while spending less money.\u003csup\u003e6\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eWith a large universal public health care system\u003csup\u003e7\u003c/sup\u003e and a successful history of community-based PHC,\u003csup\u003e8\u003c/sup\u003e Brazil has been portrayed as an example to be followed by low- and middle-income countries (LMIC). The Family Health Strategy (\u003cem\u003eEstrat\u0026eacute;gia de Sa\u0026uacute;de da Fam\u0026iacute;lia\u003c/em\u003e \u0026ndash; FHS) launched by the federal government in 1994, established a structure for PHC at the municipal level, providing financial resources for Family Health Teams\u0026nbsp;(FHT) formed by one physician, one nurse, one nurse assistant and four to six Community Health Workers (CHW) to provide care for up to 4000 people living in a given catchment area. This initiative has substantially reduced infant and neonatal mortality,\u003csup\u003e9\u003c/sup\u003e hospital admissions related to ambulatory-care sensitive conditions,\u003csup\u003e10\u0026ndash;13\u003c/sup\u003e and cardiovascular deaths.\u003csup\u003e14,15\u003c/sup\u003e Today 43,000 FHTs provide public-funded community-based PHC to 64% of the Brazilian population covered by the FHS.\u003csup\u003e16\u003c/sup\u003e However, many of these FHTs have only a nurse and CHW as health care providers and, when a doctor is available, it is very unlikely to be a trained Family Physician (FP).\u003c/p\u003e\n\u003cp\u003eDespite recent policies that have tried to boost the creation and growth of residency programs in Family Medicine (FM) in Brazil,\u003csup\u003e17,18\u003c/sup\u003e only 4.4% of the residency seats are dedicated to FM. With only 5,500 FP in the country\u003csup\u003e19\u003c/sup\u003e (1.4% of all medical specialists), FM is still not seen by policymakers and health managers as a necessary medical specialty for doctors working in PHC.\u003csup\u003e20\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eBetween 2008 and 2016, the Rio de Janeiro Municipal Health Department (RJ-MHD) expanded the FHS coverage from 3.5 to 70% in the city and allocated financial incentives for capacity building of human resources in FM.\u003csup\u003e21\u003c/sup\u003e A new FM residency training program was created and two established programs were expanded.\u003csup\u003e22,23\u003c/sup\u003e The rationale behind this initiative was that the investments made in residency training in FM (RTFM) would be translated into a more qualified provision of PHC with a wider scope of practice and better use of health resources.\u003csup\u003e24\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eMeasuring the impact that RTFM can make in promoting the attributes of PHC can be a hard task due to its characteristics, complexity and broad scope of practice, making it necessary to approach one aspect at a time. With FPs and Generalists (physicians without RTFM) working side by side for the last 10 years, the city of Rio de Janeiro can be a unique case study to address important research questions about the development of human resources for PHC in LMIC.\u003csup\u003e25\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThis study analyzes the impact of RTFM on two key attributes of PHC \u0026ndash; continuity and coordination of care \u0026ndash; by testing the hypothesis that trained FPs will be less likely to refer their patients to secondary care, but will be more likely to provide follow-up visits for patients once referred. It aims to compare FPs and Generalists performance by measuring (1) the risk of their patients being referred to SC for outpatient consultations and diagnostic tests; (2) the risk of those patients having a follow-up medical consultation in PHC within three and six months after being referred. Finally, it aims (3) to determine the population attributable fractions (PAFs) in a scenario in which all medical consultations and referrals were carried out by FPs.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eSTUDY DESIGN AND DATA SOURCE\u003c/p\u003e\n\u003cp\u003eWe conducted a retrospective longitudinal observational analysis of medical consultations in PHC and referrals to SC. This sample combines information from 504.940 patients (205.961 men and 298.508 women), 2.414.508 medical consultations, 284.754 referrals to SC, and 837 physicians working non-concurrently in one health district between January 2015 and December 2018. Patients\u0026rsquo; consent was not necessary since only anonymized information was used during the study and the RJ-MHD, the actual caretaker of this information, gave the consent to use this dataset for this research. The study was approved by the RJ-MHD research ethics board and it is registered under the number 03795118.0.0000.5279. It was conducted in accordance with the 466/12 resolution from the Brazilian National Health Council\u003csup\u003e26\u003c/sup\u003e and the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eEXPOSURE\u003c/p\u003e\n\u003cp\u003ePhysicians were divided into two categories: (1) Generalists - the reference category aggregating doctors without residency training in FM; and (2) Family physicians (FP) - graduated family physicians, FM preceptors and residents enrolled in the FM residency programs. Residents in FM were included in the same category as FP because they spend two years working 48 hours a week in a community-based primary care clinic under the full supervision of a senior FP (FM preceptor), sharing responsibilities for the same patients in one FHT. Every week they have learning sessions developed by the faculty members\u003csup\u003e23\u003c/sup\u003e using active learning methods\u003csup\u003e27,28\u003c/sup\u003e to address topics of FM and PHC, such as clinical reasoning, management of the most prevalent health conditions in PHC, communication skills, evidence based-medicine, PHC and health care systems, vulnerable populations, elderly care, multimorbidity, polypharmacy, among others.\u003csup\u003e29\u003c/sup\u003e They also have rotations in maternal care, pediatrics, internal medicine, and emergency care. These activities were designed in line with the National Committee for Medical Residencies (CNRM)\u003csup\u003e30\u003c/sup\u003e and with the Brazilian Society of Family and Community Medicine (SBMFC).\u003csup\u003e31\u003c/sup\u003e Information about other forms of post-graduate training were not available in the database and were not taken into account, nor the number of years in practice for any doctor.\u003c/p\u003e\n\u003cp\u003eINDEPENDENT VARIABLES\u003c/p\u003e\n\u003cp\u003eEvery patient contributed to the models with individual information \u0026ndash; (1) age (linear), (2) sex, and (3) the Charlson Comorbidity Index\u003csup\u003e32\u003c/sup\u003e \u0026ndash; and contextual information \u0026ndash; (4) the Social Development Index (SDI). The SDI is a linear scale combining information about sanitation, schooling, income, and housing conditions from every household in the FHT catchment area, representing the grade of social development of a neighborhood.\u003csup\u003e33\u003c/sup\u003e Hence, patients registered in the same FHT have the same SDI. It varies from 0 (least developed) to 1 (most developed).\u003c/p\u003e\n\u003cp\u003eCharlson Comorbidity Index\u003csup\u003e32\u003c/sup\u003e was used to add information about patients\u0026rsquo; morbidity burden to the models, assuming that those with more chronic conditions would be more likely to be referred to secondary care and have follow-up consultations after being referred.