Utilization of primary care was found to be associated with more high-value care, slightly more low-value care, and an improved overall health care experience, according to a study published in JAMA Internal Medicine.

Data from the Medical Expenditure Panel Survey were used to examine whether visits to a primary care facility were associated with high-value care or low-value care, as well as the impact of those visits on patient access to and experience with health care. For the purpose of this study, the population was restricted to adults aged 18 years and older recruited from 2012 to 2014; sample sizes ranged from 21,915 to 26,509 respondents per year.

Primary care was defined using the following characteristics: first contact, comprehensive care, continuous care, and coordinated care. Of the primary care health professionals selected by the respondents, 70% were general or family practice physicians, 19% were general internists, 3% were nurse practitioners or physician assistants, 1% were pediatricians, 1% were obstetrician/gynecologists, and the remainder were from other specialties.

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The research team evaluated performance based on 39 clinical quality measures: 25 high-value and 14 low-value measures. From these, 6 clinically meaningful underuse composites, in which delivery of a service is likely of benefit to the respondent, and 4 overuse composites, in which delivery of the service is either inappropriate or of little benefit, were constructed. To calculate the performance of each measure, respondents were identified according to their eligibility for the measure (such as those having diabetes) and then assessed whether or not they received the necessary care (eg, retinal examination). To calculate composites, the total number of all instances in which recommended care was delivered (high-value measure) or avoided (low-value measure) was divided by the number of times respondents were eligible for care in the category.

Respondents were asked to rate their experience with all health care providers (from 0  representing the “worst health care possible” to 10 representing the “best health care possible”), as well as clinician communication (“How often did the doctor spend enough time with you?”) and access to care (“How often did you get a medical appointment as soon as you wanted?”).

Respondents with or without primary care used health care with similar frequency, including similar mean numbers of annual office visits (6.7 vs 5.9), annual emergency department visits (0.2 for both groups), and annual hospital admissions (0.1 for both). However, respondents with primary care filled more prescriptions per year (14.1 vs 10.7) and more frequently scheduled a routine preventive visit (72.2% vs 57.5%). Approximately 78% of respondents with primary care received high-value cancer screening compared with 67% of respondents without primary care. Respondents with primary care also received more recommended diagnostic and preventive testing (difference, 9.9%). High-value counseling was higher among participants with primary care (difference, 6.9%). Both types of participants received similar rates of high-value medical treatments.

Approximately half (49%) of respondents with primary care received low-value cancer screening compared with 44% of participants without primacy care. No significant difference was found between groups for low-value medical treatments (11% for both) or low-value imaging (~10% in both groups). Respondents with primary care received more low-value antibiotics compared with those without primary care (59% vs 48%).

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Respondents with primary care reported an excellent global rating of health care compared with 69% of those without primary care; physician communication was highly rated for those with vs without primary care (64% vs 54%, respectively), as was access to care (59% vs 52%, respectively).

“Receipt of primary care characterized by first-contact continuous care that was whole-person oriented and responded to patient needs was associated with significantly more high-value care, slightly more low-value care, and better health care experience,” the authors concluded.


Levine DM, Landon BE, Linder JA. Quality and experience of outpatient care in the United States for adults with or without primary care [published online January 28, 2019]. JAMA Intern Med. doi:10.1001/jamainternmed.2018.6716