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Study Overview
Objective. To examine whether receiving primary care is associated with receipt of high-value services and low-value services and quality of patient experience.
Design. Secondary data analysis of the Medical Expenditure
To define whether a respondent received primary care, respondents were asked if they have a “usual source of care” and to provide the name of a physician they usually visit if they “are sick or need advice” about their health. Four additional questions asked respondents if they would visit their usual source of care for (1) “new health problems,” (2) “preventive health care such as general checkups, examinations, and immunizations,” (3) “ongoing health problems,” and (4) “referrals to other health professionals when needed.” These questions were intended to reflect the essential functions of primary care: providing first contact care that is comprehensive, continuous, and coordinated. Any respondents who indicated that they did not have a usual source of care or answered no to any of the 4 questions were considered to not have primary care. Among respondents who identified a usual source of care, 95% met criteria for having primary care.
Setting and participants. The study included 49,286 US adults with primary care and 21,133 US adults without primary care. The average age was 50 years (95% confidence interval [CI], 50-51) among those with primary care and 38 years (95% CI, 38-39) among those without primary care. Among those who had primary care, 55% were female, 50% were non-Hispanic white, 32% Hispanic, and 13% black; among those without primary care, 43% were female, 43% were non-Hispanic white, 35% Hispanic, and 13% black. Among respondents with primary care, 58% considered their health status to be excellent or very good, as compared with 66% of respondents without primary care. Lack of insurance was reported by 7% of respondents with primary care and 34% of respondents without primary care. Chronic disease was reported in 78% of respondents without primary care, as compared with 42% of respondents with primary care. The study uses propensity score matching methods to produce a matched cohort, taking into account potential confounders. The matching procedure resulted in a final sample of 43,766 respondents with primary care matched to 17,964 respondents without primary care.
Main outcome measures. Main study outcome measures included 39 quality measures aggregated into quality composites (6 high-value services and 4 low-value services), and 7 patient care experience measures aggregated into an overall patient experience rating and 2 experience composites. High-value services are defined as delivery of services that are likely of benefit, and include the use of recommended cancer screening such as colorectal cancer screening in appropriate age groups; recommended diagnostic and preventive testing such as cholesterol measurement and influenza vaccination; recommended diabetes care such as hemoglobin A1c measurement; recommended medical treatment for medical conditions such as heart failure, coronary artery disease, and chronic obstructive pulmonary disease; and recommended counseling such as smoking cessation. Low-value services are defined as delivery of services that are considered either inappropriate or of little to no benefit, and include cancer screening in older adults; inappropriate use of antibiotics such as for bronchitis; inappropriate medical treatment such as anxiolytic, sedative, or hypnotic prescriptions for older adults; and inappropriate imaging tests for certain conditions.
Composites of underuse (high-value care) and overuse (low-value care) were constructed from each measure of high- or low-value services by identifying respondents who were eligible for the measure and determining the proportion in which recommended care was delivered (for high-value measures) or avoided (for low-value measures). Patient care experience was measured by standardized CAHPS (Consumer Assessment of Healthcare Providers and Systems) measurement for global rating of health care, doctor communication, and access to care. The patient care experience measures were dichotomized into positive responses as a rating of 8, 9, or 10 on items scored from 0 to 10, and 4 for items scored from 1 to 4. The experience composite was constructed by computing the mean for each respondent and then the mean for all respondents.
Main results. The study found that respondents with primary care were more likely to receive high-value care in 4 of 5 composite measures—cancer screening, diagnostic and preventive testing, diabetes care, and recommended counseling such as smoking cessation—but not in the composite recommended treatment for specific medical conditions such as heart failure. Respondents with primary care were more likely to receive recommended cancer screening, as compared to those without primary care (78% vs 67%, respectively, with a difference of 10.8%; 95% CI, 8.5%-13.0%). Respondents with primary care were also more likely to receive recommended diagnostic and preventive testing (with a difference of 9.9%; 95% CI, 8.7%-11.2%), to receive high-value diabetes care (with a difference of 7.8%; 95% CI, 1.2%-14.4%), and to receive counselling (with a difference of 6.9%; 95% CI, 4.1%-9.7%) when compared to respondents without primary care. However the rates of receipt of high-value medical treatments were similar among respondents with or without primary care (with a difference of –4.6% (95% CI, –14.3% to 5.0%). In contrast, rates of low-value care were similar for those with or without primary care in 3 of 4 composites, including low-value cancer screening, medical treatment, and imaging, while those with primary care had higher rates of low-value antibiotic use (with a difference of 11.0%; 95% CI, 2.8%-19.3%). Respondents with primary care reported better patient care experience, including global rating of their health care, physician communication, and access to care, when compared to those without primary care.
