Impact of Primary Care a Focused Review

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HindawiPublishingCorporation
Scienti�ca
Volume2012,ArticleID432892,22pages
http://dx.doi.org/10.6064/2012/432892
Review Article
The Impact of Primary Care: A Focused Review
LeiyuShi
JohnsHopkinsBloombergSchoolofPublicHealth,624NorthBroadway,Baltimore,MD21205,USA
CorrespondenceshouldbeaddressedtoLeiyuShi,[email protected]
Received27September2012;Accepted8November2012
AcademicEditors:K.Eriksson,A.P.Giardino,G.Mastrangelo,andP.J.Schluter
Copyright©2012LeiyuShi.isisanopenaccessarticledistributedundertheCreativeCommonsAttributionLicense,which
permitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkisproperlycited.
Primarycareservesasthecornerstoneinastronghealthcaresystem.However,ithaslongbeenoverlookedintheUnitedStates
(USA),andanimbalancebetweenspecialtyandprimarycareexists.eobjectiveofthisfocusedreviewpaperistoidentifyresearch
evidenceonthevalueofprimarycarebothintheUSAandinternationally,focusingontheimportanceofeffectiveprimarycare
servicesindeliveringqualityhealthcare,improvinghealthoutcomes,andreducingdisparities.Literaturesearcheswereperformed
inPubMedaswellas“snowballing”basedonthebibliographiesoftheretrievedarticles.eareasreviewedincludedprimarycare
de�nitions,primarycaremeasurement,primarycarepractice,primarycareandhealth,primarycareandquality,primarycare
andcost,primarycareandequity,primarycareandhealthcenters,andprimarycareandhealthcarereform.Inbothdeveloped
anddevelopingcountries,primarycarehasbeendemonstratedtobeassociatedwithenhancedaccesstohealthcareservices,better
healthoutcomes,andadecreaseinhospitalizationanduseofemergencydepartmentvisits.Primarycarecanalsohelpcounteract
thenegativeimpactofpooreconomicconditionsonhealth.
1.Introduction theworld.Forexample,intheUSA,in2008,among954,224
total doctors of medicine, 784,199 were actively practicing
Primarycareservesasthecornerstoneforbuildingastrong
and305,264werepracticinginprimarycarespecialties(32
healthcare system that ensures positive health outcomes
of the total and 39 of actively practicing physicians) [7].
and health equity [1, 2]. In the past century, there has
eproportionofspecialistswasover60 ofallpatientcar%e
been a transition in healthcare from focusing on disease-
physicians. %
oriented etiologies to examining the interacting in�uences
emajordrivingforcebehindthein%creasingnumberof
of factors rooted in culture, race/ethnicity, policy, and
medicalspecialistsisthedevelopmentofmedicaltechnology.
environment. Such a transition called for person/family-
e rapid advances in medical technology continuously
focused and community-oriented primary care services to
expanded the diagnostic and therapeutic options at the
be provided in a continuous and coordinated manner in
disposal of physician specialists. e majority of patients,
order to meet the health needs of the population. In 2001,
signi�cantlyfreedfrom�nancialconstraintsthankstothird-
the World Health Organization (WHO) proposed a global
party insurance payment, have turned to physicians who
goalofachievinguniversalprimarycareinthesixdomains
can provide them with the most up-to-date, sophisticated
establishedbythe1978Alma-AtaDeclaration:�rstcontact,
treatment. Hence, the rapid advance of medical technology
longitudinality,comprehensiveness,coordination,personor
contributestothedemandforspecialtyservicesandprovides
family-centeredness, and community orientation. ese six
animpetusforfurtherspecialtydevelopment.
attributes,agreeduponinternationally,haveprovedeffective
inidentifyingbreadthofprimarycareservicesandmonitor- In addition, signi�cantly higher insurance reimburse-
ingprimarycarequality[3–6]. ment for specialists relative to primary care physicians
However, despite near consensus around the world that also contributes to the current imbalance. Under the
primarycareisacriticalcomponentofanyhealthcaresystem, resource-based relative value scale (RBRVS), implemented
thereisaconsiderableimbalancebetweenprimaryandspe- forUSMedicarephysicianpayment,primarycarephysicians
cialtycareintheUnitedStates(USA)andmanyotherpartsof continue to receive lower payments than specialists for
2 Scienti�ca
comparableworkbecausephysicianpaymentsarebasedon satisfy the inclusion criteria were discarded. e resulting
historically determined, estimated practice costs as well as referenceswererequiredtoberelatedtoprimarycarequality
totalworkeffort[8,9].Moreover,manyinsurancecompanies andoutcomestudies.Articlesfocusingonclinicalprocedures
will pay for hospital-based complex diagnostic and inva- wereexcludedsincethefocusofthispaperwasonthegeneral
sive procedures using high technology, but not for routine characteristicsofprimarycare.Additionalimportantarticles
preventive visits and consultations. Such practices not only were subsequently located by examining the bibliographies
encouragemedicalstudents’careerchoicesinsubspecialties of the retrieved articles. e content areas to be reviewed
and practicing physicians’ provision of intensive specialty include the following: primary care de�nitions, primary
services, but also discourage the provision of important caremeasurement,primarycarepractice,primarycareand
primary care services and deter patients from early care- health, primary care and quality, primary care and cost,
seekingbehavior. primarycareandequity,primarycareandhealthcenters,and
Specialist physicians enjoy other bene�ts as well. �ot primarycareandhealthcarereform.
only do specialists earn signi�cantly higher incomes than
primary care physicians, but also they are more likely to (cid:19)(cid:15)(cid:18)(cid:15) (cid:49)(cid:83)(cid:74)(cid:78)(cid:66)(cid:83)(cid:90) (cid:36)(cid:66)(cid:83)(cid:70) (cid:37)(cid:70)(cid:277)(cid:79)(cid:74)(cid:85)(cid:74)(cid:80)(cid:79)(cid:84)(cid:15) e terms “primary care”
havepredictableworkhoursandenjoyhigherprestigeboth and “primary healthcare” describe two different concepts.
amongtheircolleaguesandfromthepublicatlarge[10,11]. eformer,primarycare,referstofamilymedicineservices
Problemstypicallycitedinrecruitingprimarycarephysicians typicallyprovidedbyphysicianstoindividualpatientsandis
include longer working hours during the day as well as on person-oriented,longitudinalcare[20].Primaryhealthcare,
call, less �nancial reward for service, and less access to the in contrast, is a broader concept intended to describe both
highly technological approaches to diagnosis which is an individual-level care and population-focused activities that
important part of the medical center approach to patient incorporate public health elements. In addition, primary
care [12]. Among factors affecting medical students’ career healthcare may include broader societal policies such as
choice, society’s perception of value, intellectual challenge, universalaccesstohealthcare,anemphasisonhealthequity,
andlifestylefactors(e.g.,hoursworked)wererankedasvery andcollaborationwithinandbeyondthemedicalsector[20].