\u003c/p\u003e\n\u003cp\u003eTime effects were regarded using dummy variables for months and years in all models. A dummy variable was used to include information identifying if the consultation was a prenatal care visit or not.\u003c/p\u003e\n\u003cp\u003eAll clinics in this sample have the same physical structure, offices equipped with computer, printer, medical equipment, room for small surgical procedures, the same arsenal of laboratory tests and medicines in the pharmacy, and the same type of human resources available: nurses, technicians, dentists, pharmacists, and managers. The availability of medical specialties in SC and diagnostics tests, and the referral procedures are the same for all doctors and clinics in the sample. The distribution of doctors among different clinics and FHT didn\u0026rsquo;t follow any criteria that could interfere in the relationship between the medical categories, the population assisted, and the study outcomes.\u003c/p\u003e\n\u003cp\u003eOUTCOMES\u003c/p\u003e\n\u003cp\u003eReferrals to SC were divided into three groups: (1) outpatient consultations for ambulatory care; (2) surgical evaluation; and (3) diagnostics tests. They were considered as a binary event (referred versus non-referred). To estimate the relative risks (RR) of having a follow-up visit in the PHC clinic after the referral, only patients who had been referred to the specific specialty under analysis were considered. Follow up visits were also considered binary events categorized as the patient having or not having one medical consultation (a) 90 days after the referral or (b) 180 days after the referral. The 32 most commonly requested medical specialties consultations and diagnostics tests in our dataset were used to perform this analysis.\u003c/p\u003e\n\u003cp\u003eComparing both the risk of a patient being referred to SC and the risk of having a follow-up visit by doctors with different types of training can bring us evidence about the effect that RTFM has on promoting both a more effective healthcare for the patient in primary care and a better continuity of care and coordination between primary and secondary levels of care. This notion is aligned with the definition of FM from the Brazilian,\u003csup\u003e31\u003c/sup\u003e Canadian\u003csup\u003e34\u003c/sup\u003e and European\u003csup\u003e35\u003c/sup\u003e curricula for FM, i.e., that experts in FM \u0026ldquo;are skilled clinicians that are capable of managing a full range of health conditions\u0026rdquo;, \u0026ldquo;make efficient use of health care resources through coordinating care\u0026rdquo; and \u0026ldquo;are responsible for the provision of longitudinal continuity of care as determined by the needs of the patient.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003eSTATISTICAL ANALYSES\u003c/p\u003e\n\u003cp\u003eMultilevel multivariate binomial regression models were used to estimate the RRs of patients being referred to SC in one medical consultation and patients having a follow-up visit in three and six months after being referred to SC, according to the medical category of the doctor in charge. A hierarchical data structure was created with consultations from the same patient clustered and ordered per each individual patient, taking into account the correlation among consultations from the same patient.\u003c/p\u003e\n\u003cp\u003eEach outcome was analyzed individually. Mammography, Gynecology and Gynecologic Surgery entailed just women and high-risk prenatal care (HRPC) entailed only pregnant women. Models were adjusted for first level covariates (consultation), i.e., patient\u0026rsquo;s age, patient\u0026rsquo;s Charlson Comorbidity Index, prenatal care consultation, time, and medical category; and for second level covariates \u0026ndash; SDI and patient\u0026rsquo;s sex.\u003c/p\u003e\n\u003cp\u003eVariance partition coefficients were calculated for all adjusted models in order to explore the proportion of the variance attributed to the second level, i.e., the variance attributed to patients characteristics.\u003csup\u003e36\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003ePAF for each requested service was calculated using the RR from the multivariate regression models to estimate the impact in the number of referrals requested per year in the same health care district if all medical consultations were performed by trained FPs.\u003csup\u003e37,38\u003c/sup\u003e Data processing and statistical analysis were performed using R version 3.6.2 and lme4 package.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA similar proportion of women (2/3) and men (1/3) with a small difference for age and SDI distributions was seen by FPs and generalists. Each subgroup had patients from the most affluent (SDI = 0.689) and the least affluent areas (SDI = 0.416). Although doctors in the sample had not necessarily worked throughout the entire study period, the proportion in the sample represents the distribution of the categories among 30 clinics and 196 FHT (Table 1).\u003c/p\u003e\n\u003cp\u003eAmbulatory care services were less likely to be requested by FPs, except for Ophthalmology, Physiotherapy, and Rehabilitation, which were requested more frequently by FPs (Table 2). Surgical specialties tended to be requested less often by FPs to ambulatory care in ENT, Orthopedics, General Surgery, Gynecology, Vascular Surgery, and Urology. When the referral was related to surgical evaluation in Plastic Surgery, Orthopedic Surgery or Eye Surgery, FPs tended to refer their patients more frequently.\u003c/p\u003e\n\u003cp\u003eDiagnostic tests, such as Colonoscopy, Echocardiogram, EGD, and CPX tests were less frequently requested by FPs. Spirometry and Mammography were the only exceptions. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients referred to SC by FPs were at a higher risk of having a follow-up visit in primary care after three and six months than those referred by Generalists for almost every service requested. HRPC was the only ambulatory care service that FPs and Generalists presented similar risk of a patient having a follow-up visit in the three and six-months period (Table 3).\u003c/p\u003e\n\u003cp\u003eIn a hypothetical scenario where all medical consultations were performed by FPs, all medical specialties would experience a decrease in demand for ambulatory care, with Angiology being, in relative terms, the most affected \u0026ndash; PAF 55.6% (95%CI 51.3%; 58.9%) \u0026ndash; and Dermatology and Orthopedics having the biggest absolute reduction, with 1532 (95%CI 1458; 1602) and 1696 (95%CI 1612; 1780) fewer requests every year. Contrarily, replacing Generalists by FPs would increase by 37.6% (95% CI 32.4%; 42.4%) the demand for Rehabilitation services and by 13.3% (95% CI 10.9%; 16.2%) the demand for Eye Surgery (Table 2). Surgical specialties such as Plastic Surgery and Orthopedic Surgery would have an increase in demand for consultations, while ENT and General Surgery would have a decrease in demand. For these two surgical specialties there would be 439 (95%CI 374; 506) and 111 (95%CI 48; 174) fewer requests every year, respectively.\u003c/p\u003e\n\u003cp\u003eAt the same time, the demand for most of the diagnostics tests would decrease, and 403 (95% CI 365; 441) fewer EGD tests and 277 (95% CI 232; 315) fewer Echocardiograms would be requested every year.\u003c/p\u003e\n\u003cp\u003eAlthough the inclusion of the age, sex, SDI, time, and the CCI in the models slightly changed the effect sizes and confidence intervals of the main exposure, these variables were kept in the models that provided the RRs and PAFs reported here. Variance-inflation factors were always below 3 in all models.