Patient Access to Core Attributes of Primary Care Linked to Lower Mortality

New research published in the January/February issue of Annals of Family Medicine suggests that patient access to certain attributes of primary care associated with the patient-centered medical home model of care are associated with lower individual mortality risk.

Specifically, authors of "Primary Care Attributes and Mortality: A National Person-Level Study" (8-page PDF; About PDFs) found that patients who reported three attributes in their usual source of care -- comprehensiveness, patient-centeredness and enhanced access -- had lower mortality during up to six years follow-up than patients reporting less access to those three attributes.

According to the study's researchers, their findings "advance the primary care evidence base and suggest that ongoing health care and primary care practice redesign efforts in the United States may have the potential to reduce preventable deaths."

In an interview with AAFP News Now, corresponding author Anthony Jerant, M.D., in the Department of Family and Community Medicine, Center for Healthcare Policy and Research at the University of California Davis in Sacramento, took that sentiment even further.

"Primary care and the patient-centered medical home are hot right now politically, but I'm a bit worried about that," Jerant said, recalling the era of managed care when primary care rode to the top for a while and then suffered a backlash when the managed care movement failed to deliver on many of its promises.

"To help avoid similar backlash against the medical home concept, we need to make sure that claims regarding its potential effects on health outcomes are grounded in research evidence as much as possible," he said.

Previous studies suggest that geographic locations that have more primary care doctors tend to have lower mortality risk, said Jerant. "But area-level associations do not necessarily apply to individuals within the studied populations," he added. Furthermore, the term "primary care" in previous studies was defined based on specialty, yet "We know there is huge variability among primary care doctors as to the types of specific services and attributes they offer," Jerant said.

In this most recent study, researchers looked at how patients reported on whether their doctors offered attributes that are considered core indicators of good primary care, and then assessed whether reported access to those attributes were associated with lower mortality.

"Nobody has ever done this at a national level," said Jerant.

"Relatively few people have recognized the ability to link the Medical Expenditure Panel Survey (MEPS) data with the mortality data found in the National Death Index, (NDI)" as we did," said Jerant, giving credit to Peter Franks, M.D., senior author on the paper, for realizing that it could be done and for having the expertise to manage the data.

Researchers looked at data on 60,199 adults aged 18 years to 90 years who had complete baseline data entered into the MEPS and for whom mortality information was available. Respondents who had a usual source of care -- such as a doctor's office, clinic or health center -- were asked to indicate with "yes" or "no" answers as to whether their usual source of care

The researchers adjusted for a number of socio-demographic characteristics in their analyses, including age, sex, race and ethnicity; U.S. census region; education; household income level; and health insurance status. They also adjusted for the overall health; health conditions; health habits, such as smoking; and health care use of respondents.

Mortality was assessed using the NDI through the end of December 2006.

"To the extent that primary care is comprehensive, patient-centered care and available to patients when needed, patients may be more likely to receive the timely preventive, acute and chronic care that has been shown to reduce mortality," said the authors. "Increased access to these attributes might also minimize unnecessary and potentially harmful care, thereby mitigating iatrogenic mortality," they added.

Researchers pointed out that certain groups, namely racial and ethnic minorities, poorer and less-educated individuals, and those without health insurance reported "notably lower access" to the medical home attributes than others.

Authors called this disturbing "in light of health disparities disfavoring these groups," and suggested interventions to promote equitable access to health care professionals who can provide the primary care medical home attributes measured in the study.

In addition, researchers said they found evidence of "geographic variation" with regard to patient access to health care professionals who offered the medical home attributes and suggested a move toward ensuring uniform dissemination across all regions of the United States.

Jerant concluded that there was much work yet to be done.

"I would like to see other researchers replicate and expand on our findings," he said. "For example, we now need to study the potential mortality impact of other medical home attributes -- such as team-oriented care -- for which we had no measures in our data set."

Jerant said further research could show that in an even more advanced medical home setting, patients live longer and report that they feel healthier.