importantalongwith�nancialreward[13–15].emedical Primarycareplaysacentralroleinahealthcaredelivery
education environment, organized according to specialties system.Otheressentiallevelsofcareincludesecondaryand
and controlled largely by those who have achieved their tertiary care, which encompass different roles within the
leadershippositionsbydemonstratingtheirabilityinnarrow healthspectrum.Comparedtoprimarycare,secondaryand
scienti�c or clinical areas, emphasizes technology intensive tertiary care services are more complex and specialized,
procedures,andtertiarycaresettingsalsodeterthechoiceby andthetypesofcarearefurtherdistinguishedaccordingto
studentsofprimarycarespecialties[16,17]. duration,frequency,andlevelofintensity.Secondarycareis
Perhapsthemostimportantreasonforthisimbalanceis usually short-term, involving sporadic consultation from a
the lack of appreciation for the true value of primary care. specialisttoprovideexpertopinionand/orsurgicalorother
�elative to disease-speci�c research, primary care-oriented advancedinterventionsthatprimarycarephysicians(PCPs)
studies have been relatively few. eir dissemination and are not equipped to perform. Secondary care thus includes
recognitionwithinthemedical�eldarealsoproblematic.Pol- hospitalization, routine surgery, specialty consultation, and
icymakersandthegeneralpublicalsohavelittleknowledge rehabilitation.Tertiarycareisthemostcomplexlevelofcare,
oftheefficacyofprimarycare,itsimpactonindividualand needed for conditions that are relatively uncommon. Typ-
populationhealth,anditsroleintoday’shealthcaredelivery. ically, tertiary care is institution-based, highly specialized,
eserealitieshaveledtosuper�uouspoliticalcommitments and technology-driven. Much of tertiary care is rendered
and the disengagement of related sectors [18, 19]. A WHO in large teaching hospitals, especially university-affiliated
2000reportannouncedthatprimarycarehasfailedtoserve teaching hospitals. Examples include trauma care, burn
asthefoundationofcareforallpeople[2]. treatment, neonatal intensive care, tissue transplants, and
e objective of this focused review paper is to present open heart surgery. In some instances, tertiary treatment
the research �ndings regarding the efficacy of primary care maybeextended,andthetertiarycarephysicianmayassume
so that the value of primary care can be better appreciated. long-termresponsibilityforthebulkofthepatient’scare.It
Speci�cally, it will demonstrate the importance of effec- has been estimated that 75 to 85 of people in a general
tive primary care services in delivering quality healthcare, populationrequireonlyprimarycareservicesinagivenyear;
improvinghealthoutcomes,andreducingdisparities. 10 to 12 require referra%ls to sh%ort-term secondary care
services;5 to10 usetertiarycarespecialists[21].
%Sinceit%sintroductionin1961,thetermprimarycarehas
2.Methods
been de�n%ed in v%arious ways, o�en using one or more of
the following categories of classi�cation [4, 22–24]. ese
LiteraturesearcheswereperformedinPubMedusingthefol-
categoriesincludethefollowing.
lowingkeysearchterms:primarycare(alsogeneralpractice,
familymedicine)andquality,performance,healthoutcome, (i)e care provided by certain clinicians, the Clinton
andhealthequity.esearchwaslimitedtoEnglishlanguage administration’s Health Security Act, for example,
journals. e titles and abstracts of all papers identi�ed by speci�ed primary care as family medicine, general
the electronic search were inspected. Papers that failed to internal medicine, general pediatrics, and obstetrics
Scienti�ca 3
andgynecology.Someexpertsandgroupshavealso traditionalmedicineprofessionals(suchasinpartsofAsia).
includednursepractitionersandphysicianassistants. Depending on the nature of the health condition, patients
maythenbereferredforsecondaryortertiarycare.
(ii)Asetofactivitieswhosefunctionsactasthebound-
�erhaps the most comprehensive de�nition of primary
aries of primary care—such as curing or alleviating
care was given by Star�eld in her landmark book Primary
commonillnessesanddisabilities.
care: balancing health needs, services and technology [4];
(iii)Alevelofcareorsetting—anentrypointtoasystem
Star�eldde�nedprimarycareastheprovisionofintegrated,
that also includes secondary care (by community
accessiblehealthcareservicesbyclinicianswhoareaccount-
hospitals) and tertiary care (by medical centers and
able for addressing a large majority of personal healthcare
teachinghospitals).
needs,developingasustainedpartnershipwithpatients,and
(iv)A set of attributes, as in the 197� IO� de�ni- practicing in the context of family and community. She
tion—carethatisaccessible,comprehensive,coordi- summarizedthefollowingcharacteristicsofprimarycare(pp.
nated, continuous, and accountable—or as de�ned 19–34).
by Star�eld [4]—care that is characterized by �rst
contact, accessibility, longitudinality, and compre- (i)Integrated care is intended to encompass the provi-
hensiveness. sionofcomprehensive,coordinated,andcontinuous
servicesthatprovideaseamlessprocessofcare.Inte-
(v)A strategy for organizing the healthcare system as a
grationcombinesinformationabouteventsoccurring
whole—such as community-oriented primary care,
indisparatesettingsandlevelsofcareaswellasover
which gives priority and resources to community-
time,preferablythroughoutthelifespan.
based healthcare while placing less emphasis on
hospital-based,technology-intensive,andacute-care (ii)Comprehensivecareaddressesanyhealthproblemat
medicine. anygivenstageofapatient’slifecycle.
(iii)Coordinated care ensures the provision of a combi-
De�nitions of primary care o�en focus on the type or
nation of health services and information to meet
level of services, such as prevention, diagnostic and thera-
a patient’s needs. It also refers to the connection
peuticservices,healtheducationandcounseling,andminor
between, or the rational ordering of, those services,
surgery.Althoughprimarycarespeci�callyemphasizesthese
includingtheresourcesofthecommunity.
services,manyspecialistsalsoprovidethesamespectrumof
services.Forexample,thepracticeofmostophthalmologists (iv)Continuouscareisacharacteristicthatreferstocare
has a large element of prevention, as well as diagnosis, overtimebyasingleindividualorteamofhealthcare
treatment, followup, and minor surgery. Similarly, most professionals (“clinician continuity”) as well as to
cardiologistsareengagedinhealtheducationandcounseling. effective and timely maintenance and communica-
Hence, according to some experts, primary care should be tionofhealthinformation(events,risks,advice,and
more appropriately viewed as an approach to providing patientpreferences)(“recordcontinuity”).
healthcare,ratherthanasasetofspeci�cservices[21].
