Tuesday, November 9, 2010

No Relationship Between Primary Care and Deaths from Coronary Artery Disease?

Listen in on the average health care Conference, Meeting or Grand Rounds with health care patriarchs or D.C. brainiacs speaking about "primary care," and it's likely that you'll hear at least one PowerPoint slide's worth of praise for PCPs. It reminds the Disease Management Care Blog of what it's read about about the hollow admiration of the Saudis for their hardy Bedouins, the Norwegians for their rugged Laplanders and the Ben and Jerrys for their Vermont dairy farmers. Sure, these special folks may deserve special regard, but no one actually wants to live in a desert, above the Arctic Circle or close to a smelly barn. All the special attention is of small comfort us PCPs who just can't seem to get any respect.

And now this study isn't helping at all. Titled "Association of Features of Primary Health Care with Coronary Heart Disease Mortality," it was published in the November 10 issue of JAMA. Louis Levene, Richard Baker, John Bankart and Kamlesh Khunti accessed ALL of England's health data on mortality, patient characteristics and primary care delivery to explore the relationship between heart disease deaths and the local availability of primary care. This was an impressive study involving 54.3 million Brits being cared for in 152 of their regional "trusts." Regression analysis was used to determine if there was any statistical correlation between deaths from heart disease versus race, socioeconomic status (a "multiple deprivation" index), tobacco use, weight, diabetes, high blood pressure, number of physicians, staff and practices and pay for performance bonuses that were awarded to the docs.

Based on common wisdom, most persons would think that all of the above factors are independently and statistically significantly correlated with death rates. Thousands of DMCB readers know otherwise. That's because they know primary care is not the panacea for all that ails health care and that the DMCB likes to look at published research that goes contrary to the common wisdom.

It turns out that only five characteristics were associated with heart attack death. The risks were 1) being white, 2) having a low socioeconomic status, 3) using tobacco and 4) being diabetic. Having high blood pressure detected (this is not the same as having high blood pressure: patients can have hypertension that goes undetected) was associated with less risk.

What turned out to have no impact was availability or the quality of primary care. According to the authors:

"Neither provision of primary health care as indicated by the numbers of physicians or staff per 100 000 population, nor clinical performance as reflected by the quality and outcomes framework indicator scores predicted mortality in any year."

This should give pause to the universal assumption that manufacturing and then parachuting more PCPs into areas of the U.S. with a high burden of coronary artery disease and showering them with pay for performance dollars will save lives.

As an aside, that was also the conclusion of this recently published RAND review paper from Health Affairs titled "Primary Care: A Critical Review of the Evidence On Quality and Cost of Care." The authors state:

"....a recent survey of primary care physicians found that those in the highest-spending regions of the Dartmouth Atlas of Health Care were significantly more likely than those in the lowest-spending regions to report more aggressive use of discretionary visits, tests, and interventions. In other words, care by primary care physicians in high-cost areas is not the same as care delivered by primary care physicians in low-cost areas. This finding ....suggests that adding more primary care physicians in regions such as South Florida may increase mortality rates. Such analyses offer evidence that adding more primary care providers in high-spending areas could have deleterious effects if local provider cultures and other system-level characteristics are not simultaneously reoriented."

Of course, there are other studies on the topic that say otherwise and England isn't the same as the United States. Time will tell.

One last point: the good news about the JAMA paper is that the detection of high blood pressure seems to pay off. If population-based detection and pursuit of hypertension is what counts and it's independent of the availability of primary care physicians, there are other population-based solutions available. It's called disease management. Examples are here and here.

Image from Wikipedia

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