\u003c/p\u003e\n\u003cp\u003eThe partition coefficients of variance (VPC) showed that the proportion of variance attributed to the second level (patient characteristics) is more important for the occurrence of a referral than for the occurrence of a follow-up visit, with a consistent pattern for all types of services studied. The proportion of the variance attributed to the patient level for Pulmonology, Endocrinology and Spirometry, for example, are up to 53%, 40% and 43%. At the same time, for the risks of follow-up visits for those patients referred to these three services, no more than 0.05%, 0.03% and 0.01% of the variance can be attributed to differences between patients.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis research has taken a non-judgmental approach to the doctor-patient clinical encounter. It considers that every doctor in this sample has made the best possible decisions to provide the most appropriate health care to their patients and the comparisons between FPs and Generalists aim solely to analyze the patterns behind the numbers that represent the impact of having two extra years of training to work in primary care.\u003c/p\u003e\n\u003cp\u003eOur study findings highlight a significant distinction in the types of consultation services that are more or less likely to be requested by FPs. When FPs were in charge of the consultation, the number of referrals in half of the ambulatory care specialties decreased by more than 50%. Services that did not require equipment or special skills other than clinical reasoning or general medical skills also had a significantly lower risk. On the other hand, Ophthalmology, Physiotherapy, and Rehabilitation \u0026ndash; ambulatory care services that make use of special equipment and demand specific skills to be performed \u0026ndash; were more often requested by FPs. (Table 2).\u003c/p\u003e\n\u003cp\u003eBoth Physiotherapy (reserved for minor musculoskeletal injuries) and Rehabilitation (motor, neurological, intellectual, and respiratory rehabilitation, as well as orthosis confection, prosthesis, and stoma care) are services that require specific biomedical technology and skilled professionals to be performed. These are usually available at the secondary level of the health care system. At the same time, Ophthalmology, Plastic surgery (exclusively reconstructive procedures), and Eye surgery followed the same pattern, and patients were more frequently referred by FPs.\u003c/p\u003e\n\u003cp\u003ePart of the lower risk for requesting a referral to ambulatory care services among FPs can be explained by the learning opportunities that residents have during the two years of training. As part of the learning activities,\u003csup\u003e22\u003c/sup\u003e residents have case discussions with Dermatologists and Psychiatrists every other week at the clinic. They can book the patients they are facing difficulties to have a joint consultation with a specialist, sharing decisions about diagnostics and management, and discussing the resident\u0026rsquo;s educational needs, based on that case.\u003csup\u003e39\u003c/sup\u003e Biopsies and small procedures are mostly performed at the clinic as well. Due to its high prevalence, residents are trained in chronic pain management to deal with myofascial pain, to perform dry needling to relief trigger points, and simple physiotherapy exercises that can be performed by the patient alone or with the supervision of the physical educator at the local community gym available in every primary care clinic. Without the supervision of those specialists and the focused training in chronic pain management, FP would probably request referrals to Dermatology, Psychiatry, and Physiotherapy more frequently.\u003c/p\u003e\n\u003cp\u003eHowever, the vast majority of the patients, including cases involving skin lesions and mental health issues, are regularly managed by the FHT with the help of a preceptor in FM. Cases that could also have been referred to a General Surgeon, such as lipomas, sebaceous cysts, and skin biopsies, or Vascular Surgery, such as chronic venous insufficiency, are included in the residents\u0026rsquo; training, making them more competent to manage these conditions in PHC. On the other hand, Plastic surgery (exclusively reconstructive procedures) is another specialty that needs trained professionals to be performed and FPs are more likely to request it.\u003c/p\u003e\n\u003cp\u003eLearning how to manage the most prevalent health conditions in PHC during RTFM can increase both the awareness about the conditions and the built-in capacity to manage them. The former makes FPs more prepared to recognize and diagnose the condition; the latter provides the necessary tools to treat it. This can explain why FPs are less inclined to request diagnostic tests for their patients. Diagnostic tests are part of the clinical reasoning process and if residents learn how to use them with an evidence-based approach, it is more likely that they will more cautiously select the patients that need them. This is not a new concern in PHC\u003csup\u003e40\u003c/sup\u003e and is aligned with the Choosing Wisely\u003csup\u003e41\u003c/sup\u003e and the Quaternary Prevention\u003csup\u003e42\u003c/sup\u003e initiatives, that exert a strong influence in the FM community by calling the attention of doctors and patients to the potential harms that unnecessary tests, treatments, and procedures can make. This requires a balanced approach to healthcare that takes into account issues around the underuse and the overuse of tests and/or treatments. Our study shows the distinction between services that patients are less likely from those they are more likely to be referred by FPs. This gives us a clue about what has been requested too much (Cardiology, Endocrinology, Allergology) and what has been requested too little (Eye surgery, Orthopedic surgery, Physiotherapy) in the public PHC system in Rio de Janeiro.\u003c/p\u003e\n\u003cp\u003eIn regard to the risk of occurrence of a follow-up visit being consistently higher among FPs, one could argue that the turnover and the shortage of doctors \u0026ndash; two common issues in the Brazilian PHC \u0026ndash; could have influenced the occurrence of this event. We cannot assure that retention in the same FHT was the same for every category. But if FPs were more inclined to stay working in the same FHT, we would not see a similar risk of follow-up for women referred to HRPC \u0026ndash; RR 1.16; 95%CI 0.93-1.44 in three months and RR 0.92; 95%CI 0.71-1.19 in six months. Pregnant women have regular medical visits in PHC every month in the first semester, every two weeks in the last trimester, and every week in the last month. Of the 3547 women referred to that service (885 by FPs and 2662 by generalists), similar proportions had a follow-up visit within three (85.6% by FPS vs. 83.6% by generalists) and six months (89.5% by FPs vs. 90.2% by generalists). Comparing to Cardiology, where FPs were more likely to follow-up their patients in three months (RR 1.86; 95% CI 1.62-2.14) and in six months (RR 1.74; 95%CI 1.48-2.04), only 53.9% and 71.3% of those referred by Generalists had a follow-up visit in three and six months, while FPs have followed-up 68.3% and 81.3% of their referred patients, respectively.\u003c/p\u003e\n\u003cp\u003eTable 2 highlights in absolute numbers how much change this intervention can make. Some results show a big difference in terms of distribution and provision of specialized care since some of the services would have their demand decreased by more than 50%. The investments made by the RJ-MHD to promote RTFM have already achieved some results, and its impact could be extended to the whole population if a feasible and sustainable expansion plan is put in place. This expansion should account for several variables that were not explored in this study and may rely not only on political will but on individual aspirations and preferences as well.