Conclusion. Receipt of primary care is associated with a better patient care experience, more high-value care, and slightly more low-value care.
Commentary
Primary care has long been considered the bedrock of modern health care, and the delivery of comprehensive, continuous, high-quality primary care yields benefits to patients and the health care system.1 Primary care is associated with better outcomes, such as lower mortality and reduced rates of potentially avoidable hospitalizations, and people living in areas with higher concentrations of primary care are more likely to report better health.2 Primary care is also associated with reductions in health care cost and utilization while maintaining quality.2 The current study adds to what is known about the potential benefits of primary care by directly examining the association of the use of primary care versus no primary care with outcomes of high-value care, low-value care, and patient care experience. Because this study used nationally representative data, it was able to examine adults in all age groups, not only older adults in Medicare, which prior studies have relied on.3 The study’s findings—that adults seen in primary care receive more high-value care and report better care experiences—are not surprising. The study also found that slightly more low-value care is being delivered in primary care. These findings are consistent with prior studies. Also, although primary care overall may be associated with health care benefits, there is substantial variation in the rates of overuse (of low-value care) and underuse (of high-value care) in primary care, and this may represent opportunities for improvement.4
This study has several limitations. Because the study defined primary care using questions that identify essential elements of primary care—first contact, comprehensiveness, continuity, and coordinated care—the findings may not apply to all individuals who have identified a primary care provider, but only to those who experience comprehensive, continuous, and coordinated care. Inclusion of all individuals who identify a usual source of primary care as the sole criteria may attenuate the association of primary care with the outcome measures. It is, however, reassuring that among those who identified a usual source of care (primary care), 95% indicated that they have care that is consistent with the principles of first contact care, comprehensiveness, continuity, and coordinated care. Another limitation is that the use of the criteria to indicate high- or low-value care may not capture the nuances of patient-centered care, preferences, or individualized decision-making that occurs in clinical care. Nonetheless, definitions used in the study for high- and low-value care are consistent with prior literature, and offer a standardized measure to indicate quality of care.
Applications for Clinical Practice
A recent trend in health care is the shift of continuity of care from primary care providers or practices to facility-based care or no continuity of care at all, and this shift disproportionately affects patients with low income and is associated with more emergency room visits.5 The current study makes a strong case for the potential benefits of receiving primary care that is comprehensive, continuous, and coordinated, as patients in primary care are more likely to receive high-value over low-value care, and to have a better care experience. The ongoing debate on changes to the health care system and insurance options must take into account the impact of any changes on the population receiving primary care coverage, with the goal that more, rather than fewer, individuals realize the potential benefits of comprehensive primary care.
— William W. Hung, MD MPH
1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502.
2. American College of Physicians. How is a shortage of primary care physicians affecting the quality and cost of medical care? www.acponline.org/acp_policy/policies/primary_care_shortage_affecting_hc_2008.pdf. Published 2008. Accessed June 11, 2019.
3. Bazemore A, Petterson S, Peterson LE, et al. Higher primary care physician continuity is associated with lower costs and hospitalizations. Ann Fam Med. 2018;16:492-497.
4. O’Sullivan JW, Albasri A, Nicholson BD, et al. Overtesting and undertesting in primary care: a systematic review and meta-analysis. BMJ Open. 2018;8:e018557.
5. Liaw W, Jetty A, Petterson S, et al. Trends in the types of usual sources of care: a shift from people to places or nothing at all. Health Serv Res. 2018;53:2346-2367.
