Clinical research study
Health Care Utilization and the Proportion of Primary Care Physicians

https://doi.org/10.1016/j.amjmed.2007.10.021Get rights and content

Abstract

Background

The impact of primary care physicians on health care utilization remains controversial. Some have hypothesized that primary care physicians decrease health care utilization through enhanced coordination of care and a preventive care focus.

Methods

Using data from the Area Resource File (a Health Resources and Services Administration US county-level database) for the years 1990, 1995, and 1999, we performed a retrospective cross-sectional analysis with generalized estimating equations to determine if measures of health care utilization (inpatient admissions, outpatient visits, emergency department visits, and surgeries) were associated with the proportion of primary care physicians to total physicians within metropolitan statistical areas.

Results

The average proportion of primary care physicians in each metropolitan statistical area was 0.34 (SD 0.46, range 0.20-0.54). Higher proportions of primary care physicians were associated with significantly decreased utilization, with each 1% increase in proportion of primary care physicians associated with decreased yearly utilization for an average-sized metropolitan statistical area of 503 admissions, 2968 emergency department visits, and 512 surgeries (all P <.03). These relationships were consistent each year studied.

Conclusions

Increased proportions of primary care physicians appear to be associated with significant decreases in measures of health care utilization across the 1990s. National efforts aimed at limiting health care utilization may benefit from focusing on the proportion of primary care physicians relative to specialists in this country.

Section snippets

Study Design

A retrospective cross-sectional study using multivariate regression was performed to evaluate the relationship between the proportion of physicians practicing primary care within metropolitan statistical areas and 4 key indicators of health care utilization.

Data Source

The Area Resource File database contains county-level data from 3028 US counties, and allows aggregation of the data into 323 metropolitan statistical areas. The Area Resource File defines a metropolitan statistical area as an area

Results

Table 1 summarizes the independent variables. Across the 323 metropolitan statistical areas, there was a mean of 165 office-based physicians per 100,000 population when combining the datasets from the 3 years (1990, 1995, and 1999). Across the metropolitan statistical areas, 34% of these doctors were primary care physicians (range 20.3%-54.1%). The mean population density for these time points was 388 persons per square mile, 12.6% of whom were aged >65 years, and 10.7% of whom were

Discussion

The results of this study suggest that as the proportion of physicians who are in primary care practice increases, health care utilization decreases. This relationship remained statistically significant for inpatient hospitalizations, emergency department visits, and total surgeries, even when controlled for population and physician variables. In practical terms, if a metropolitan statistical area with a population of 775,000 increased its proportion of primary care physicians from 35% to 40%,

Acknowledgments

We are indebted to Dr. Douglas Hough for his guidance and inspiration, and to Ms. Cheri Smith and Dr. Eric Bass for their assistance. Dr. Wright is an Arnold P. Gold Foundation Associate Professor of Medicine. Drs. Kravet and Wright are Miller-Coulson Scholars.

References (36)

  • R.K. Kanter et al.

    Hospital emergency surge capacity: an empiric New York statewide study

    Ann Emerg Med.

    (2007)
  • K.E. Hauer et al.

    Educational responses to declining student interest in internal medicine careers

    Am J Med.

    (2005)
  • R.B. Levine et al.

    Opting in: part-time careers in academic medicine

    Am J Med.

    (2006)
  • C.K. Cassel et al.

    Managing medical resources: return to the commons?

    JAMA

    (2007)
  • J. Macinko et al.

    The contribution of primary care systems to health outcomes within organization for economic cooperation and development (OECD) countries, 1970-1998

    Health Serv Res.

    (2003)
  • C. Schoen et al.

    U.S. health system performance: a national scorecard

    Health Aff (Millwood)

    (2006)
  • P. Franks et al.

    Primary care physicians and specialists as personal physiciansHealth care expenditures and mortality experience

    J Fam Pract.

    (1998)
  • A.V. Chobanian et al.

    The seventh report of the joint national committee on prevention, detection, evaluation, and treatment of high blood pressure: the JNC 7 report

    JAMA

    (2003)
  • D. Murphy et al.

    Moving diabetes care from science to practice: the evolution of the National Diabetes Prevention and Control Program

    Ann Intern Med.

    (2004)
  • C.B. Forrest et al.

    The effect of first-contact care with primary care clinicians on ambulatory health care expenditures

    J Fam Pract.

    (1996)
  • Y.A. Ozcan et al.

    Do primary care physicians or specialists provide more efficient care?

    Health Serv Manage Res.

    (2000)
  • S. Greenfield et al.

    Outcomes of patients with hypertension and non-insulin dependent diabetes mellitus treated by different systems and specialtiesResults from the medical outcomes study

    JAMA

    (1995)
  • V. Parekh et al.

    What effect does inpatient physician specialty and experience have on clinical outcomes and resource utilization on a general medical service?

    J Gen Intern Med.

    (2004)
  • T. Bodenheimer

    High and rising health care costsPart 3: the role of health care providers

    Ann Intern Med

    (2005)
  • The impending collapse of primary care medicine and its implications for the state of the nation’s health care: a report from the American College of Physicians

  • P.A. Pugno et al.

    Results of the 2005 National Resident Matching Program: family medicine

    Fam Med.

    (2005)
  • Area Resource File

    (2001)
  • P.J. Diggle et al.

    Analysis of Longitudinal Data

    (1994)
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