(v)Accessiblecarereferstotheeasewithwhichapatient
e World Health Organization (WHO) describes pri- caninitiateaninteractionforanyhealthproblemwith
marycareasessentialhealthcarebasedonpractical,scienti�- aclinician(e.g.,byphoneoratatreatmentlocation)
callysound,andsociallyacceptablemethodsandtechnology and includes efforts to eliminate barriers such as
madeuniversallyaccessibletoindividualsandfamiliesinthe those posed by geography, administrative hurdles,
communitybymeansacceptabletothemandatacostthatthe �nancing,culture,andlanguage.
communityandthecountrycanaffordtomaintainatevery
(vi)Healthcare services refer to an array of services
stageoftheirdevelopmentinaspiritofself-relianceandself-
that are performed by healthcare professionals or
determination.Itformsanintegralpartofboththecountry’s
undertheirdirection,forthepurposeofpromoting,
healthsystem(ofwhichitisthecentralfunction)andamain
maintaining, or restoring health. e term refers
focusoftheoverallsocialandeconomicdevelopmentofthe
to all settings of care (such as hospitals, nursing
community.Itisthe�rstlevelofcontactforindividuals,the
homes,physicians’offices,intermediatecarefacilities,
family,andthecommunitywiththenationalhealthsystem,
schools,andhomes).
bringinghealthcareascloseaspossibletowherepeoplelive
and work, and constitutes the �rst element of a continuing (vii)A clinician is an individual who uses a recognized
healthcareprocess[25]. scienti�c knowledge base and has the authority to
direct the delivery of personal health services to
Othersde�neprimarycareasthehealthservicesrendered
patients.
byprovidersactingastheprincipalpointofconsultationfor
patients within a healthcare system [26, 27]. is provider (viii)Accountability is applied to primary care clinicians
could be a primary care physician, such as a general prac- and the systems in which they operate. ese clin-
titioner or family physician, or (depending on the locality, icians and systems are responsible to their patients
health system organization, and the patient’s discretion) a and communities for addressing a large majority of
pharmacist, a physician assistant, a nurse practitioner, a personal health needs through a sustained partner-
nurse (as is common in the United Kingdom), a clinical ship with a patient in the context of a family and
officer(suchasinpartsofAfrica),oranAyurvedicorother community and for (1) quality of care, (2) patient
4 Scienti�ca
satisfaction, (3) efficient use of resources, and (4) care (�rst contact, longitudinality, comprehensiveness, and
ethicalbehavior. coordination) and three supplementary aspects of primary
care (family centeredness, community orientation, and cul-
(ix)A majority of personal healthcare needs refer to
tural competence). e �rst PCAT-adult questionnaire was
the essential characteristic of primary care clini-
developedandvalidatedintheUSA[31,32]butitsvalidity
cians: that they receive all problems that patients
and reliability have been demonstrated in other countries,
bring—unrestricted by problem or organ system—
such as in Brazil [33] and Spain [34]. Several forms of
andhavetheappropriatetrainingtomanagealarge
the PCAT exist, varying in length and target population.
majority of those problems, involving other prac-
For example, while the Primary Care Assessment Tool-
titioners for further evaluation or treatment when
Adult Edition’s (PCAT-AE) original form includes 74 items
appropriate.Personalhealthcareneedsincludephys-
assessingadultpatientexperienceswithprimarycare[31,32]
ical, mental, emotional, and social concerns that
ashort10-itemversion,thePCAT10-AEhasalsobeenused
involvethefunctioningofanindividual.
andintegratedintoanationalpopulationhealthsurvey[34].
(x)Sustainedpartnershipreferstotherelationshipestab- APCATassessingtheprimarycareexperiencesofchildren
lished between the patient and clinician with the has been developed as well [33, 35]. In addition to these
mutual expectation of continuation over time. It questionnairestargetingpatients,versionsofthePCAThave
is predicated on the development of mutual trust, beendevelopedthatalsosurveyprovidersandadministrators
respect,andresponsibility. offacilities,providinganotherperspectiveontheprovisionof
primarycare[36].
(xi)A patient is an individual who interacts with a InadditiontothePCATcollectionofsurveyinstruments,
clinicianeitherbecauseofrealorperceivedillnessor researchers have used other surveys to measure aspects
forhealthpromotionanddiseaseprevention. of primary care provision from the patient and provider
perspective in the USA and in international settings. ese
(xii)Context of family and community refers to an
include the Health Tracking Physician Survey [37], the
understandingofthepatient’slivingconditions,fam-
InternationalHealthPolicySurvey[38],andtheAmbulatory
ily dynamics, and cultural background. Community
CareExperiencesSurvey[39].Otherstudieshaveusedclaims
refers to the population served, whether they are
data[40,41]andmedicalrecordreview[40,42–44]toassess
patientsornot.Itcanrefertoageopoliticalboundary
the quality, performance, and cost-effectiveness of primary
(a city, county, or state), members of a health plan,
careinvarioussettings.
orneighborswhosharevalues,experiences,language,
Medical experts have de�ned standards of practice for
religion,culture,orethnicheritage.
assessment of providers or facilities in terms of whether
they are practicing according to recommended guidelines
2.2. Primary Care Measurement. Measurement enables [38, 44]. For example, a survey �elded in �ve countries
assessment of the performance of a healthcare delivery determined that the USA performed well in delivering
systemandindividualproviders.Additionally,measurement preventivecareaccordingtoclinicalguidelines[38],hypoth-
facilitates efforts to improve accountability, quality, appro- esizingthatthisresultmightbeduetothirdpartyinsurers’
priateuseofresources,andpatientoutcomesandtolowerthe increasing emphasis on quality measurement using tools
riskofadverseevents[28].Measurementisalsoincreasingly such as the National Committee for Quality Assurance’s
tied to healthcare �nancing through pay-for-performance (NCQA)HealthcareEffectivenessDataandInformationSet
programs. As the USA attempts to emphasize primary (HEDIS). In addition to HEDIS, other indicators, such as
care functions through aspects of the Patient Protection the Diabetes Quality Improvement Project [40], have been
and Affordable Care Act [29], measurement of primary developed to support measurement of the quality of care
care will take on even greater importance. Shi notes that providedinaprimarycaresettingforaparticularcondition.
assessments of the quality of primary care patients receive Manymeasuresofperformanceandqualityinthehealthcare
should consider the four dimensions of primary care: the setting are disease-speci�c. �iven primary care’s emphasis
�rst contact experience, longitudinality, coordination, and on patient-centered and comprehensive care, these disease-
comprehensiveness[30]. speci�cmeasuresmaynotbemostusefulfortheprimarycare
Researcherscanusevarioustypesofindicatorsdepend- context.Othermeasurementeffortsattempttomovebeyond
ingonthegoalofmeasurement[28].Indicatorscanprovide condition-speci�cindicators.Hospitalizationforambulatory
some sense of the structure, process, or outcome of care, care sensitive conditions (ACSC), de�ned as �diagnoses for
can be used to measure activity, performance, and quality, whichtimelyandeffectiveoutpatientcarecanhelptoreduce
and can help determine whether the care is being provided the risk of hospitalization” [45], has been proposed as a
according to guidelines speci�ed by an expert body or way to assess access to care and as an outcome measure
consensus[28]. of the effectiveness of prior primary care intervention [41].