Study Overview
Objective. To examine whether receiving primary care is associated with receipt of high-value services and low-value services and quality of patient experience.
Design. Secondary data analysis of the Medical Expenditure
To define whether a respondent received primary care, respondents were asked if they have a “usual source of care” and to provide the name of a physician they usually visit if they “are sick or need advice” about their health. Four additional questions asked respondents if they would visit their usual source of care for (1) “new health problems,” (2) “preventive health care such as general checkups, examinations, and immunizations,” (3) “ongoing health problems,” and (4) “referrals to other health professionals when needed.” These questions were intended to reflect the essential functions of primary care: providing first contact care that is comprehensive, continuous, and coordinated. Any respondents who indicated that they did not have a usual source of care or answered no to any of the 4 questions were considered to not have primary care. Among respondents who identified a usual source of care, 95% met criteria for having primary care.
Setting and participants. The study included 49,286 US adults with primary care and 21,133 US adults without primary care. The average age was 50 years (95% confidence interval [CI], 50-51) among those with primary care and 38 years (95% CI, 38-39) among those without primary care. Among those who had primary care, 55% were female, 50% were non-Hispanic white, 32% Hispanic, and 13% black; among those without primary care, 43% were female, 43% were non-Hispanic white, 35% Hispanic, and 13% black. Among respondents with primary care, 58% considered their health status to be excellent or very good, as compared with 66% of respondents without primary care. Lack of insurance was reported by 7% of respondents with primary care and 34% of respondents without primary care. Chronic disease was reported in 78% of respondents without primary care, as compared with 42% of respondents with primary care. The study uses propensity score matching methods to produce a matched cohort, taking into account potential confounders. The matching procedure resulted in a final sample of 43,766 respondents with primary care matched to 17,964 respondents without primary care.
Main outcome measures. Main study outcome measures included 39 quality measures aggregated into quality composites (6 high-value services and 4 low-value services), and 7 patient care experience measures aggregated into an overall patient experience rating and 2 experience composites. High-value services are defined as delivery of services that are likely of benefit, and include the use of recommended cancer screening such as colorectal cancer screening in appropriate age groups; recommended diagnostic and preventive testing such as cholesterol measurement and influenza vaccination; recommended diabetes care such as hemoglobin A1c measurement; recommended medical treatment for medical conditions such as heart failure, coronary artery disease, and chronic obstructive pulmonary disease; and recommended counseling such as smoking cessation. Low-value services are defined as delivery of services that are considered either inappropriate or of little to no benefit, and include cancer screening in older adults; inappropriate use of antibiotics such as for bronchitis; inappropriate medical treatment such as anxiolytic, sedative, or hypnotic prescriptions for older adults; and inappropriate imaging tests for certain conditions.
Composites of underuse (high-value care) and overuse (low-value care) were constructed from each measure of high- or low-value services by identifying respondents who were eligible for the measure and determining the proportion in which recommended care was delivered (for high-value measures) or avoided (for low-value measures). Patient care experience was measured by standardized CAHPS (Consumer Assessment of Healthcare Providers and Systems) measurement for global rating of health care, doctor communication, and access to care. The patient care experience measures were dichotomized into positive responses as a rating of 8, 9, or 10 on items scored from 0 to 10, and 4 for items scored from 1 to 4. The experience composite was constructed by computing the mean for each respondent and then the mean for all respondents.
Main results. The study found that respondents with primary care were more likely to receive high-value care in 4 of 5 composite measures—cancer screening, diagnostic and preventive testing, diabetes care, and recommended counseling such as smoking cessation—but not in the composite recommended treatment for specific medical conditions such as heart failure. Respondents with primary care were more likely to receive recommended cancer screening, as compared to those without primary care (78% vs 67%, respectively, with a difference of 10.8%; 95% CI, 8.5%-13.0%). Respondents with primary care were also more likely to receive recommended diagnostic and preventive testing (with a difference of 9.9%; 95% CI, 8.7%-11.2%), to receive high-value diabetes care (with a difference of 7.8%; 95% CI, 1.2%-14.4%), and to receive counselling (with a difference of 6.9%; 95% CI, 4.1%-9.7%) when compared to respondents without primary care. However the rates of receipt of high-value medical treatments were similar among respondents with or without primary care (with a difference of –4.6% (95% CI, –14.3% to 5.0%). In contrast, rates of low-value care were similar for those with or without primary care in 3 of 4 composites, including low-value cancer screening, medical treatment, and imaging, while those with primary care had higher rates of low-value antibiotic use (with a difference of 11.0%; 95% CI, 2.8%-19.3%). Respondents with primary care reported better patient care experience, including global rating of their health care, physician communication, and access to care, when compared to those without primary care.
