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