ePrimaryCareAssessmentTool(PCAT)isacollection However, research has shown that ACSC-related hospital-
of questionnaires, developed by Johns Hopkins Primary izations may occur too infrequently and be too difficult to
Care Policy Center under the leadership of the late Dr. linkwithpreviousreceiptofprimarycaretoserveasaviable
Barbara Star�eld, that assess whether a healthcare provider outcomemeasure[41].Ontheotherhand,increasedaccess
or system is achieving the four core functions of primary to healthcare services is accomplished through expanded
Scienti�ca 5
insurancecoverage,thusalsoenablinggreater�nancialaccess claimsdataandmedicalchartabstraction.Giventhenature
to hospital resources. erefore, studies using preventable ofprimarycarepractice,indicatorsthatarepatient-centered
hospitalizationsasoutcomemeasurestoexaminetheimpacts ratherthandisease-speci�carelikelygoingtobeincreasingly
of primary care access should consider how that improved importantinenablingamoreaccurateassessmentofthecare
access is being facilitated [46]. Another survey attempting patientsreceive.
toidentifygoodindicatorsaskedphysiciansaboutthetypes
of patient outcomes that they value as good indicators of
2.3. Primary Care Practice. Many countries place great
primarycareproviders’performance;respondentsidenti�ed
emphasis on primary care and have developed strong pri-
nineteen indicators related to patients’ physical function-
marycareinfrastructures[52–54].ExamplesincludeBritain’s
ing, physical pain, physical symptoms besides pain, clinical
National Health Service (NHS), which established Primary
indicators,emotionaldistress,healthbehaviors,andgeneral
Care Trusts (PCT) that integrate primary and hospital-
qualityoflife.
based care and comprise the bulk of the NHS budget [52,
Other literature examines the measurement of primary
55]. Canada has a more balanced primary care-specialist
care with respect to unique populations, particular models
physicianratiothantheUSAwithonly10 morespecialists
of care, or atypical settings [39, 47, 48]. One challenge
thanprimarycarephysicians,incontrasttoover50 morein
is measuring care provided to complex patients (patients
theUSA[56].Developingcountries,likeBr%azilandailand,
withmultiplechronicconditions),giventhatdisease-speci�c
have also implemented national-level strategies to%increase
measures are ill-suited for this population [48]. erefore,
accesstoprimarycareservices[57,58].
indicatorsofthecontinuityandcoordinationaspectsofpri-
Anincreasinglypopularmodelfororientingthehealth-
marycareprovisionareparticularlyimportantforassessing
caresystemtoprimarycareisthegatekeepermodel,which
thequalityofcarethiscomplexpopulationexperiences[48].
requires patients to select a primary care physician (PCP)
Given the increasing emphasis on patient-centered medical
and then obtain referrals through that PCP to specialists
homes(PCMH),measuringtheimpactofmultidisciplinary
[59].However,gatekeepermodelsmaymeetresistancefrom
teams(incontrasttoindividualproviders)maybettereluci-
medicalprofessionalsandconsumersinsomecountries[60].
date the patient experience of care in PCMH settings [39].
erefore, efforts to promote gate keeping in a healthcare
However, NCQA standards to assess medical homes may
systemshouldconsidergradual,incentive-drivenapproaches
notbeappropriateforallpracticesettings;forexample,the
[60].
military health system confronts different challenges when
In conjunction with acting, in some systems, as gate-
establishing medical homes related to deployment and the
keepers to more specialized services, PCPs also may serve
frequentmovementofpatientsandproviders[47].
aspatients’pointof�rstcontactwiththehealthcaresystem.
Finally, the facilitators and barriers to implementing
Many countries have expanded access to primary care by
quality measurement in primary care were systematically
establishingcallcenters,�exiblehours,andclinics.Spain,for
reviewed in a study on primary care in Canada [49]. Con-
example,hassoughttomakecareaccessiblebothin�nancial
tent analysis of the 57 English-language articles published
andgeographicterms,byenactinguniversalinsurancecover-
between1996and2005identi�edsevencommoncategories
ageandstrivingtomakehealthcarefacilitiesavailablewithin
of facilitators and barriers for implementing innovations,
��eenminutestoeverypersoninneed[61].
guidelines, and quality indicators. e authors found that
successful implementation of quality measures can occur Continuity of care is also promoted through structures
but that success depends on the interaction of multiple suchasmedicalhomesorwell-developedhealthinformation
factors,includingmeasurementcharacteristics,promotional technology (health IT) systems [59]. In Spain, for exam-
messages,implementationstrategies,resources,theintended ple, nearly every resident has an identi�cation card that
adopters,andtheintraorganizationalandinterorganizational enablesproviderstoaccesstheirmedicalhistoryandrelevant
contexts. Research has also found that the nature of the information at an appointment or emergency [61]. ese
relationship between the patient and PCP impacts patients’ countrieshavealsosoughttoraisethestatusofprimarycare
perception of the quality of care they are receiving [50] byestablishingthedisciplineasaspecialtywithinmedicine
and correlates positively with measures of primary care andinstitutingreformstopaymentsystems[59].
providerperformance[51].However,whilethequalityofcare Team-based models of providing primary care and the
patientsreceivemaybeheavilyimpactedbythestrengthof connections of these models with quality are becoming
connection patients feel with their providers, research has increasinglyimportantasinsurersusepay-for-performance
found that patients generally do not feel well connected to incentives in payment schemes [62]. In order to support
theirPCPs[51]. high-functioning teams, the associations between team-
In summary, primary care measurement includes tools level job satisfaction and performance should be explored,
that assess many aspects of care: the extent to which a a relationship which may be affected by the status and
primarycaresettingful�llsthemajorcomponentsofprimary supportenjoyedbythePCPsinasetting[62].Researchalso
care;theperformanceoftheproviderorfacility;thequality suggests that the functioning level of primary care teams
of care patients receive; how facets of care delivery, such may affect patient outcomes, with those patients cared for
as various models of care, team approaches, and different byhighfunctioningprimarycareteamsexperiencingbetter
settings, impact care. Tools to collect data include primary health outcomes [63]. Team-based approaches to primary
data collection from surveys and secondary analysis using care may also facilitate integration of mental health and
6 Scienti�ca
primarycare.Asanexample,theUSA-basedIntermountain Inordertoaddressthesefears,moreresearchisneededon
Healthcare’smentalhealthintegrationsystemincludesPCPs, thecapabilitiesandcapacitiesofthecurrentPCPworkforce,
psychiatrists, nurses, family members, and other parties to as well as projections about how it will change over time.
integrate mental health services into the usual practice of Indeed, a 2011 Robert Wood Johnson Foundation (RWJF)
primarycare[64]. report observes that workforce projections are complicated
Scopeofpractice,theextentofhealthinsurancecoverage [66].ereportcautionsthatalthoughtheworkforceislikely
in a region, ease of coordination with other sectors, and to be strained by the country’s changing demographics and
myriadotherfactorsimpactthewayinwhichprimarycare increasing demand under the ACA, other clinicians, such
is practiced in a country, region, or individual practice. as NPs and PAs, in addition to new team-based models of
Countries that have enacted reforms that build on their care, may change primary care workforce needs in unan-
existingprimarycareinfrastructurescanserveascasestudies ticipated ways [66]. Nevertheless, the irregular distribution
for the USA, where the ongoing implementation of the of providers in the USA remains a signi�cant issue that is
Patient Protection and Affordable Care Act (ACA) seeks to likelytocontinueinhibitingaccesstoprimarycareservices
enhancetheroleofprimarycareintheUShealthcaresystem. amongparticularsegmentsofthepopulationandincertain
Currently,incontrasttosomeofitsindustrializedpeers, geographicregions[66].
