East Leicester Medical Practice, United Kingdom.
PLoS One. 2012;7(10):e47800. doi: 10.1371/journal.pone.0047800. Epub 2012 Oct 24.
Wide variations in mortality rates persist between different areas in England, despite an overall steady decline. To evaluate a conceptual model that might explain how population and service characteristics influence population mortality variations, an overall null hypothesis was tested: variations in primary healthcare service do not predict variations in mortality at population level, after adjusting for population characteristics.
METHODOLOGY/PRINCIPAL FINDINGS: In an observational study of all 152 English primary care trusts (geographical groupings of population and primary care services, total population 52 million), routinely available published data from 2008 and 2009 were modelled using negative binomial regression. Counts for all-cause, coronary heart disease, all cancers, stroke, and chronic obstructive pulmonary disease mortality were analyzed using explanatory variables of relevant population and service-related characteristics, including an age-correction factor. The main predictors of mortality variations were population characteristics, especially age and socio-economic deprivation. For the service characteristics, a 1% increase in the percentage of patients on a primary care hypertension register was associated with decreases in coronary heart disease mortality of 3% (95% CI 1-4%, p = 0.006) and in stroke mortality of 6% (CI 3-9%, p<0.0001); a 1% increase in the percentage of patients recalling being better able to see their preferred doctor was associated with decreases in chronic obstructive pulmonary disease mortality of 0.7% (CI 0.2-2.0%, p = 0.02) and in all cancer mortality of 0.3% (CI 0.1-0.5%, p = 0.009) (continuity of care). The study found no evidence of an association at primary care trust population level between variations in achievement of pay for performance and mortality.
CONCLUSIONS/SIGNIFICANCE: Some primary healthcare service characteristics were also associated with variations in mortality at population level, supporting the conceptual model. Health care system reforms should strengthen these characteristics by delivering cost-effective evidence-based interventions to whole populations, and fostering sustained patient-provider partnerships.
尽管英格兰各地的死亡率总体呈稳步下降趋势，但仍存在巨大差异。为了评估一个可能解释人口和服务特征如何影响人群死亡率变化的概念模型，我们检验了一个总体零假设：在调整人口特征后，初级保健服务的变化不能预测人群水平的死亡率变化。
方法/主要发现：在一项对英格兰所有 152 个初级保健信托机构（人口和初级保健服务的地理分组，总人口 5200 万）的观察性研究中，使用负二项回归模型对 2008 年和 2009 年的常规公布数据进行建模。使用与人口和服务相关特征相关的解释变量（包括年龄校正因子）分析了所有原因、冠心病、所有癌症、中风和慢性阻塞性肺疾病死亡率的计数。死亡率变化的主要预测因素是人口特征，特别是年龄和社会经济贫困程度。对于服务特征，初级保健高血压登记处每增加 1%的患者比例，冠心病死亡率降低 3%（95%CI 1-4%，p=0.006），中风死亡率降低 6%（CI 3-9%，p<0.0001）；每增加 1%的患者回忆自己更能看到首选医生的比例，与慢性阻塞性肺疾病死亡率降低 0.7%（CI 0.2-2.0%，p=0.02）和所有癌症死亡率降低 0.3%（CI 0.1-0.5%，p=0.009）（连续护理）相关。该研究未发现初级保健信托机构人群水平上绩效薪酬变化与死亡率之间存在关联的证据。
结论/意义：一些初级医疗保健服务特征也与人群水平的死亡率变化有关，支持了该概念模型。医疗保健系统改革应通过向整个人群提供具有成本效益的循证干预措施，并促进持续的医患伙伴关系，来加强这些特征。
