Blog | Friday, September 10, 2010

QD: News Every Day--'No simple relationship' between primary care access, better health


More primary care visits and services don't necessarily lead to recommended care, better outcomes or fewer hospitalizations, according to a new report by the Dartmouth Atlas Project.

Instead, geography was a leading driver of health care, more so than race or income. For example, 77.6% of people in the study had an annual visit to a primary care clinician, but visits varied widely depending upon where patients lived. Primary care visits ranged from about 60% of beneficiaries in the Bronx, N.Y. and Manhattan to nearly 90% in Wilmington, N.C. and Florence, S.C.

Researchers studied enrollment and claims data among fee-for-service Medicare population from 2003 to 2007. No HMO patients were included. Geographic areas were based on Dartmouth Atlas hospital service areas, defined on the basis of travel for common causes of hospitalization, and Dartmouth Atlas hospital referral regions, larger natural markets of travel for tertiary care that include one or more service areas and at least one major referral hospital.

There was no correlation between the supply of physicians and access to primary care. In some regions, a relatively high proportion of beneficiaries had at least one annual visit, even when there were fewer primary care physicians per capita. In Wilmington, N.C., which has 69 primary care physicians per 100,000 residents, 87.4% of patients had at least one annual primary care visit. In White Plains, N.Y., which has 101.4 primary care physicians per 100,000, less than 70% of beneficiaries had at least one primary care visit.

Dartmouth Atlas of Healthcare, copyright Dartmouth College"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, MD, MPH, 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."

For example, there was no relationship between rates of breast cancer screening and the amount of primary care delivered. There was a modest relationship between rates of A1c testing in beneficiaries with diabetes and the overall likelihood that beneficiaries saw a primary care physician annually. There was no relationship between rates of blood lipid testing and eye exams and the overall likelihood that beneficiaries with diabetes saw a primary care clinician at least once a year.

Rates of leg amputation also had no relationship with an annual visit to a primary care clinician. Again, geography played a bigger role. 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 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 postulates that primary care is most effective when it is embedded within a health care system where care is coordinated, physicians communicate with one another and with other clinicians about their patients, and feedback is available about performance that allows physicians and local hospitals to continually improve.

"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, MD, MS, 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."