the US healthcare system is much more heavily skewed Nextstepsandfuturedirectionshavebeenidenti�edto
toward specialty care [56, 58]. Although 51.3 of office strengthentheprimarycareinfrastructureabroadandinthe
visits were to primary care physicians in 2008, only about USA.Tostart,therehasbeenincreasinginterestinexploring
one-third of practicing physicians specialize %in primary howprimarycareandpublichealthmightbettercoordinate
care [65]. A combination of primary care physicians, nurse in order to support population health improvement efforts
practitioners(NPs),andphysicianassistants(PAs)comprise [75,76].Areviewofliteratureonthecoordinationofprimary
the estimated 400,000 primary care providers in the USA, care with public health suggests that combinatory efforts
withphysicianscontributingthelargestportion(74 )[66]. can lead to improvements in the management of chronic
ScopesofpracticeforNPsandPAshavebroadenedinmany diseases,controlofcommunicablediseases,andinmaternal
states in recent years, enabling these providers to%take on andchildhealth[76].Inaddition,thereisneedforadditional
more responsibilities in the provision of care. However, the clari�cationontheuniquerolesofprimarycareandpublic
distributionofprimarycareprovidersintheUSAisuneven, healthandthewaysinwhichthesesectorscanworktogether
with 5,902 communities designated as primary care health [77].
professionalshortageareas[67]. In the USA in particular, new models of delivering
Changes to the Medicare fee schedule (which had pre- carethroughpatient-centeredmedicalhomes(PCMHs)and
viously favored specialists in reimbursement rates) [68], accountable care organizations (ACOs) require team-based
support for Title VII health professions training programs approaches to care with a heavy emphasis on primary care.
[69,70],andtherecentACAaresomeexamplesofpolicies Aspreviouslydiscussed,someexpertssuggestthattheshi
that have attempted to strengthen the role of primary care tothesemodelsfordeliveringcarewillrequireanincreased
within the US healthcare system. Some experts have sug- supply of primary care providers [58] whereas others note
gestedthattheACAandtheagingpopulationwillplacean that little is de�nitively known about how these models of
increasedburdenontheprimarycareworkforceintheUSA, care will impact provider productivity [66]. is renewed
contributingtoasevereworkforceshortageinthefuture[71]. interestinimprovingprimarycarecapacityhasledtosome
Although about one-third of practicing physicians work in recommended initiatives for enhancing the stature of pri-
primary care, less than a fourth of current medical school marycareintheUSA,includingincreasingTitleVIIfunding
graduates are pursuing careers in primary care �elds, and to better support the education of primary care providers
many primary care physicians are projected to retire in thatagreetopracticeinunderservedcommunities[69,70];
comingyears,raisingadditionalconcernsthatthefutureUS addressing salary disparities between PCPs and specialists
primary care workforce will be unable to respond to the by changing Medicare’s resource-based relative value scale
growingdemandforprimarycare[72].Afactorcontributing to give more equal reimbursement, which also in�uences
tothesmallpercentageofgraduatingmedicalstudentsthat private insurance reimbursement rates [78]; exploring the
pursueresidenciesinprimarycareisthesigni�cantlylower rolethatotherprimarycareproviders,suchasNPsandPAs,
salaries in these �elds, a trend that has continued despite canplayinreducingburdensonprimarycarephysicians[66].
someeffortstoreducethisdisparity[71,73]. Additional research is obviously needed; topics that should
Similarly, in order to incentivize providers to accept beexamined includethemethodsandtoolsforconducting
patients newly eligible for Medicaid under the reforms, the research on primary care, clinical issues of relevance to the
ACA temporarily raises reimbursement for PCPs serving practiceofprimarycare,primarycareservicedelivery,health
Medicaid patients to the same level as Medicare reim- systems (including the social and political factors affecting
bursements [74]. However, a study found that those states primarycareprovision),andhowtoimprovetheeducation
that have a low supply of PCPs serving Medicaid enrollees andtrainingofprimarycareproviders[54].
already have higher reimbursement levels [74]. erefore,
thisincreasemayhavelittleeffectinincreasingthesupplyof 2.4.PrimaryCareandHealth. Logically,primarycareisseen
PCPsavailabletocarefordisadvantagedgroups,suchasthe as an important medical specialty and healthcare necessity
Medicaidpopulation. because it is assumed to have a positive impact on health
Scienti�ca 7
outcomes; the USA and most other countries believe that and fewer laboratory and diagnostic tests. Total medical
increasingthequalityandquantityofprimarycareservices chargesfortheyearwerealsosigni�cantlyreduced.
willleadtobetterpopulationhealth.Anumberofecological Another US study examined the relationship between
studieshaveexaminedtherelationshipbetweenprimarycare physician-patient connectedness and measures of physician
infrastructure and health outcomes internationally [79–83] performance [51]. 155,590 patients who made one or more
as well as in the USA at various levels of geographic units visits to a study practice from 2003 to 2005 in the Mas-
[84,85].Studiesconductedinindustrializedcountries,such sachusetts General Hospital adult primary care network
asmembernationsoftheOrganizationforEconomicCoop- were identi�ed, and a validated algorithm was used to
erationandDevelopment(OECD),doindicatethatstronger connect patients to physicians or practices. Performance
primary care systems are generally associated with better measures, including breast, cervical, and colorectal can-
populationhealthoutcomesincludinglowermortalityrates, cer screening in eligible patients, hemoglobin A1C mea-
ratesofprematuredeathandhospitalizationsforambulatory surement and control in patients with diabetes, and low-
care sensitive conditions, and higher infant birth weight, density lipoprotein cholesterol measurement and control in
life expectancy, and satisfaction with the healthcare system patients with diabetes and coronary artery disease, were
[79,80,82,86].StudiesintheUSAhavealsoindicatedthat usedtoexamineclinicalperformance.eresultsindicated
greaterprimarycareavailabilityinacommunityiscorrelated that physician-connected patients were signi�cantly more
with both better health outcomes [87] and a decrease in likelythanpractice-connectedpatientstoreceiveguideline-
utilizationofmoreexpensivetypesofhealthservices,suchas consistent care. Receipt of preventive care varied more by
hospitalizationsandemergencydepartment(ED)visits[88]. whether patients were more or less connected to a primary
Experiencesintheinternationalcontextsuggestthatpri- carephysicianthanbyraceorethnicity,whichareoencited
marycare-orientedhealthcaredeliverysystemscanproduce asmajordeterminantsofhealthcareusage.
