Outcomes Research in Review

Receipt of Primary Care Linked to High-Value Care, Better Health Care Experience

Levine DM, Landon BE, Linder JA. Quality and experience of outpatient care in the United States for adults with or without primary care. JAMA Intern Med. 2019;179:363-372.



Study Overview

Objective. To examine whether receiving primary care is associated with receipt of high-value services and low-value services and quality of patient experience.

Design. Secondary data analysis of the Medical Expenditure Panel Survey, which is an annual survey of a nationally representative sample of noninstitutionalized adults in the United States aged ≥ 18 years drawn from the National Health Interview Survey. The study used data from 2012 to 2014, and during these years the survey had a response rate ranging from 49% to 65%. The survey collected data through computer-assisted personal interviews and included data on demographic characteristics, health conditions, health status, medical services utilization, medications, costs, and experience with care. Between 21,905 and 26,509 respondents were surveyed each year.

To define whether a respondent received primary care, respondents were asked if they have a “usual source of care” and to provide the name of a physician they usually visit if they “are sick or need advice” about their health. Four additional questions asked respondents if they would visit their usual source of care for (1) “new health problems,” (2) “preventive health care such as general checkups, examinations, and immunizations,” (3) “ongoing health problems,” and (4) “referrals to other health professionals when needed.” These questions were intended to reflect the essential functions of primary care: providing first contact care that is comprehensive, continuous, and coordinated. Any respondents who indicated that they did not have a usual source of care or answered no to any of the 4 questions were considered to not have primary care. Among respondents who identified a usual source of care, 95% met criteria for having primary care.

Setting and participants. The study included 49,286 US adults with primary care and 21,133 US adults without primary care. The average age was 50 years (95% confidence interval [CI], 50-51) among those with primary care and 38 years (95% CI, 38-39) among those without primary care. Among those who had primary care, 55% were female, 50% were non-Hispanic white, 32% Hispanic, and 13% black; among those without primary care, 43% were female, 43% were non-Hispanic white, 35% Hispanic, and 13% black. Among respondents with primary care, 58% considered their health status to be excellent or very good, as compared with 66% of respondents without primary care. Lack of insurance was reported by 7% of respondents with primary care and 34% of respondents without primary care. Chronic disease was reported in 78% of respondents without primary care, as compared with 42% of respondents with primary care. The study uses propensity score matching methods to produce a matched cohort, taking into account potential confounders. The matching procedure resulted in a final sample of 43,766 respondents with primary care matched to 17,964 respondents without primary care.

Main outcome measures. Main study outcome measures included 39 quality measures aggregated into quality composites (6 high-value services and 4 low-value services), and 7 patient care experience measures aggregated into an overall patient experience rating and 2 experience composites. High-value services are defined as delivery of services that are likely of benefit, and include the use of recommended cancer screening such as colorectal cancer screening in appropriate age groups; recommended diagnostic and preventive testing such as cholesterol measurement and influenza vaccination; recommended diabetes care such as hemoglobin A1c measurement; recommended medical treatment for medical conditions such as heart failure, coronary artery disease, and chronic obstructive pulmonary disease; and recommended counseling such as smoking cessation. Low-value services are defined as delivery of services that are considered either inappropriate or of little to no benefit, and include cancer screening in older adults; inappropriate use of antibiotics such as for bronchitis; inappropriate medical treatment such as anxiolytic, sedative, or hypnotic prescriptions for older adults; and inappropriate imaging tests for certain conditions.

Composites of underuse (high-value care) and overuse (low-value care) were constructed from each measure of high- or low-value services by identifying respondents who were eligible for the measure and determining the proportion in which recommended care was delivered (for high-value measures) or avoided (for low-value measures). Patient care experience was measured by standardized CAHPS (Consumer Assessment of Healthcare Providers and Systems) measurement for global rating of health care, doctor communication, and access to care. The patient care experience measures were dichotomized into positive responses as a rating of 8, 9, or 10 on items scored from 0 to 10, and 4 for items scored from 1 to 4. The experience composite was constructed by computing the mean for each respondent and then the mean for all respondents.

Main results. The study found that respondents with primary care were more likely to receive high-value care in 4 of 5 composite measures—cancer screening, diagnostic and preventive testing, diabetes care, and recommended counseling such as smoking cessation—but not in the composite recommended treatment for specific medical conditions such as heart failure. Respondents with primary care were more likely to receive recommended cancer screening, as compared to those without primary care (78% vs 67%, respectively, with a difference of 10.8%; 95% CI, 8.5%-13.0%). Respondents with primary care were also more likely to receive recommended diagnostic and preventive testing (with a difference of 9.9%; 95% CI, 8.7%-11.2%), to receive high-value diabetes care (with a difference of 7.8%; 95% CI, 1.2%-14.4%), and to receive counselling (with a difference of 6.9%; 95% CI, 4.1%-9.7%) when compared to respondents without primary care. However the rates of receipt of high-value medical treatments were similar among respondents with or without primary care (with a difference of –4.6% (95% CI, –14.3% to 5.0%). In contrast, rates of low-value care were similar for those with or without primary care in 3 of 4 composites, including low-value cancer screening, medical treatment, and imaging, while those with primary care had higher rates of low-value antibiotic use (with a difference of 11.0%; 95% CI, 2.8%-19.3%). Respondents with primary care reported better patient care experience, including global rating of their health care, physician communication, and access to care, when compared to those without primary care.

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