Primary care is the foundation of health care in the United States as in most of the world. According to the Institute of Medicine, primary care is defined as âthe ...
Vol. 36, No. 1
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Commentary
The Structure of Primary Care: Framing a Big Picture James M. Gill, MD, MPH
Primary care is the foundation of health care in the United States as in most of the world. According to the Institute of Medicine, primary care is defined as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”1 Despite the widespread agreement regarding its conceptual definition, however, many questions remain about primary care. For example, which components of primary care are most essential to high-quality care? How can these comp onents be be st achieved in practice? Can specialists provide some components of primary care without providing the full spectrum of primary care ? Which components of primary care are associated with improved health outcomes? The articles in this issue of Family Medicine address some of these questions. They add to a growing body of literature regarding the components of primary care.
(Fam Med 2004;36(1):65-8.)
From the Department of Family and Community Medicine, Christiana Care Health Services, Wilmington, Del.
One of the most fundamental components of primary care is continuity of care. It is often assumed that continuity should have positive benefits to health care because of the accumulated knowledge and trust that develops between a patient and provider. In fact, a number of previous studies have found positive benefits from higher continuity of care. This includes studies that have shown continuity to be related to higher immunization rates for children, 2 higher rates of adherence to prescriptions,3,4 better recognition of medical problems,5 higher patient and provider satisfaction,6,7 fewer emergency department visits,8,9 fewer hospitalizations,7,10 and improved control of chronic diseases such as diabetes mellitus.11 However, other studies have found that continuity does not always have positive benefits.12 For example, a recent study found that higher continuity was not related to improved monitoring for diabetes.13 Several articles in this issue also raise doubts as to whether higher continuity always leads to better care. Mainous et al14 examined the impact of continuity on early detection and stage of diagnosis for persons diagnosed with breast and colorectal cancer. They found that continuity was associated with a higher likelihood of having had a ma mmogr a m for wome n with breast cancer. However, continuity was not associated with an earlier
stage of diagnosis for either type of cancer. Further, having a longer relationship with one’s physician was associated with neither earlier diagnosis nor screening. The article by Parkerton et al15 raises even further doubts regarding the benefit of continuity. In a group model HMO consisting of 25 practices, continuity of care was not associated with preventive health screening, monitoring for diabetes, satisfaction with care, or ambulatory care costs. One reason for this apparent contradiction could be that continuity of care is more complex than simply length of time with a regular doctor or concentration of visits with that doctor. A recent article by Saultz helped to clarify these complexities.16 He described three types of continuity: institutional, longitudinal, and interpersonal. He argued that interpersonal continuity is what is needed to facilitate knowledge and trust and thereby improve care. Several articles in this issue help to further elucidate the complexities of continuity of care. The article by Parchman and Burge17 is one of the most sophisticated studies to date to elucidate the mechanism by which continuity works. Using a path analysis to analyze data from the Medicare Current Beneficiary Survey, Parchman and Burge determined that continuity (as defined by a sustained patientprovider relationship over time) predicted a higher level of provider
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knowledge about a patient, that better knowledge predicted a higher level of trust, and that higher level of trust predicted higher rates of quality indicators such as preventive care. The association between continuity and trust and the impact of trust and knowledge on quality measures have also been shown in previous studies.18,19 The article by Mainous et al 14 adds further evidence to support this mechanism. They found that in a sample of women with breast cancer, having higher continuity of care was associated with trust in one’s physician. Trust was associated with better care, as defined by earlier stage of diagnosis. However, neither having a longer relationship with one’s physician nor concentrating care with the same physician were associated with earlier diagnosis. The association between continuity and trust has also been shown in previous studies.18 This suggests that the mechanism by which continuity works is by increasing trust in one’s physician; therefore, higher continuity without greater trust may not have positive benefits. This may be one reason why some studies have shown continuity to have positive benefits, but others have not. It could be that continuity has positive benefits primarily when knowledge and trust are critical to medical decision making. The article by Schers et al 20 demonstrated that physicians also agree that continuity is most important when knowledge and trust are essential components of care. In a survey study of physicians in The Netherlands, physicians felt that continuity was very important when discussing prognosis and treatment options for patients who are seriously ill but much less important for minor problems such as an ankle sprain or the flu.20 If continuity can have positive benefits by increasing knowledge and thereby trust, how can continuity be best achieved? The study by Christakis et al21 suggests that con-
