Strengthening Primary Care Might Not Mean Better Outcomes
September 12, 2010 at 7:05 AM
General Health News
Strengthening primary care might not necessarily mean better outcomes, a new US study shows.
Interestingly, blacks were less likely to see a primary care clinician than whites—70.4 percent had at least one annual visit in 2003-07 compared with 78.1 percent for whites—about 11 percent more than blacks, though there were some exceptions too.
A new report from the Dartmouth Atlas Project shows that improving access to primary care alone does not always keep people with chronic conditions out of the hospital, improve their chances of getting the optimal care recommended for their condition, or improve health outcomes.
"Our findings suggest that the nation's primary care deficit won't be solved by simply increasing access to primary care, either by boosting the number of primary care physicians in an area or by ensuring that most patients have better insurance coverage," said David C. Goodman, M.D., M.S., lead author and co-principal investigator for the Dartmouth Atlas Project. "Policy should also focus on improving the actual services primary care clinicians provide and making sure their efforts are coordinated with those of other providers, including specialists, nurses and hospitals."
Regardless of race and income, patients receive care of widely varying quality depending upon where they live and the health system that provides their care. During the report period, 77.6 percent of beneficiaries had an annual visit to a primary care clinician, but patients' chances of an annual primary care visit varied widely depending upon where they lived. The rate of primary care visits ranged from about 60 percent of beneficiaries in the Bronx, N.Y. and Manhattan to nearly 90 percent in Wilmington, N.C. and Florence, S.C.—about a 50 percent difference between the highest and lowest regions.
The relationship between the per capita supply of total primary care physicians and the percent of Medicare beneficiaries who had at least one annual visit with a primary care clinician during 2003-07 suggests that there is no correlation between the supply of physicians and access to primary care.
"A commonly cited reason for the wide variation in access to primary care is a shortage of clinicians, particularly physicians. This may contribute to the problem in some locations, but the findings suggest that there is no simple relationship between the supply of physicians and access to primary care," said Elliott S. Fisher, M.D., M.P.H., report author and co-principal investigator for the Dartmouth Atlas Project. "As is often the case in health care—it's not always how much you spend, but how you spend it."
There is strong evidence that primary care physicians can play a crucial role in ensuring that patients get high-quality care. However, despite the central role that primary care can play, access is not always enough to ensure that patients receive high-quality care or get better outcomes.
For instance, rates of leg amputation, a serious complication of diabetes and peripheral vascular disease, had no relationship with having at least one annual visit with a primary care clinician. And patients' risk of leg amputation varied dramatically depending upon where they lived - there was a tenfold difference in the rate of leg amputation, ranging from 0.33 per 1,000 beneficiaries in Provo, Utah to 3.29 per 1,000 in McAllen, Texas.
The report also found that having an annual primary care visit did not keep patients out of the hospital for ambulatory care-sensitive conditions such as diabetes and congestive heart failure. There was a more than fourfold difference in the rate of ambulatory care-sensitive discharges among Medicare beneficiaries, ranging from 30.7 per 1,000 in Honolulu to 135.0 per 1,000 in Monroe, La.
The report measured primary care at a regional level. A higher supply of primary care may be more important in smaller areas, but unfortunately public policy and reimbursement practices have not matched patient needs with supply at any level, local or regional.
To explain this gap in access to primary care and health outcomes, researchers theorize that the patients most in need of this care may not be receiving it. Another possible reason is that primary care is most effective when it is embedded within a health care system where care is coordinated, physicians communicate with one another about their patients, and feedback is available about performance that allows physicians and local hospitals to continually improve.
Achieving the benefits of primary care is likely to require both improving the services provided by primary care clinicians and more effective integration and coordination with other providers.
The Dartmouth Atlas Project is run by the Dartmouth Institute for Health Policy and Clinical Practice and principally funded by the Robert Wood Johnson Foundation.
For more than 20 years, the Dartmouth Atlas Project has documented glaring variations in how medical resources are distributed and used in the United States. The project uses Medicare data to provide comprehensive information and analysis about national, regional, and local markets, as well as individual hospitals and their affiliated physicians.