Conclusion. Receipt of primary care is associated with a better patient care experience, more high-value care, and slightly more low-value care.
Commentary
Primary care has long been considered the bedrock of modern health care, and the delivery of comprehensive, continuous, high-quality primary care yields benefits to patients and the health care system.1 Primary care is associated with better outcomes, such as lower mortality and reduced rates of potentially avoidable hospitalizations, and people living in areas with higher concentrations of primary care are more likely to report better health.2 Primary care is also associated with reductions in health care cost and utilization while maintaining quality.2 The current study adds to what is known about the potential benefits of primary care by directly examining the association of the use of primary care versus no primary care with outcomes of high-value care, low-value care, and patient care experience. Because this study used nationally representative data, it was able to examine adults in all age groups, not only older adults in Medicare, which prior studies have relied on.3 The study’s findings—that adults seen in primary care receive more high-value care and report better care experiences—are not surprising. The study also found that slightly more low-value care is being delivered in primary care. These findings are consistent with prior studies. Also, although primary care overall may be associated with health care benefits, there is substantial variation in the rates of overuse (of low-value care) and underuse (of high-value care) in primary care, and this may represent opportunities for improvement.4
This study has several limitations. Because the study defined primary care using questions that identify essential elements of primary care—first contact, comprehensiveness, continuity, and coordinated care—the findings may not apply to all individuals who have identified a primary care provider, but only to those who experience comprehensive, continuous, and coordinated care. Inclusion of all individuals who identify a usual source of primary care as the sole criteria may attenuate the association of primary care with the outcome measures. It is, however, reassuring that among those who identified a usual source of care (primary care), 95% indicated that they have care that is consistent with the principles of first contact care, comprehensiveness, continuity, and coordinated care. Another limitation is that the use of the criteria to indicate high- or low-value care may not capture the nuances of patient-centered care, preferences, or individualized decision-making that occurs in clinical care. Nonetheless, definitions used in the study for high- and low-value care are consistent with prior literature, and offer a standardized measure to indicate quality of care.
Applications for Clinical Practice
A recent trend in health care is the shift of continuity of care from primary care providers or practices to facility-based care or no continuity of care at all, and this shift disproportionately affects patients with low income and is associated with more emergency room visits.5 The current study makes a strong case for the potential benefits of receiving primary care that is comprehensive, continuous, and coordinated, as patients in primary care are more likely to receive high-value over low-value care, and to have a better care experience. The ongoing debate on changes to the health care system and insurance options must take into account the impact of any changes on the population receiving primary care coverage, with the goal that more, rather than fewer, individuals realize the potential benefits of comprehensive primary care.
— William W. Hung, MD MPH
Study Overview
Objective. To examine whether receiving primary care is associated with receipt of high-value services and low-value services and quality of patient experience.
Design. Secondary data analysis of the Medical Expenditure
To define whether a respondent received primary care, respondents were asked if they have a “usual source of care” and to provide the name of a physician they usually visit if they “are sick or need advice” about their health. Four additional questions asked respondents if they would visit their usual source of care for (1) “new health problems,” (2) “preventive health care such as general checkups, examinations, and immunizations,” (3) “ongoing health problems,” and (4) “referrals to other health professionals when needed.” These questions were intended to reflect the essential functions of primary care: providing first contact care that is comprehensive, continuous, and coordinated. Any respondents who indicated that they did not have a usual source of care or answered no to any of the 4 questions were considered to not have primary care. Among respondents who identified a usual source of care, 95% met criteria for having primary care.