Family Medicine tinuity is dependent on a second component of primary care: accessibility. To build a sustained relationship of knowledge and trust by seeing the same provider over time, that provider has to be accessible to the patient. In fact, Christakis et al found that in a residency teaching practice, provider availability was the strongest predictor of continuity. Availability was particularly problematic for resident physicians, who may only be available to see patients 2 or 3 half days per week. However, even physicians in fulltime practice are not always available to their patients, especially for acute problems. This suggests one reason why continuity has become more difficult to achieve: since physicians are not always available to see their own patients, they are often seen by partners or in urgent care settings rather than by their primary physician. Given the practical barriers to achieving continuity, another component becomes particularly important: coordination. If every patient had perfect continuity, their physician would know everything about their health ca re. But given that most patients see more than one provider, it is the responsibility of their primary provider to coordinate this care. For patients seeing many different providers, coordination of this care by the primary care provider can be difficult and often is not optimal. The article by Low22 illustrates the potential problems with lack of coordinated care, even in a country such as Great Britain that has a well-developed system of primary care. The article describes the difficulty in coordinating care for patients who are seeing both primary care providers and specialists, in both inpatient and outpatient settings. It shows that even for patients with attentive providers and attentive family members, care can be fragmented. There are certainly methods to improve coordination of care. One
way is to assist the primary care provider through the use of care management teams. The article by Nasmith et al23 describes such a coordinated team approach for patients with diabetes mellitus. Previous studies have found that such systems can improve quality of care for diabetes 2 4 as well as other chronic diseases such as depression.25 In many places, however, such systems are either not available or are not financially feasible. The artic le by Lester et a l26 describes the difficulties encountered in mental health care when systems are not in place to coordinate care for patients with chronic mental illness. However, even when formal systems are not in place for case management, coordination can be improved by office systems that facilitate communication. In the study by Parkerton et al,15 although continuity of care was not associated with improved quality of care, office systems that facilitated coordination were. Specifically, having arrangements where physicians share patients on a team, and agree to communicate about their team patients, is associated with better preventive care and improved monitoring for patients with diabetes. Further, having a team of physicians who has worked together longer was associated with improved quality of care, not only improved prevention and diabetes monitoring but also greater patient satisfaction and lower ambulatory costs. Finally, perhaps the most basic hallmark of primary care is comprehensiveness. While comprehensiveness may be the most basic component of primary care and may be the easiest to understand, it is often given little attention when determining what providers provide primary care. In most countries, there is little confusion about what providers provide primary care: general practitioners provide primary care, and specialists provide secondary and tertiary care. But in
Commentary the United States, care is often fragmented, and specialists sometime provide services that would normally come under the auspices of primary care. One example is when gynecologists provide routine cancer screening for women or provide other prevention and treatment to patients without a referral. Other specialists sometimes provide limited primary care services to some of their patients, especially those who visit them regularly for chronic illnesses. In fact, a recent study tried to quantify the amount of primary care services provided by specialists in the United States. They concluded that up to 15% of elderly patients receive primary care services from non-primary care providers and that gynecologists and pulmonologists are the physicians most likely to provide these services.27 This is sometimes considered the “hidden system” of primary care. However, while specialists sometimes provide services that are usually considered in the realm of primary care, that does not mean that they are truly providing primary care. By definition, primary care is comprehensive and is not defined by any disease state or organ system. The study by Koopman et al28 suggests that specialists rarely provide true primary care that is either comprehe nsive or coordinated. When specialists provide services outside of their specialty area, these services tend to be ad hoc and uncoordinated. So, rather than representing a hidden system of primary care, these services represent the absence of true primary care. In summary, the articles in this issue of Family Medicine help us to better understand the complexities of primary care. First, continuity of care works through the development of accumulated knowledge and trust between a patient and a provider. Having continuity in and of itself, as defined by a regular provider over time or by concentrating care with that provider, probably
Vol. 36, No. 1 does not lead to better care unless it also results in an interpersonal relationship of knowledge and trust. Second, continuity requires accessibility and availability; since providers are not always available, continuity is not always easy to achieve, and coordination becomes more important. In fact, given the practical barriers to continuity, coordination may be a more important factor than continuity in improving health outcomes. Improving coordination requires good communication among health care providers and may be facilitated through the use of care management teams. Finally, true primary care requires a comprehensive approach to the patient that is not limited by disease state or organ system. While specialists may provide some of the services that are usually under the auspices of primary care, it is rare that specialists provide true primary care. There is really no such thing as “primary care of the female reproductive system” or “primary care of the patient’s lung disease.” Primary care requires management of most of the patients’ health care needs and coordination of care that is provided other places. Without the provision of comprehensive and coordinated care in the context of a continuous relationship, there is no primary care. Correspon dence: Address correspond ence to Dr Gill, Christiana Care Health Services, Department of Family and Community Medicine, 1401 Foulk Road, Wilmington, DE 19 803. 302 -477 -332 4. Fax: 30 2-47 8-7 528 . jgill@ christianacare.org.