\u003c/p\u003e\n\u003cp\u003eThe variance partition coefficients show us that the proportion of the variance attributed to the patient has major importance in the risk of a referral to SC being requested, but little influence on the occurrence of a follow-up visit. Although patients\u0026rsquo; information has a major influence on the variance, FPs (a first level variable) reduce significantly the risk of a patient being referred. The little influence that patients\u0026rsquo; information has on the occurrence of a follow-up visit demands additional studies exploring other aspects affecting it. If aspects related to the physician in charge (FP or generalist) can better explain part of the variance, it would provide another piece of evidence that RTFM improves coordination and, in this case, continuity of care.\u003c/p\u003e\n\u003cp\u003eFinally, the impact of RTFM cannot be summarized exclusively in terms of referrals to SC. Residents in FM are not trained to perform one task, but to take care of people from cradle to grave.\u003csup\u003e43\u003c/sup\u003e During two years of RTFM they develop clinical, relational, scholar, and managerial competencies to provide the best patient-centered care in a community.\u003csup\u003e31,44,45\u003c/sup\u003e They are not trained exclusively to decide if a patient should or should not be referred to SC. This is just a detail of a much larger learning process whose effect goes beyond the RR measured in this study. That being said, it is reasonable to believe that RTFM must have an impact that goes beyond changing patterns of referrals to SC, affecting positively the quality of care delivered, and outcomes related to patients\u0026rsquo; morbidity and mortality. Without a doubt, further research must be performed testing this hypothesis.\u003c/p\u003e"},{"header":"Strengths and Limitations","content":"\u003cp\u003eEvaluating PHC is a hard task and we tried to do it by aiming two specific aspects of PHC \u0026ndash; professional training and referrals to SC. The first is a complex intervention and the second a surrogate outcome. Endpoint outcomes, such as hospital-admissions, quality of life, quality of care, patients\u0026rsquo; satisfaction, survival, and \u003cem\u003eabsenteeism\u003c/em\u003e\u0026nbsp;in\u0026nbsp;the referral \u003cem\u003econsultations \u003c/em\u003eshould be studied in the future to draw a clearer dimension of the impact measured in this study. As mentioned before, having the full information about doctors\u0026rsquo; individual and educational characteristics would have helped to better measure the role that training FM plays in the attributes of PHC.\u003c/p\u003e\n\u003cp\u003eApart from these limitations, empirical evidence about a real experience from a middle-income country can be better translated to similar countries that face the same difficulties to develop their PHC systems.\u003csup\u003e46\u003c/sup\u003e This kind of evidence can help to promote the development of FM in countries where PHC is still very incipient,\u003csup\u003e47\u003c/sup\u003e and FM is often not recognized as a medical specialty.\u003csup\u003e48,49\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eTraining doctors to develop the competencies needed to manage a broad scope of health conditions in PHC is one of the main goals of residency programs in FM. As a public health intervention, RTFM changes the pattern of referrals commonly seen in PHC when only Generalists take care of the population. In summary, it makes FPs more competent to retain those health conditions that can be properly managed in primary care and, at the same time, makes them more capable of detecting health issues that require specific biomedical technologies and skills, increasing the demand for those services. Besides, it increases the chances of a patient having a follow-up visit, improving coordination and continuity of care of their FHT. This is a real change not only in terms of comprehensiveness and coordination of care but also in costs paid by health systems, families, and society. Policymakers should look closely at the findings described in this article and consider carefully that investments in RTFM can make their PHC systems more comprehensive, with better coordination and continuity of care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eACKNOWLEDGMENTS\u003c/p\u003e\n\u003cp\u003eWe are very grateful to the colleagues at the Rio de Janeiro Municipal Health Department that gave us support for this research and provided the dataset we used to perform the study. We would also like to thank Dr. Armando Norman for his feedback on the writing and for his suggestions in the discussion section, especially regarding Quaternary Prevention.\u003c/p\u003e\n\u003cp\u003ePATIENT AND PUBLIC INVOLVMENT\u003c/p\u003e\n\u003cp\u003ePatients and/or the public WERE NOT involved in the design, or conduct, or reporting, or dissemination plans of this research.\u003c/p\u003e\n\u003cp\u003ePATIENT CONSENT FOR PUBLICATION\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot required.\u003c/p\u003e\n\u003cp\u003eETHICS APPROVAL\u003c/p\u003e\n\u003cp\u003eThe study was approved by the RJ-MHD research ethics board and it is registered under the number 03795118.0.0000.5279. It was conducted in accordance with the 466/12 resolution from the Brazilian National Health Council\u003csup\u003e26\u003c/sup\u003e and the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eProvenance and peer review Not commissioned; externally peer reviewed.\u003c/p\u003e\n\u003cp\u003eData availability statement No additional data are available as this work draws on de-identified data provided by patients as a part of their routine primary care.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFUNDING\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no funding from any source supporting this research.\u003c/p\u003e\n\u003cp\u003eCONFLICTS OF INTEREST\u003c/p\u003e\n\u003cp\u003eThe authors declare that there is no conflict of interest in publishing this article or in conducting this study.\u003c/p\u003e\n\u003cp\u003eDATA STATEMENT\u003c/p\u003e\n\u003cp\u003eAll data used in this research represent patients, health care providers and medical consultations information that are under the protection of the Rio de Janeiro Municipal Health Department. These data can be obtained from the Rio de Janeiro Superintendence of Primary Care ([email protected]) under the authorization of the Rio de Janeiro Municipal Health Department Research Ethics Committee ([email protected]).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAUTHOR STATEMENT\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was designed and conceived by AGJ, BB, GN, APDL. AGJ conducted the first data analysis and wrote the first draft of this manuscript. AGJ and APDL performed the multilevel analysis. AGJ, BB, GN and APDL discussed the results from the multilevel analysis and decided together what were the most relevant information to be reported at the manuscript. BB, GN and APDL reviewed and made comments on the manuscript. AGJ, BB, GN and APDL wrote and have agreed to submit the final version of the manuscript\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWHO-Unicef. Declaration of Alma-Ata. \u003cem\u003eInt Conf Prim Heal Care\u003c/em\u003e. 1978.