Setting and participants. The study included 49,286 US adults with primary care and 21,133 US adults without primary care. The average age was 50 years (95% confidence interval [CI], 50-51) among those with primary care and 38 years (95% CI, 38-39) among those without primary care. Among those who had primary care, 55% were female, 50% were non-Hispanic white, 32% Hispanic, and 13% black; among those without primary care, 43% were female, 43% were non-Hispanic white, 35% Hispanic, and 13% black. Among respondents with primary care, 58% considered their health status to be excellent or very good, as compared with 66% of respondents without primary care. Lack of insurance was reported by 7% of respondents with primary care and 34% of respondents without primary care. Chronic disease was reported in 78% of respondents without primary care, as compared with 42% of respondents with primary care. The study uses propensity score matching methods to produce a matched cohort, taking into account potential confounders. The matching procedure resulted in a final sample of 43,766 respondents with primary care matched to 17,964 respondents without primary care.
Main outcome measures. Main study outcome measures included 39 quality measures aggregated into quality composites (6 high-value services and 4 low-value services), and 7 patient care experience measures aggregated into an overall patient experience rating and 2 experience composites. High-value services are defined as delivery of services that are likely of benefit, and include the use of recommended cancer screening such as colorectal cancer screening in appropriate age groups; recommended diagnostic and preventive testing such as cholesterol measurement and influenza vaccination; recommended diabetes care such as hemoglobin A1c measurement; recommended medical treatment for medical conditions such as heart failure, coronary artery disease, and chronic obstructive pulmonary disease; and recommended counseling such as smoking cessation. Low-value services are defined as delivery of services that are considered either inappropriate or of little to no benefit, and include cancer screening in older adults; inappropriate use of antibiotics such as for bronchitis; inappropriate medical treatment such as anxiolytic, sedative, or hypnotic prescriptions for older adults; and inappropriate imaging tests for certain conditions.
Composites of underuse (high-value care) and overuse (low-value care) were constructed from each measure of high- or low-value services by identifying respondents who were eligible for the measure and determining the proportion in which recommended care was delivered (for high-value measures) or avoided (for low-value measures). Patient care experience was measured by standardized CAHPS (Consumer Assessment of Healthcare Providers and Systems) measurement for global rating of health care, doctor communication, and access to care. The patient care experience measures were dichotomized into positive responses as a rating of 8, 9, or 10 on items scored from 0 to 10, and 4 for items scored from 1 to 4. The experience composite was constructed by computing the mean for each respondent and then the mean for all respondents.
Main results. The study found that respondents with primary care were more likely to receive high-value care in 4 of 5 composite measures—cancer screening, diagnostic and preventive testing, diabetes care, and recommended counseling such as smoking cessation—but not in the composite recommended treatment for specific medical conditions such as heart failure. Respondents with primary care were more likely to receive recommended cancer screening, as compared to those without primary care (78% vs 67%, respectively, with a difference of 10.8%; 95% CI, 8.5%-13.0%). Respondents with primary care were also more likely to receive recommended diagnostic and preventive testing (with a difference of 9.9%; 95% CI, 8.7%-11.2%), to receive high-value diabetes care (with a difference of 7.8%; 95% CI, 1.2%-14.4%), and to receive counselling (with a difference of 6.9%; 95% CI, 4.1%-9.7%) when compared to respondents without primary care. However the rates of receipt of high-value medical treatments were similar among respondents with or without primary care (with a difference of –4.6% (95% CI, –14.3% to 5.0%). In contrast, rates of low-value care were similar for those with or without primary care in 3 of 4 composites, including low-value cancer screening, medical treatment, and imaging, while those with primary care had higher rates of low-value antibiotic use (with a difference of 11.0%; 95% CI, 2.8%-19.3%). Respondents with primary care reported better patient care experience, including global rating of their health care, physician communication, and access to care, when compared to those without primary care.
Conclusion. Receipt of primary care is associated with a better patient care experience, more high-value care, and slightly more low-value care.