betterhealthoutcomes[52–55]inadditiontocounteracting, e role of primary care in referral was studied in a
to some extent, the negative impact of poor economic multicountryprojectinEuropeandAustralia[92].estudy
conditions on health [57]. Reforms of healthcare systems comparedweightlossachievedthroughstandardtreatment
to emphasize primary care generally are associated with in primary care versus weight loss achieved aer referral
improvedhealthoutcomes,includingevidencefromseveral by the primary care team to a commercial provider in the
countries in Latin America and Asia [83]. However, given community.Inthisparallelgroup,nonblinded,randomized
that these reforms typically included multiple components, controlled trial, 772 overweight, and obese adults were
attributingchangeinpopulationhealthtoanyoneaspectof recruited by primary care practices in Australia, Germany,
thereformisdifficult[83].Increasingprimarycareavailabil- and the UK to receive either 12 months of standard care,
ityinlow-andmiddle-incomecountriesalsocorrelateswith as de�ned by national treatment guidelines or 12 months
improvedhealth;however,manyofthesestudiesarelimited of free membership in a commercial program; analysis was
tochildandinfanthealthoutcomes[81].Additionally,much by intention to treat amongst the population who com-
oftheresearchinthissettingconsistsofobservationalstudies pleted the 12-month assessment. e results showed that
ratherthanmorerigorousresearchdesigns,andstudiesmay the participants referred to community-based commercial
also use different de�nitions of what constitutes a “primary providerslostmorethantwiceasmuchweightovertheyear
caresystem”or“program”[81]. as compared to those who received standard care. ese
InareviewofUSprimarycareanditsrelationshipwith results indicate that referral to a commercial weight loss
health outcomes, Star�eld et al. [89] note that there may program that provides regular weighing, advice about diet
be several mechanisms of primary care that explain this andphysicalactivity,motivation,andgroupsupportcanoffer
positiveassociationwithpopulationhealth:(1)betteraccess aclinicallyusefulearlyinterventionforweightmanagement
tohealthservices;(2)improvedqualityofcare;(3)emphasis in overweight and obese people and can be delivered on a
onprevention;(4)theidenti�cationandearlymanagementof largescaleaswell.However,italsodemonstratesthatprimary
conditions;(5)thecombinedimpactofmanycharacteristics carephysiciansandteamshavelimitsinthescopeandquality
ofsolidprimarycaresystems;(6)reductioninunnecessary of interventions they can provide; in this case, the primary
specialistcare[89,90]. care team provided better care through the referral to an
Primarycareandhealthserviceusewerealsostudiedin outsidecompanythanthroughtheteam-managedcareseen
theUSAusinganinteractionalanalysisinstrumenttochar- asstandard.
acterizepatient-centeredcareintheprimarycaresettingand eimpactofprimarycareoutreachwastestedinaCana-
examine its relationship with healthcare utilization [91]. A dian study [93] using a randomized, controlled trial design
totalof509adultpatientsatauniversitymedicalcenterwere to evaluate the impact of a provider-initiated primary care
randomizedintogroupsreceivingcarebyfamilyphysicians outreach intervention as compared with usual care among
orgeneralinternists.AnadaptationoftheDavisObservation older adults at risk of functional decline. e sample was
Code was used to measure patient-centered practices; the comprisedof719patientsenrolledwith35familyphysicians
main outcome measures of the study were the patients’ use in�veprimarycarenetworksinHamilton,Ontario,Canada.
of medical services and accrued charges over one year. e e12-monthintervention,providedbyexperiencedhome
resultsindicatedthathigheramountsofpatient-centeredcare carenursesfrom2004to2006,consistedofacomprehensive
were related to a signi�cantly decreased annual number of initialassessmentusingtheResidentAssessmentInstrument
visits to specialty providers, less frequent hospitalizations, forhomecare,collaborativecareplanningwithpatients,their
8 Scienti�ca
families,andfamilyphysicians,healthpromotionactivities, (A1C) level in a primary care-based diabetes disease man-
andreferraltocommunityhealthandsocialsupportservices. agement program (DDMP) [96]. A total of 217 patients
e primary outcome measures were quality adjusted life withtype2diabetesmellitusandpoorglucosecontrolwere
years (QALYs), use and costs of health and social services, enrolled.eresultsshowedthatpatientsintheintervention
functionalstatus,self-ratedhealth,andmortality.eresults group had signi�cantly greater improvement in A1C level
forthemeandifferenceinQALYs,overallcostofprescription than the control group that received no additional disease
drugsandservices,andchangesover12monthsinfunctional managementsupport.Inmultivariateanalysis,nosigni�cant
statusandself-ratedhealthwerenotstatisticallysigni�cant. differences in A1C level improvement were observed when
erefore,theresultsofthisstudydonotsupportadoptionof strati�edbyage,race�ethnicity,income,orinsurancestatus,
thisparticularpreventiveprimarycareinterventionforthis andnointeractioneffectwasobservedbetweenanycovariate
targetpopulationofhigh-riskolderadults. andinterventionstatus.Laborinputsweresimilarregardless
Another study conducted in Pittsburgh, Pennsylvania, of age, race�ethnicity, sex, or education and may re�ect
examined the role of nurses in primary care [94]. is thenondiscriminatorynatureofprovidingalgorithm-based
studyevaluated�ndingsfromatrialtreatmentforbehavioral diseasemanagementcare.
problemsin163clinicallyreferredchildrenfromsixprimary eroleofprimarycareinpreventivecarehasalsobeen
careofficesinPittsburgh.Participantswererandomizedtobe studied. In a study conducted in Spain on physical activity
treatedineithertheon-site,nurse-administeredintervention promotion by general practitioners, researchers sought to
(PONI) in primary care or enhanced usual care (EUC) assess the effectiveness of a physical activity promotion
characterizedbyon-sitediagnosticassessmentandfacilitated program at 11 Spanish public primary care centers using
referraltoalocalmentalhealthprovider.emainoutcomes 6-, 12-, and 24-month follow-up measurements [97]. ey
were measured by standardized rating scales. e results recruited 4,317 individuals (2,248 intervention and 2,069
showedthatchildrenrandomizedtothePONIintervention control), and ��y-six general practitioners (�Ps) were ran-
weresigni�cantlymorelikelytoaccesstheirassignedtreat- domly assigned to intervention or standard care (control)
ment, received more direct treatment, adjunctive services, groups.eprimaryoutcomemeasurewasthechangeinself-
andalongerdurationoftreatment,andhadgreaterlevelsof reportedphysicalactivityfrombaseline.eresultsindicated
siblingparticipationthanchildrenassignedtoreceiveEUC. thatgeneralpractitionerswereeffectiveatincreasingthelevel
ese �ndings indicate that a psychosocial intervention for ofphysicalactivityamongtheirinactivepatientsduringthe
behavioral problems delivered by nurses in a primary care initialsixmonthsofaninterventionbuttheeffectleveledoff
settingisfeasible,improvesaccesstomentalhealthservices, at12and24months.Onlythesubgroupofpatientsreceiving
andhassomeclinicalefficacy.Optionsforenhancingclinical repeat prescriptions of physical activity maintained gains
outcomesmayincludemultifacetedcollaborativecareinter- overthelongterm.
