Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts.
Harvard Medical School, Boston, Massachusetts.
JAMA Intern Med. 2019 Mar 1;179(3):363-372. doi: 10.1001/jamainternmed.2018.6716.
The US health care system is typically organized around hospitals and specialty care. The value of primary care remains unclear and debated.
To determine whether an association exists between receipt of primary care and high-value services, low-value services, and patient experience.
DESIGN, SETTING, AND PARTICIPANTS: This is a nationally representative analysis of noninstitutionalized US adults 18 years or older who participated in the Medical Expenditure Panel Survey. Propensity score-weighted quality and experience of care were compared between 49 286 US adults with and 21 133 adults without primary care from 2012 to 2014. Temporal trends were also analyzed from 2002 to 2014.
Patient-reported receipt of primary care, determined by the 4 "Cs" of primary care: first-contact care that is comprehensive, continuous, and coordinated.
Thirty-nine clinical quality measures and 7 patient experience measures aggregated into 10 clinical quality composites (6 high-value and 4 low-value services), an overall patient experience rating, and 2 experience composites.
From 2002 to 2014, the mean annual survey response rate was 58% (range, 49%-65%). Between 2012 and 2014, compared with respondents without primary care (before adjustment), those with primary care were older (50 [95% CI, 50-51] vs 38 [95% CI, 38-39] years old), more often female (55% [95% CI, 54%-55%] vs 42% [95% CI, 41%-43%]), and predominately white individuals (50% [95% CI, 49%-52%] vs 43% [95% CI, 41%-45%]). After propensity score weighting, US adults with or without primary care had the same mean numbers of outpatient (6.7 vs 5.9; difference, 0.8 [95% CI, -0.2 to 1.8]; P = .11), emergency department (0.2 for both; difference, 0.0 [95% CI, -0.1 to 0.0]; P = .17), and inpatient (0.1 for both; difference, 0.0 [95% CI, 0.0-0.0]; P = .92) encounters annually, but those with primary care filled more prescriptions (mean, 14.1 vs 10.7; difference, 3.4 [95% CI, 2.0-4.7]; P < .001) and were more likely to have a routine preventive visit in the past year (mean, 72.2% vs 57.5%; difference, 14.7% [95% CI, 12.3%-17.1%]; P < .001). From 2012 to 2014, Americans with primary care received more high-value care in 4 of 5 composites. For example, 78% of those with primary care received high-value cancer screening compared with 67% without primary care (difference, 10.8% [95% CI, 8.5%-13.0%]; P < .001). Americans with or without primary care received low-value care with similar frequencies on 3 of 4 composites, although Americans with primary care received more low-value antibiotics (59% vs 48%; difference, 11.0% [95% CI, 2.8%-19.3%] P < .001). Respondents with primary care also reported significantly better health care access and experience. For example, physician communication was highly rated for a greater proportion of those with (64%) vs without (54%) primary care (difference, 10.2%; 95% CI, 7.2%-13.1%; P < .001). Differences in quality and experience between Americans with or without primary care were essentially stable between 2002 and 2014.
Receipt of primary care was associated with significantly more high-value care, slightly more low-value care, and better health care experience. Policymakers and health system leaders seeking to improve value should consider increasing investments in primary care.
重要性：美国的医疗保健系统通常围绕医院和专科护理组织。初级保健的价值仍不清楚，存在争议。
目的：确定接受初级保健与高价值服务、低价值服务和患者体验之间是否存在关联。
设计、地点和参与者：这是一项对 2012 年至 2014 年期间参加医疗支出面板调查的非机构化美国 18 岁或以上成年人的全国代表性分析。对有和没有初级保健的 49286 名美国成年人（2012 年）和 21133 名成年人（2014 年）进行了质量和护理体验的倾向评分加权比较。还分析了 2002 年至 2014 年的时间趋势。
暴露：患者报告接受初级保健，由初级保健的“4C”确定：全面、连续和协调的首次接触护理。
主要结果和措施：将 39 项临床质量指标和 7 项患者体验指标汇总为 10 项临床质量综合指标（6 项高价值服务和 4 项低价值服务）、整体患者体验评分和 2 项体验综合指标。
结果：2002 年至 2014 年，平均年度调查回复率为 58%（范围为 49%-65%）。与没有初级保健的受访者（调整前）相比，2012 年至 2014 年期间，有初级保健的受访者年龄更大（50[95%CI，50-51] vs 38[95%CI，38-39]岁），更多为女性（55%[95%CI，54%-55%] vs 42%[95%CI，41%-43%]），主要为白人（50%[95%CI，49%-52%] vs 43%[95%CI，41%-45%]）。在进行倾向评分加权后，有或没有初级保健的美国成年人每年的门诊就诊次数相同（6.7 次与 5.9 次；差异为 0.8[95%CI，-0.2 至 1.8]；P=0.11）、急诊就诊次数相同（均为 0.2 次；差异为 0.0[95%CI，-0.1 至 0.0]；P=0.17）和住院就诊次数相同（均为 0.1 次；差异为 0.0[95%CI，0.0-0.0]；P=0.92），但有初级保健的人开的处方更多（平均为 14.1 次与 10.7 次；差异为 3.4[95%CI，2.0-4.7]；P<0.001），在过去一年中更有可能进行常规预防就诊（平均为 72.2%与 57.5%；差异为 14.7%[95%CI，12.3%-17.1%]；P<0.001）。从 2012 年到 2014 年，接受初级保健的美国人在 5 项综合指标中的 4 项中接受了更多的高价值护理。例如，78%的有初级保健的人接受了高价值的癌症筛查，而没有初级保健的人只有 67%（差异为 10.8%[95%CI，8.5%-13.0%]；P<0.001）。有或没有初级保健的美国人在 4 项综合指标中的 3 项中接受低价值护理的频率相似，尽管有初级保健的人接受的低价值抗生素更多（59%与 48%；差异为 11.0%[95%CI，2.8%-19.3%]；P<0.001）。接受初级保健的受访者还报告说，医疗保健的获取和体验明显更好。例如，有 64%的人对医生的沟通评价很高，而没有初级保健的人只有 54%（差异为 10.2%；95%CI，7.2%-13.1%；P<0.001）。在 2002 年至 2014 年期间，有或没有初级保健的美国人在质量和体验方面的差异基本保持稳定。
结论和相关性：接受初级保健与高价值护理显著增加，低价值护理略有增加，且健康护理体验更好。寻求提高价值的政策制定者和医疗系统领导者应考虑增加对初级保健的投资。