Commentary
Primary care has long been considered the bedrock of modern health care, and the delivery of comprehensive, continuous, high-quality primary care yields benefits to patients and the health care system.1 Primary care is associated with better outcomes, such as lower mortality and reduced rates of potentially avoidable hospitalizations, and people living in areas with higher concentrations of primary care are more likely to report better health.2 Primary care is also associated with reductions in health care cost and utilization while maintaining quality.2 The current study adds to what is known about the potential benefits of primary care by directly examining the association of the use of primary care versus no primary care with outcomes of high-value care, low-value care, and patient care experience. Because this study used nationally representative data, it was able to examine adults in all age groups, not only older adults in Medicare, which prior studies have relied on.3 The study’s findings—that adults seen in primary care receive more high-value care and report better care experiences—are not surprising. The study also found that slightly more low-value care is being delivered in primary care. These findings are consistent with prior studies. Also, although primary care overall may be associated with health care benefits, there is substantial variation in the rates of overuse (of low-value care) and underuse (of high-value care) in primary care, and this may represent opportunities for improvement.4
This study has several limitations. Because the study defined primary care using questions that identify essential elements of primary care—first contact, comprehensiveness, continuity, and coordinated care—the findings may not apply to all individuals who have identified a primary care provider, but only to those who experience comprehensive, continuous, and coordinated care. Inclusion of all individuals who identify a usual source of primary care as the sole criteria may attenuate the association of primary care with the outcome measures. It is, however, reassuring that among those who identified a usual source of care (primary care), 95% indicated that they have care that is consistent with the principles of first contact care, comprehensiveness, continuity, and coordinated care. Another limitation is that the use of the criteria to indicate high- or low-value care may not capture the nuances of patient-centered care, preferences, or individualized decision-making that occurs in clinical care. Nonetheless, definitions used in the study for high- and low-value care are consistent with prior literature, and offer a standardized measure to indicate quality of care.
Applications for Clinical Practice
A recent trend in health care is the shift of continuity of care from primary care providers or practices to facility-based care or no continuity of care at all, and this shift disproportionately affects patients with low income and is associated with more emergency room visits.5 The current study makes a strong case for the potential benefits of receiving primary care that is comprehensive, continuous, and coordinated, as patients in primary care are more likely to receive high-value over low-value care, and to have a better care experience. The ongoing debate on changes to the health care system and insurance options must take into account the impact of any changes on the population receiving primary care coverage, with the goal that more, rather than fewer, individuals realize the potential benefits of comprehensive primary care.
— William W. Hung, MD MPH
1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502.
2. American College of Physicians. How is a shortage of primary care physicians affecting the quality and cost of medical care? www.acponline.org/acp_policy/policies/primary_care_shortage_affecting_hc_2008.pdf. Published 2008. Accessed June 11, 2019.
3. Bazemore A, Petterson S, Peterson LE, et al. Higher primary care physician continuity is associated with lower costs and hospitalizations. Ann Fam Med. 2018;16:492-497.
4. O’Sullivan JW, Albasri A, Nicholson BD, et al. Overtesting and undertesting in primary care: a systematic review and meta-analysis. BMJ Open. 2018;8:e018557.
5. Liaw W, Jetty A, Petterson S, et al. Trends in the types of usual sources of care: a shift from people to places or nothing at all. Health Serv Res. 2018;53:2346-2367.
1. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83:457-502.
2. American College of Physicians. How is a shortage of primary care physicians affecting the quality and cost of medical care? www.acponline.org/acp_policy/policies/primary_care_shortage_affecting_hc_2008.pdf. Published 2008. Accessed June 11, 2019.
3. Bazemore A, Petterson S, Peterson LE, et al. Higher primary care physician continuity is associated with lower costs and hospitalizations. Ann Fam Med. 2018;16:492-497.
4. O’Sullivan JW, Albasri A, Nicholson BD, et al. Overtesting and undertesting in primary care: a systematic review and meta-analysis. BMJ Open. 2018;8:e018557.
5. Liaw W, Jetty A, Petterson S, et al. Trends in the types of usual sources of care: a shift from people to places or nothing at all. Health Serv Res. 2018;53:2346-2367.