ventionsinthepediatricpractice. Many people suffering from mental health issues also
e impact of primary care on chronic disease man- receivehealthservicesinaprimarycaresetting[98].Inthe
agement is the subject of much research. For example, a USA,anevaluationofaDepartmentofVeteransAffairs(VA)
USA-based study examined the impact of a multifaceted program establishing primary care clinics in underserved
intervention on cholesterol management in primary care communities found that while these clinics did improve
practices [95]. e study used a practice-based trial to test access to more general health services, without a spe-
the hypothesis that a multifaceted intervention consisting cialtymentalhealthcarecomponent,theydidnoteffectively
of guideline dissemination enhanced by a computerized expand access to mental health services [99]. Research is
decision support system (CDSS) would improve primary mixed on whether psychotherapy and counseling in the
care physician adherence to the ird Adult Treatment primary care setting is cost-effective but it does suggest
Panel(ATPIII)guidelinesandimprovethemanagementof that patients may be more open to these strategies than
cholesterol levels. A total of 61 primary care families and to antidepressant prescriptions, and psychotherapy may be
internal medicine practices in North Carolina enrolled in more effective in treating depression than counseling [98].
thetrial;29receivedtheirdAdultTreatmentPanel(ATP Researchhasfoundthatwhilecounselinginprimarycareis
III) intervention and 32 received an alternate intervention associatedwithshort-termimprovementandpatientsatisfac-
(JNC-7). e ATP III providers received a personal digital tion,thereislittleevidenceofitseffectiveness,incomparison
assistant providing the Framingham risk scores and ATP tousualcare,intreatingdepressioninthelongrun[100].
III-recommended treatment. ey examined 5,057 baseline Anoverviewoflow-andmiddle-incomecountriesfound
and 3,821 follow-up medical records. e study reports the that 14 countries, including China, with comprehensive
positive effect on screening of lipid levels and appropri- primary care (de�ned as 80 skilled birth attendance
ate management of lipid level test results and concludes rates) experienced health gains compared with countries
thatamultifactorialintervention,includingpersonaldigital with more selective primary>car%e approaches. ese health
assistant-baseddecisionsupport,mayimproveprimarycare improvementsseemedto“dependonprogressiontocompre-
physicianadherencetotheATPIIIguidelines. hensive primary care with a reliable referral system linking
In a US study that focused on diabetes disease man- to functioning facilities” [101, p. 958]. However, the study
agement, researchers used a randomized, controlled trial lookedatcountriesasawholeandsocouldnotaccountfor
to examine the relationships among patient characteristics, within-countryvariation,andadditionally,thestudyde�ned
labor inputs, and improvement in glycosylated hemoglobin countriesashavingcomprehensiveprimarycarebasedonly
Scienti�ca 9
upontheirskilledbirthattendancerates,andotherprimary and lower perceived �exibility in selecting a PCP [5, 107].
careattributeswerenotconsidered. Levelofaccesstoprimarycareimpactsotherfacetsofquality
In the USA, a growing body of research has focused as well. For example, improved access to primary care may
on the impact of primary care supply, infrastructure, and alsoimprovethecontinuityofcareforpatientswithdepres-
models of care on health outcomes. A review of studies sion [108]. An evaluation of a PCP access program found
assessing the relationship between supply of PCPs and thatbetteraccessledtoreducedemergencydepartmentuse
various outcomes, such as all-cause and disease-speci�c in the long term [109]. Family-centered primary care may
mortality, life expectancy, low birth weight, and self-rated also lower rates of nonurgent emergency department visits
health,foundcorrelationsatthestate,county,andMSAlevels andhospitalizationsforcertainpopulations[110].However,
[84]. Research also indicates that local supply of PCPs per arelationshipbetweenothermeasuresofqualityofprimary
capita,usingradiiaroundzipcodestode�neserviceareas,is care and urgent hospitalizations has not been established
associatedpositivelywithpatientreceiptofpreventivehealth [110,111].
servicesandthatthislocalprimarycareavailabilitymediates, e structure of the primary care delivery system may
tosomeextent,theimpactofsocioeconomicfactorsonthe alsoaffectlevelsofaccessandquality.Forexample,oneNew
receipt of preventive care [102]. In addition, according to �ealand study comparing nonpro�t and for-pro�t primary
one study, Medicaid-enrolled children who have access to carepracticesfoundthatthenonpro�tpracticesinthestudy
high quality, family-centered primary care have both lower offeredincreasedaccessatalowercostinadditiontooffering
nonurgentandurgenthospitalizationrates[103]. a more expansive array of services and instituting written
policies related to quality management [112]. In the USA,
However,methodologicalchallengesexistinconducting
patientsmayexperiencedifferinglevelsofqualityofprimary
research linking PCP supply to population health. When
caredependingoninsurancetype.Inananalysiscomparing
doing these analyses, the ratio of primary care to specialist
qualityofprimarycareacrossvariousmanagedcaremodels
physicians may be a more appropriate measure than just
(i.e.,managedindemnity,pointofservice,staff-modelHMO,
physiciansupply[85].Forexample,whileacorrelationexists
etc.),managedindemnitymodelsperformedbestonquality
between the PCP supply and health outcomes, there is no
of primary care measures, followed by point of service
association between specialist supply and health outcomes
andnetwork-modelHMOstructures[113].emotivations
[89,90].erefore,usingameasureofphysiciansupplyper
withinthedeliverysystemcanaffectpatientcareaswell;in
capita,withoutconsiderationofthebalanceofprimarycare
a study of the impact of pay-for-performance initiatives on
andspecialistphysicians,mayskew�ndings.
thequalityofprimarycarereceivedbypatientswithchronic
In response to this policy-relevant research, next steps
conditions, researchers found a positive quality association
have included proposals to increase the supply of primary
forpatientswithtwoofthethreeconditionsstudied[114].
carephysiciansintheUSA.Findingssuggestthatincreasing
US Medicare recipients have a choice between private
the supply of PCPs by just one unit per 10,000 physicians
managed care plans (through the Medicare Advantage pro-
might improve health outcomes by 0.66 to as much as
gram)andthetraditionalgovernment-managedfeeforser-
10.8 ,dependingontheoutcomeconsidered[84].