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Charney E, Bynum R, Eldredge D, et al. How well do patients take oral penicillin? A collaborative study in private practice. Pediatrics 1967;40(2):188-95. Koopman RJ, Mainous AG III, Baker R, Gill JM, Gilbert GE. Continuity of care and recognition of diabetes, hypertension, and hyp erch oles tero lemia. Arch Intern M ed 2003;163(11):1357-61. Blankfield RP, Kelly RB, Alemagno SA, King CM. Continuity of care in a family practice residency program. Impact on phys ician s atisfaction. J Fam Pract 1990 ; 31(1):69-73. Wasson JH, Sauvigne AE, Mogielnicki RP, et al. Continuity of outpatient medical care in elderly men. A randomized trial. JAMA 1984;252(17):2413-7. Christakis DA, Wright JA, Koepsell TD, Emerson S, Connell FA. Is greater continuity of care associated with less emergency department utilization? Pediatrics 199 9; 103(4):738-42. Gill JM , Mainous AG III, Nsereko M. The effect of continuity of care on emergency department use. Arch Fam Med 2000;9(4): 333-8. Gill J M, Mainous AG III. The role of provider continuity in preventing hospitalizations. Arch Fam Med 1998;7(4):352-7. Parchman ML, Pugh JA, Noel PH, Larme AC. Continuity of care, self-management behaviors, and glucose control in patients with type 2 diabetes. Med Care 2002;40(2):13744. Dietrich AJ, Marton KI. Does continuous care from a physician make a difference? J Fam Pract 1982;15(5):929-37. Gill JM, et al. Impact of provider continuity on quality of care for persons with diabetes mellitus. Ann Fam Med 2003;1:162-70. Mainous AG III, Kern D, Hainer B, KneuperHall R, Stephans J, Geesey ME. The relationship between continuity of care, trust, and stage of cancer at diagnosis. Fam Med 2004;36(1):35-9. Parkerton PH, Smith DG, Straley HL. Primary care practice coordination versus physician continuity. Fam Med 2004;36(1):1521. Saultz JW. Defining and measuring interpersonal contin uity of care. Ann Fam Med 2003;1(3):134-43. Parchman ML, Burge SK. The patient-physician relationship, primary care attributes, an d p rev entive serv ices . Fam M ed 2004;36(1):22-7. Mainous AG III, Baker R, Love MM, Gray DP, Gill JM. Continuity of care and trust in one’s physician: evidence from primary care in the United States and the United Kingdom. Fam Med 2001;33(1):22-7. Safran DG, Taira DA, Rogers WH, Kosinski M, Ware JE, Tarlov AR. Linking primary care performance to outcomes of care. J Fam Pract 1998;47(3):213-20. Schers H, van de ven C, van den Hoogen H, Grol R, van den Bos ch W. Family practice trainees still value continuity of care. Fam Med 2004;36(1):51-4. Christakis DA, Kazak AE, Wright JA, Zimmerman FJ, Bassett AL, Connell FA. What factors are associated with achieving h igh co ntin uity o f care? Fam M ed 2004;36(1):55-60.
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22. Low J. Continuity of care from a patient’s point of view: context, process, relation. Fam Med 2004;36(1):61-4. 23. Nasmith L, Cote B, Cox J, et al. The challen ge of p romo tin g in tegration : co nceptualization, implementation, and assessment of a pilot care delivery model. Fam Med 2004;36(1):40-5. 24. Peters AL, Davidson MB, Ossorio RC .Management of patients with diabetes by nurses with support of subspecialists. HMO Practice 1995;9(1):8-13.
Family Medicine 25. Unützer J, et al. Collaborative care management of late-life depression in the primary care setting. A randomized controlled trial. JAMA 2002;288(22):2836- 45. 26. Lester H, Tritter JQ, Sorohan H. Managing crisis:the role of primary care for people with seriou s mental illn ess. Fam Med 2004 ; 36(1):28-34. 27. Rosenblatt RA, et al. The generalist role of specialty physicians: is there a hidden system of primary care? JAMA 1998;279(17): 1364-70.
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