\u003c/li\u003e\n\u003cli\u003eWatkins DA, Yamey G, Sch\u0026auml;ferhoff M, et al. The Lancet Commissions Alma-Ata at 40 years : reflections from the Lancet Commission on Investing in Health. \u003cem\u003eLancet\u003c/em\u003e. 2018;392(10156):1434-1460. doi:10.1016/S0140-6736(18)32389-4\u003c/li\u003e\n\u003cli\u003eRohde J, Cousens S, Chopra M, et al. 30 years after Alma-Ata: has primary health care worked in countries? \u003cem\u003eLancet\u003c/em\u003e. 2008;372(9642):950-961. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(08)61405-1/fulltext.\u003c/li\u003e\n\u003cli\u003eStarfield B. Primary Care and Health: A Cross-National Comparison. \u003cem\u003eJAMA J Am Med Assoc\u003c/em\u003e. 1991. doi:10.1001/jama.1991.03470160100040\u003c/li\u003e\n\u003cli\u003eStarfield B, Shi L, Macinko J. 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Rio de Janeiro: SBMFC; 2016. http://portalmultiplica.org/.\u003c/li\u003e\n\u003cli\u003eMinist\u0026eacute;rio da Educa\u0026ccedil;\u0026atilde;o. Comiss\u0026atilde;o Nacional de Resid\u0026ecirc;ncia M\u0026eacute;dica. http://portal.mec.gov.br/residencias-em-saude/residencia-medica. Published 2020.\u003c/li\u003e\n\u003cli\u003eSBMFC. Curr\u0026iacute;culo Baseado em Compet\u0026ecirc;ncias para Medicina de Fam\u0026iacute;lia e Comunidade. Curr\u0026iacute;culo Baseado em Compet\u0026ecirc;ncias para Medicina de Fam\u0026iacute;lia e Comunidade. http://www.sbmfc.org.br/wp-content/uploads/media/Curriculo Baseado em Competencias(1).pdf. Published 2015. Accessed February 27, 2020.\u003c/li\u003e\n\u003cli\u003eCharlson M, Szatrowski TP, Peterson J, Gold J. 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CRC Press; 2001.\u003c/li\u003e\n\u003cli\u003eWilkin D, Smith AG. Variation in general practitioners\u0026rsquo; referral rates to consultants. \u003cem\u003eJ R Coll Gen Prctitioners\u003c/em\u003e. 1987;(August):0-3.\u003c/li\u003e\n\u003cli\u003eLevinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA. \u0026lsquo;Choosing Wisely\u0026rsquo;: a growing international campaign. \u003cem\u003eBMJ\u003c/em\u003e. 2014;(December):1-9. doi:10.1136/bmjqs-2014-003821\u003c/li\u003e\n\u003cli\u003eJamoulle M. 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Family medicine around the world: overview by region. \u003cem\u003eCan Fam Physician\u003c/em\u003e. 2017;63(June 2017):436-441.\u003c/li\u003e\n\u003cli\u003ePonka D. The Besrour Papers: Seeking evidence for family medicine. \u003cem\u003eAfr J Prim Heal Care Fam Med\u003c/em\u003e. 2017:1-2. doi:10.4102/phcfm.v9i1.1559\u003c/li\u003e\n\u003cli\u003ePonka D, Rouleau K, Arya N, et al. Developing the evidentiary basis for family medicine in the global context. \u003cem\u003eCan Fam physician Médecin Fam Can\u003c/em\u003e. 2015;61(7):596-600.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003ctable border=\"1\" width=\"100%\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"10\" width=\"100%\"\u003e\n\u003cp\u003eTable 1: Number of medical consultations and patients\u0026rsquo; characteristics according to each medical category in the study sample. Rio de Janeiro, Brazil, 2015 \u0026ndash; 2018.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd rowspan=\"2\" width=\"14%\"\u003e\n\u003cp\u003eMedical category\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"9%\"\u003e\n\u003cp\u003eNumber of doctors \u0026ndash; N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"14%\"\u003e\n\u003cp\u003eConsultations \u0026ndash; N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"14%\"\u003e\n\u003cp\u003eReferrals per 100 consultations\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd rowspan=\"2\" width=\"7%\"\u003e\n\u003cp\u003eSDI -mean (SD)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" width=\"19%\"\u003e\n\u003cp\u003ePatients age (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"2\" width=\"20%\"\u003e\n\u003cp\u003ePatients according to sex \u0026ndash; N (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"6%\"\u003e\n\u003cp\u003e\u0026lt; 18\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"7%\"\u003e\n\u003cp\u003e\u0026gt; 18 \u0026amp; \u0026lt; 45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"6%\"\u003e\n\u003cp\u003e\u0026gt; 45\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003eWomen\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"9%\"\u003e\n\u003cp\u003emen\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003eGeneralists\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"9%\"\u003e\n\u003cp\u003e633 (75.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e1.629.235 (67.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e12.7\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"7%\"\u003e\n\u003cp\u003e0.573 (0.03)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"6%\"\u003e\n\u003cp\u003e21.3\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"7%\"\u003e\n\u003cp\u003e31.8\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"6%\"\u003e\n\u003cp\u003e46.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e1.067.212 (65.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"9%\"\u003e\n\u003cp\u003e562.023\u003c/p\u003e\n\u003cp\u003e(34.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003eFamily physicians\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"9%\"\u003e\n\u003cp\u003e204\u003c/p\u003e\n\u003cp\u003e(24.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e785.273 (32.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"14%\"\u003e\n\u003cp\u003e9.9\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"7%\"\u003e\n\u003cp\u003e0.585 (0.03)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"6%\"\u003e\n\u003cp\u003e18.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"7%\"\u003e\n\u003cp\u003e34.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"6%\"\u003e\n\u003cp\u003e47.0\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"11%\"\u003e\n\u003cp\u003e517.813 (65.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"9%\"\u003e\n\u003cp\u003e267.460\u003c/p\u003e\n\u003cp\u003e(34.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"100%\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"100%\"\u003e\n\u003cp\u003eTable 2: Relative risk of a patient being referred to SC in one medical consultation in PHC according to the medical category of the doctor in charge \u0026ndash; Generalists (reference) and Family physicians. Rio de Janeiro, Brazil, 2015 \u0026ndash; 2018.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eMedical Specialty\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003eFamily physicians\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003eAverage number of referrals per year\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003ePopulation attributable fraction % (95% CI)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003eChange (and 95% CI) in the number of referrals per year if all doctors were family physicians\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"100%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Ambulatory care\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eCardiology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.4 (0.38-0.43)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e2008\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-50.3 (-47.2; -52.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-1010 (-948; -1052)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eNeurology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.5 (0.47-0.53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1835\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-40.3 (-37.4; -43.