vice (FFS) plan. Research indicates that while most quality
Further research is needed on which%models of care performance measures are superior in the traditional FFS
prod%uce the best health outcomes. While past research has program, enrollees in some private plans may have better
indicatedteam-basedcareproducesbetteroutcomesinsome �nancial access to care [115]. Research has also sought to
settings, few studies have examined the use of teams in identifythemostappropriatesitefordeliveringprimarycare
primarycarepractice[104]. to low-income populations in the USA; these studies have
Otherissueswillalsocontinuetoaffecttherelationship mixed �ndings, with vaccination rates higher in hospital
betweenprimarycareandhealth.Manyexpertsbelievethat outpatient settings but fewer delays in receiving care in
primarycarewillhavetochangepracticemodelstoimprove physicians’offices[116].Structuralfeaturesofprimarycare
patient outcomes and physician job satisfaction, as demon- practices,suchashavinganelectronichealthrecord(EHR)
strated in many of the previously mentioned researches. and holding regular meetings devoted to discussing quality
However,othershavealsoarguedthatinordertorevitalize issues, can also be associated with higher performance on
primary care in the USA, major system-level change is HealthcareEffectivenessDataandInformationSet(HEDIS)
needed,especiallyinthewaythatprimarycarephysiciansare measures [117]. Much research has examined EHRs and
compensatedrelativetospecialists[105]. other health IT systems in hospitals or acute care settings,
but these tools can facilitate quality improvement efforts in
primary care settings as well [118]. Researchers have also
2.5. Primary Care and Quality. Ease of access, the clinical found that health IT infrastructure facilitates provision of
qualityofthecare,interpersonalaspectsofcare,continuity, care for chronic conditions in line with the Chronic Care
and coordination all are important elements to consider Model [119]. However, there remain signi�cant challenges
whenassessingprimarycarequality[106]. in the implementation of IT due to lack of reimbursement
Research exploring access has found that factors can by insurance plans and the learning curve experienced by
impede or facilitate access, such as the availability of aer- practitionerswiththenewtechnology[120].
hours care, the length of office wait time, travel time to an Anothercomponentofprimarycarequalityiscontinuity,
appointment,lackofaspeci�cPCPatthesiteofprimarycare, de�ned as person-focused care over time. e following
10 Scienti�ca
factors may affect the extent to which continuity can be primarycareintervention[130].However,aer12months,
achieved:appointmentwaittimelength,theinsurancestatus there was no difference between the two groups [130].
of patient, and aer-hours care availability [5]. A review In Canada, a small-scale preventive primary care outreach
of studies conducted in 6 countries regarding primary care program targeting the elderly included home care, collab-
qualitysuggeststhatbettercontinuitymaydecreasehospital- orative planning between patients, families and physicians,
izationsandEDvisits,loweringhealthcarecosts[121]. and referral to appropriate social support and community
Inordertofacilitatequalityimprovementintheprimary resources;theprogram,however,hadnosigni�cantpositive
care context, information is needed on appropriate bench- �ndings and no relationship with the functional status and
marksthatcanbeusedtoevaluateperformanceinprimary self-ratedhealthofparticipants[93].
care-speci�csettings.�esselletal.[122]identifyAchievable Medical, contextual (speci�c to the medical encounter),
BenchmarksofCare(ABCs)for54qualityindicatorsbased andpolicyevidenceisneededtofurtherresearchonquality
on data collected through the Practice Partner Research inprimarycare[131].Cross-countrycomparisonsmayelu-
Network(PPRNet)demonstration.Twenty-�veto99 ofthe cidatehowbroadersystems-levelfactorsimpactprimarycare
PCPs participating in the PPRNet demonstration met the quality.Futurestudiesshouldbeundertakentoexaminepri-
ABCs [122]. A New �ealand effort identi�ed 28 ev%idence- marycarereforms;how�nancingmechanismsimpactPCP
based, population-focused indicators that may be used to cooperation and workforce issues; the relationship between
assessqualityofprimarycarein�vecategories:smokingces- balance of primary and specialty care; the patient’s role;
sation, prescribing practices, chronic disease management, community-oriented care; equity in access and outcomes
preventive health, and quality of data [123]. Furthermore, [132].
manyoftheseindicatorsarealreadyavailablefromthedata In the USA speci�cally, Friedberg et al. [133] catego-
routinelycollectedinhealthITsystems[123]. rize the focus of proposed policy interventions intended
Patientevaluationsofthequalityofcarethey receivein to strengthen primary care and improve healthcare quality
primary care settings can be appropriate complements to into three categories: (1) supply of PCPs; (2) the set of
othermeasuresofquality[106].Patientassessmentsmaybe functions and services provided by a usual source of care;
particularly useful for evaluating the quality of access, the (3)theorientationofthehealthsystem.Basedonareviewof
practitioner-patient relationship, continuity, and coordina- theevidence,theseauthorssuggestthatpolicyprescriptions
tion [106]. �hile �ndings from patient assessments, com- shouldfocusonreorientingthehealthsystemintheUSAto
monlyconductedthroughquestionnaires,mayinformqual- emphasize and reward primary care provision and support
ity improvement efforts, it is not clear that the information providers’capacityforpracticingprimarycarethroughsuch
gleanedfrompatientsassessmentscanbesuccessfullytrans- interventions as health IT, the Chronic Care Model, and
lated into actual improvements in the quality of care [106]. team-based approaches to delivering care [133]. Although
One study found that patient-reported satisfaction with experts disagree over whether the current supply of PCPs
quality of care among the elderly was not a good predictor impacts the overall quality of healthcare, some policy pre-
oftheeffectivenessofthecarethesepatientsreceived[124]. scriptionsforemphasizingprimarycareintheUSAfocuson
However,ratingsofcoordinationofcaredidhavearelation- increasingPCPsupplybymakingthecareermoreattractive
shipwithsurvivaltimeamongthehigherutilizers[124]. throughbetterwages[134]andthroughfundingofTitleVII
Studies conducted in the international setting have Section747,whichsupportsworkforcedevelopment[69,70].
assessedhowemphasisonprimarycarequalitymayimpact GrumbachandMoldalsoproposecirculatingaprimarycare
health outcomes, and whether specialists or PCPs provide versionofanagriculturalextensionagenttodisseminatethe
better quality of care for chronic conditions. e results latestknowledgeandclinicalguidelines,improvethequality
weremixed.Improvementsinhealthoutcomesfordiabetes of care provided by PCPs, and strengthen the country’s
type 2 patients in Norway may re�ect special emphasis on primary care infrastructure [135]. In addition, increased
collaboration between primary care and public health may
improving diabetes care in primary care practices [125].
improve quality and health outcomes by refocusing family
Research in Taiwan has found that patients with a PCP or
medicine on population or community health rather than
a usual source of care (USC) experience superior primary
just individuals [136]. In addition to these proposals, some
care quality, including better access, coordination, family
point out that more policy actions should be devoted to
centeredness,continuity,andculturalcompetence[126,127].
distributing primary care resources more fairly and evenly
In Britain, an evaluation comparing the quality of diabetes
[137].Low-income,deprivedcommunitiesareburdenedby
care provided in specialist diabetes clinics to that provided
highermorbidity and mortality ratesand, therefore, should
by primary care clinics found no long-term difference in
receivemorehealthservices[137].
the rates of improvement in HbA1c, cholesterol, and blood
pressureovertime[128].Incontrast,aDanishstudyfound
that patients suffering from asthma or rhinitis experience 2.6. Primary Care and Cost. One consequence of having
superiorcarequalityfromrespiratoryspecialistsasopposed many specialists is the possibility that specialist care has
to PCPs [129]. In a study in Canada looking at asthmatic contributedtoincreasingthevolumeofintensive,expensive,
patientsparticipatinginaninterventiondesignedtoimprove and invasive medical services and therefore the costs of
accesstoprimarycare,interventionpatientsdidinitiallyhave healthcare[138–144].Highersurgeonsupplyhasbeenfound
better access in comparison to those patients without the to increase the demand for initial contacts with surgeons