8 March 2019

Grist to the mill, but is Canberra listening?

General practice Public Health

Do you tremble with doubt every time yet another speaker relies on publications from back in the 1990s from that champion of primary care, the late Professor Barbara Starfield, to raise a cheer for the effectiveness of general practice (Yeah!) versus non-GP specialist practice (Nay!).

How broad can her shoulders be?

Tremble no more. The New Year had barely lost its shine before a large study, published out of Stanford, added weight to Starfield’s conclusions.

In the latest edition of JAMA Internal Medicine (published online on January 28, 2019) US researchers report that a greater density of primary care physicians is associated with better population health.

The study found that an increase of 10 primary care physicians per 100,000 population was associated with an average 51.5-day increase in life expectancy, whereas an increase of 10 non-GP specialists per 100,000 population only resulted in a 19.2-day increase in life expectancy.

Having more GPs was associated with less cardiovascular, cancer and respiratory mortality. Inversely, among populations where there were fewer GPs per head of population, there was increased morbidity and higher premature mortality.

Unlike the earlier work of Starfield and colleagues, this study has taken care to deal with potential confounders. However, the authors note that “the possibility of unobserved confounding remains because we cannot randomise people to areas with varied primary care physician supply”.

The study authors take care to emphasise that these effects are at the population level. They warn, “… to avoid the ecological fallacy, conclusions should not be drawn about individual level effects of population-level associations”.

Incidentally, it was also noted that the supply of primary care physicians across the US had decreased over the 10 years from 2005 to 2015, with the blame being squarely placed on the remuneration differential that occurs between GPs and other specialists.

“Persistent payment disparities between primary care and procedural specialties continue to erode the US primary care physician workforce,” the study authors wrote. Sound familiar?

All this is likely to gladden the heart of Australian GPs and prove grist to the mill in an election year.

But it wasn’t all a glowing reflection of the value of general practice. The enthusiasm was somewhat tempered by the authors’ suggested list of subjects for future research.

These included:

  • the quality and comprehensiveness of primary care;
  • types of primary care physician training and service delivery offerings;
  • effective access versus “just supply”;
  • the dynamics of team work across GPs and non-GP specialists and how team-based approaches may affect mortality and other outcomes.

This list is disconcerting to many of us who believe the answers to these questions are both obvious and settled.

Reference:

  1. Basu S, et al. Association of primary care physician supply with population mortality in the United States, 2005 – 2015. Published online 18 February 2019. JAMA Internal Medicine