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-740 (-686; -793)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003ePsychiatry\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.45 (0.4-0.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e897\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-45.2 (-40.3; -50.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-405 (-361; -451)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eDermatology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.49 (0.47-0.51)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e4144\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-41.3 (-39.3; -43.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-1711 (-1629; -1790)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003ePulmonology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.54 (0.48-0.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e903\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-36.5 (-31; -42.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-330 (-280; -381)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eInfectious Diseases\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.74 (0.63-0.87)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e290\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-19.2 (-9.2; -28.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-56 (-27; -82)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eUrology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.57 (0.54-0.61)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1762\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-33.7 (-30.1; -36.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-594 (-530; -643)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eAllergology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.54 (0.47-0.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e480\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-36.5 (-31; -43.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-175 (-149; -207)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eNephrology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.63 (0.57-0.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e603\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-28.4 (-22.4; -33.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-171 (-135; -203)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eEndocrinology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.42 (0.38-0.46)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1021\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-48.2 (-44.2; -52.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-492 (-451; -535)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eGastroenterology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.38 (0.34-0.42)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e867\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-52.4 (-48.2; -56.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-454 (-418; -492)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eAngiology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.35 (0.32-0.39)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1030\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-55.6 (-51.3; -58.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-573 (-528; -607)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eRheumatology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.47 (0.42-0.52)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e830\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-43.2 (-38.4; -48.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-359 (-319; -400)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003ePhysiotherapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1.17 (1.11-1.23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e2390\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e10.9 (7.2; 14.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e261 (172; 344)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eRehabilitation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1.68 (1.57-1.79)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1173\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e37.6 (32.4; 42.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e441 (380; 497)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eOphthalmology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1.09 (1.06-1.12)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e8713\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e5.9 (4; 7.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e514 (349; 680)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eENT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.71 (0.67-0.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e2269\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-21.6 (-18.4; -24.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-490 (-417; -565)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eOrthopedics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.52 (0.5-0.54)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e4934\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-38.4 (-36.5; -40.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-1895 (-1801; -1988)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eGynecology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.86 (0.79-0.94)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e738\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-9.9 (-4.1; -15.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-73 (-30; -112)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eHRPC\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.66 (0.6-0.72)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e991\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-25.8 (-20.8; -31)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-256 (-206; -307)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"100%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Surgical evaluation\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eEye Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1.21 (1.17-1.26)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e4458\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e13.3 (10.9; 16.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e593 (486; 722)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eGynecologic Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.87 (0.81-0.95)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e989\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-9.2 (-3.4; -13.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-91 (-34; -135)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eOrthopedic Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1.22 (1.02-1.47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e147\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e13.9 (1.3; 27.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e20 (2; 40)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eGeneral Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.91 (0.86-0.96)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1968\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-6.3 (-2.7; -9.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-124 (-53; -195)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003ePlastic Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1.19 (1.1-1.29)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e859\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e12.1 (6.5; 17.