A substantial proportion of this relatively young cohort of addicted adults with high health care utilization but no existing regular primary medical care relationship failed to link with primary medical care after residential detoxification. Women, those with recent episodic medical visits, family support for abstinence, and those with insurance after detoxification, were more likely to link with primary care. Recent incarceration decreased the likelihood of linkage.
Men with and without addictions are less likely to use primary medical care (Saitz, Mulvey, and Samet 1997
; Lim et al. 2002
; Gallagher et al. 1997
). That men are less likely to link to care after detoxification suggests that interventions to improve linkage could target men when they are reachable in inpatient detoxification units. Many incarcerated adults report poor health status and failure to obtain needed medical care (Conklin, Lincoln, and Tuthill 2000
). Since those with past incarceration were less likely to link with primary care after detoxification, efforts (already nascent in some communities [Conklin, Lincoln, and Flanigan 1998
]) toward improving access to primary care should be studied.
Since our data suggest that prior contacts with episodic medical care enhance the likelihood of entering primary care after detoxification, these care sites could make linkage efforts standard practice. This finding is consistent with prior work finding that episodic medical illness is associated with having primary medical care in adults with addictions (Saitz, Mulvey, and Samet 1997
). Our finding that social support for abstinence can increase linkage suggests that patients with little support could receive social support counseling, a method already known in other settings to improve follow-up ambulatory appointment-keeping (Tanner and Feldman 1998
Health insurance during follow-up but not at the time of detoxification was one of the strongest predictors of linking with primary medical care. This was particularly true for subjects who had not received an enhanced referral to a primary medical care clinic that served patients regardless of ability to pay. In studies of other populations including those with addictions (Saitz, Mulvey, and Samet 1997
; Bierman et al. 1999
), having insurance is associated with use of medical services. But in this population of addicted adults, many people who had no primary medical care had health insurance (40 percent, ). And having insurance at the time of contact with the detoxification unit was not enough to facilitate subsequent linkage with primary care. Only having health insurance at the right time—during the early period after detoxification when patients may begin to recognize and become concerned about medical symptoms as their sensorium clears and priorities change—was the predictor of importance.
Coincidentally, the period of follow-up in this study was a time when Massachusetts implemented a substantial Medicaid expansion (starting July1,1997) (MassHealth 2002
). And most of our subjects (90 percent) who had insurance in follow-up reported Medicaid as the insurer. Making health insurance coverage available to adults with addiction (a group disproportionately lacking primary medical care) at the right time (e.g., when they are more likely to access primary health care) is likely a generalizable strategy for improving receipt of primary care services (McCarthy et al. 2002
). Differing findings regarding insurance at different times (at the time of detoxification and afterward) and during implementation of a statewide policy also demonstrate the importance of accounting for the dynamic nature of insurance coverage and changing policy in health services research.
We had hypothesized that ethnicity, recent addiction or mental health treatment utilization, addiction severity, health status, substance problem recognition, and perceived need for medical care would affect linkage, yet they did not. The association between minority race and linkage did not reach statistical significance but was in the same direction as has been previously reported for linkage with alcohol treatment (Kirchner et al. 2000
). There were no discernible effects for mental health utilization or health status in our study. Health status was not associated with having a regular source of care in another study of a similarly vulnerable homeless population (Gallagher et al. 1997
). This “need” or illness factor, generally associated with health care utilization (Bierman et al. 1999
), and associated with having primary care for people with addictions (Saitz, Mulvey, and Samet 1997
), may not have risen to the top of a priority list (Gallagher et al. 1997
), or perhaps the need was met with episodic or emergency but not primary medical care. That patient beliefs about needing a physician did not lead to getting one, is also likely explained by a reordering of priorities (such as relapse or social, legal, or psychological needs) after leaving the residential detoxification facility. For addiction treatment utilization, addiction severity, and substance problem recognition, the effects were in the hypothesized direction but they did not reach statistical significance even in this large sample. In addition, the relatively low variability in the sample may explain why an expected association was not found (e.g., all had drug dependence severe enough to warrant inpatient detoxification).
The major strengths of this study were its focus on an understudied, reachable population in need, standardized prospective data collection with a high follow-up rate, and analyses based on theory. In addition, we used a broad definition of primary care based on how a physician functions in the eyes of the patient rather than based on how a health system categorizes them (Starfield 1998
); this deliberate choice makes it very likely that subjects reporting no primary medical care truly did not have it.
Limitations of our study include a 15 percent loss to follow-up that could have biased the results, however, the minimal losses and few differences in subject characteristics make this issue less of a concern. Assessment of primary medical care linkage by self-report may be a concern, but interview assessment of this outcome was a focus of the study; it was detailed, it referred to the recent past, and it was validated against administrative data. And recall for an event like a visit to a new primary care physician is more accurate than recall for less notable events (Means et al. 1989
). Finally, the generalizability of our results may be limited to adults with addictions in similar low-socioeconomic-status detoxification and treatment programs typically found in cities in the United States.
Patients with addictions who have primary care physicians have already been described in the literature, and compared with those who do not (Saitz, Mulvey, and Samet 1997
). But to our knowledge, no prospective study has reported on factors associated with linkage to primary medical care after detoxification for those without a physician. Detoxification is often not followed by addiction treatment or medical care (Samet et al. 2003
; Mark et al. 2002
). Thus detoxification presents an opportunity to reach patients without primary care, who could benefit from such care, and who may not seek it without facilitated access. Our data from this unique population do not simply mirror findings in the general population or even in persons with addictions (Saitz, Mulvey, and Samet 1997
; Lim et al. 2002
; Gallagher et al. 1997
). In this setting, social support for abstinence, episodic medical care delivery contacts, incarceration, and insurance at the right time take on importance for patients with addictions who do not have, but who need primary medical care. Identification of these factors, and others significant in general and other vulnerable populations (e.g., gender), suggest clinical and policy interventions targeted to those at greatest risk as we have outlined in this discussion. We anticipate that this knowledge of potentially modifiable factors that affect linkage with ongoing care could be used by health systems, detoxification or addiction treatment programs, and by researchers designing interventions to improve entry into primary care at a specific common point of contact with the health care system for patients with addictions.