A country's primary care needs is not just a question of numbers; increasing the amounts of primary care services or making patients routinely see a GP (general practitioner, primary care physician) does not necessarily guarantee that the patient will experience better outcomes, says a report from the Dartmouth Atlas Project. The authors found that people's access to primary care, the quality of care, and the likelihood of being hospitalized varied considerably from area to area.

The report found that improving people's access to primary care alone does not always keep patients with chronic diseases out of hospital, neither does it always improve their chances of receiving the best care recommended for their conditions, or improve health outcomes.

David C. Goodman, M.D., M.S., lead author and co-principal investigator for the Dartmouth Atlas Project, said:

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. 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.

Racial disparities in quality and outcomes might not be overcome just by increasing access to primary care, the authors found. Although African-Americans had half the chance of seeing a primary care clinician and had an 84% higher risk of being hospitalized than Caucasians within areas, these disparities were less pronounced than differences across locations.

Patients receive care of widely varying quality, depending on where they live and what health system provider they have, regardless of race or income, the authors write.

During the period 2003 to 2007, 77.6% of beneficiaries visited a primary care clinician annually. However, an individual's chances to having an annual primary care visit varied enormously, depending on their address; from 60% of beneficiaries in the Bronx, New York and Manhattan to almost 90% in Wilmington North Carolina - a difference of about 50%.

The differences between races within the same regions were found to be much smaller than the differences across regions. 70.4% of African-Americans had at least one annual visit during 2003-2007 compared to 78.1% of whites - a difference of 11%.

In Waterloo, Iowa, however, 88.7% of African-Americans had an annual primary care visit, compared to 86.5% of whites. Compare that to 42.9% of African Americans and 79.8% of whites in Olympia, Washington.

There is no correlation between the supply of physicians and access to primary care if one looks at the relationship between the per capita supply of total primary care physicians and the percentage of Medicare beneficiaries who had at least one annual visit with a primary care physician during 2003-2007.

In Wilmington, North Carolina, where the overall primary care physician supply was low - 69 primary care physicians per 100,000 inhabitants - a relatively high proportion of beneficiaries had at least one visit (87.4%).

Compare that to White Plains, New York, with 101.4 primary care physicians per 100,000 inhabitants, and less than 70% of beneficiaries saw a primary care clinician annually.

Elliott S. Fisher, M.D., M.P.H., report author and co-principal investigator for the Dartmouth Atlas Project, said:

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. As is often the case in health care - it's not always how much you spend, but how you spend it.

The authors add that there is compelling evidence that the primary care physician can play a vital role in making sure that patients receive high-quality care. However, in spite of the central role that primary care can play, access is not necessarily enough to ensure patients receive the best care or better outcomes.

"Regional and Racial Variation in Primary Care and the Quality of Care among Medicare Beneficiaries"
Shannon Brownlee, MS, Chiang-Hua Chang, PhD, Elliott S. Fisher, MD, MPH, Editor: Kristen K. Bronner, MA
A report of the Dartmouth Atlas Project

Written by Christian Nordqvist