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e104 (56; 154)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eVascular Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.87 (0.77-0.99)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e359\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-9.2 (-0.7; -16.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-33 (-3; -60)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"100%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Diagnostic tests\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eEchocardiogram\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.66 (0.62-0.71)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1201\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-25.8 (-21.6; -29.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-310 (-259; -352)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eSpirometry\u0026Dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.96 (0.85-1.09)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e385\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-2.7 (-10.6; 5.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-10 (-41; 23)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eColonoscopy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.76 (0.68-0.85)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e510\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-17.6 (-10.6; -24.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-90 (-54; -123)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eEGD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.49 (0.45-0.53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e1090\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-41.3 (-37.4; -45.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-450 (-408; -493)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eCPX test\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.72 (0.64-0.81)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e431\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-20.8 (-13.7; -27.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-90 (-59; -119)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eMammography\u0026Dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e0.98 (0.93-1.03)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"16%\"\u003e\n\u003cp\u003e2424\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-1.4 (-4.8; 2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"21%\"\u003e\n\u003cp\u003e-34 (-116; 48)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" width=\"100%\"\u003e\n\u003cp\u003e\u0026Dagger;: Non-statistically significant in the multivariate binomial models.\u003c/p\u003e\n\u003cp\u003eAll models had a p-value lower than 0.001, except those marked as \u0026Dagger;\u003c/p\u003e\n\u003cp\u003eAll models were adjusted for first level covariates (consultation), i.e., patient\u0026rsquo;s age, patient\u0026rsquo;s Charlson Comorbidity Index, prenatal care consultation, time, and medical category; and for second level covariates \u0026ndash; SDI and patient\u0026rsquo;s sex. Gynecology, Gynecologic Surgery and Mammography considered only women as population at risk.\u0026nbsp;\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" width=\"100%\"\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"100%\"\u003e\n\u003cp\u003eTable 3: Relative risk of a patient having a follow-up visit in PHC within three and six months after being referred to secondary care by Generalists (reference) or Family physicians. Rio de Janeiro, Brazil, 2015 \u0026ndash; 2018.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eMedical Specialty\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e3 months\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e6 months\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"100%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Ambulatory care\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eCardiology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.86 (1.62; 2.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.74 (1.48; 2.04)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eNeurology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.78 (1.56; 2.03)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.74 (1.49; 2.02)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003ePsychiatry\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e2.15 (1.75; 2.64)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e2.05 (1.62; 2.61)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eDermatology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.42 (1.30; 1.55)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.45 (1.32; 1.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003ePulmonology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.73 (1.41; 2.11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.76 (1.39; 2.23)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eInfectious Diseases\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e2.02 (1.47; 2.77)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.55 (1.11; 2.17)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eUrology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.74 (1.54; 1.98)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.79 (1.55; 2.06)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eAllergology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.89 (1.47; 2.41)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.97 (1.50; 2.58)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eNephrology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e2.17 (1.74; 2.71)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.89 (1.45; 2.46)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eEndocrinology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.74 (1.44; 2.11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.47 (1.19; 1.82)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eGastroenterology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.77 (1.42; 2.20)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.92 (1.48; 2.50)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eAngiology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.40 (1.15; 1.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.40 (1.12; 1.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eRheumatology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.86 (1.52; 2.28)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.58 (1.25; 1.98)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003ePhysiotherapy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.73 (1.58; 1.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.72 (1.54; 1.92)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eRehabilitation\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.73 (1.52; 1.97)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.55 (1.34; 1.80)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eOphthalmology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.62 (1.54; 1.70)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.57 (1.49; 1.66)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eENT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.70 (1.53; 1.89)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.52 (1.36; 1.71)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eOrthopedics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.83 (1.69; 1.97)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.63 (1.50; 1.78)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eGynecology\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.88 (1.57; 2.25)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.78 (1.45; 2.18)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eHRPC\u0026Dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.16 (0.93; 1.44)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e0.92 (0.71; 1.19)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"100%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; Surgical evaluation\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eEye Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.62 (1.51; 1.74)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.45 (1.34; 1.58)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eGynecologic Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.65 (1.42; 1.93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.55 (1.30; 1.84)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eOrthopedic Surgery\u0026Dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.48 (1.01; 2.16)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.22 (0.81; 1.82)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eGeneral Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.74 (1.56; 1.93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.64 (1.45; 1.84)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003ePlastic Surgery\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.51 (1.30; 1.77)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.43 (1.21; 1.68)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eVascular Surgery\u0026Dagger;\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.24 (0.96; 1.60)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.51 (1.14; 2.01)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"100%\"\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; Diagnostic tests\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eEchocardiogram\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.91 (1.64; 2.23)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.53 (1.28; 1.84)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eSpirometry\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.48 (1.15; 1.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.65 (1.22; 2.23)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eColonoscopy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e1.72 (1.38; 2.15)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.43 (1.12; 1.85)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eEGD\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e2.04 (1.71; 2.43)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e2.17 (1.75; 2.68)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eCPX test\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e2.02 (1.58; 2.58)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.70 (1.27; 2.28)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd width=\"23%\"\u003e\n\u003cp\u003eMammography\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"40%\"\u003e\n\u003cp\u003e2.03 (1.84; 2.24)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd width=\"36%\"\u003e\n\u003cp\u003e1.93 (1.72; 2.17)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"3\" width=\"100%\"\u003e\n\u003cp\u003e\u0026Dagger;: Non-statistically significant in the multivariate binomial models.\u003c/p\u003e\n\u003cp\u003eAll models had a p-value lower than 0.001, except those marked as \u0026Dagger;\u003c/p\u003e\n\u003cp\u003eAll models were adjusted for first level covariates (consultation), i.e., patient\u0026rsquo;s age, patient\u0026rsquo;s Charlson Comorbidity Index, prenatal care consultation, time, and medical category; and for second level covariates \u0026ndash; SDI and patient\u0026rsquo;s sex. Gynecology, Gynecologic Surgery and Mammography considered only women as population at risk.\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"Universidade do Estado do Rio de Janeiro","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Primary Health Care, Family Practice, Health Workforce, Developing Countries","lastPublishedDoi":"10.21203/rs.3.rs-350593/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-350593/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eObjective: To measure the effect that Residency Training in Family Medicine (RTFM) has on continuity and coordination of care. \u003c/p\u003e\u003cp\u003eDesign: Observational cohort study using electronic health records.\u003c/p\u003e\u003cp\u003eSetting: Rio de Janeiro, Brazil, public primary care system.\u003c/p\u003e\u003cp\u003eParticipants: 504940 patients, 633 generalists (physicians without RTFM) and 204 Family physicians (FP – doctors with two years of RTFM) from one health district between January 2015 and December 2018.\u003c/p\u003e\u003cp\u003eIntervention: Two years of Residency Training in Family Medicine (RTFM)\u003c/p\u003e\u003cp\u003eMain outcome measures: risk of patients being referred to secondary care for outpatient consultations and diagnostics tests; and having a follow-up medical consultation in primary care within three and six months after being referred.\u003c/p\u003e\u003cp\u003eResults: We examined 2414508 medical consultations and 284754 referrals to secondary care. Family physicians (FPs) were less likely to request ambulatory care services (including surgical specialties), but were more likely to request Ophthalmology, Physiotherapy, Rehabilitation, and Surgical evaluations for their patients. Patients referred to secondary care by FPs were at a higher risk of having a follow-up visit in primary care for almost every service requested. If all medical consultations were performed by FPs, a 37.6% (95% CI 32.4% - 42.4%) increased demand for Rehabilitation services would be noticed. Oppositely, 1532 (95%CI 1458; 1602) fewer requests for Dermatology would happen every year. \u003c/p\u003e\u003cp\u003eConclusions: RTFM improves coordination and continuity of care by making FPs more competent to retain those health conditions that can be properly managed in primary care and making FPs more competent to detect health conditions that require specific biomedical technologies and skills, increasing the demand for those services. Besides, it increases the chances of patients having follow-up visits in primary care. Policymakers in low- and middle-income countries must consider investing in RTFM to make primary care systems more comprehensive, with better coordination and continuity of care.\u003c/p\u003e","manuscriptTitle":"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","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-03-22 16:48:03","doi":"10.21203/rs.3.rs-350593/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"048e9604-2b37-43a9-82e6-ba11a7406582","owner":[],"postedDate":"March 22nd, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":3114001,"name":"General Practice"},{"id":3114002,"name":"Epidemiology"}],"tags":[],"updatedAt":"2022-02-15T18:23:24+00:00","versionOfRecord":{"articleIdentity":"rs-350593","link":"https://doi.org/10.1136/bmjopen-2021-051515","journal":{"identity":"bmj-open","isVorOnly":true,"title":"BMJ Open"},"publishedOn":"2022-02-01 18:23:24","publishedOnDateReadable":"February 1st, 2022"},"versionCreatedAt":"2021-03-22 16:48:03","video":"","vorDoi":"10.1136/bmjopen-2021-051515","vorDoiUrl":"https://doi.org/10.1136/bmjopen-2021-051515","workflowStages":[]},"version":"v1","identity":"rs-350593","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-350593","identity":"rs-350593","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}