Life Spans Drop in Areas With Primary Care Shortage: Study

Marcia Frellick

March 25, 2021

It is well documented that poor access to primary care physicians (PCPs) is associated with worse health, but new research suggests that the persistent PCP shortage also shortens lives. By increasing PCP access, more than 7200 deaths per year could be prevented, the team estimates in an article published online March 23 in Annals of Internal Medicine.

The article is a "methodologic tour de force," Laurence McMahon, MD, MPH, who was not involved with the research, told Medscape Medical News.

These new data, along with other recent research, may help make the case that a substantial investment in primary care is crucial and will pay off in saving lives, continued McMahon, who is with University of Michigan Medicine, Ann Arbor, Michigan.

"It's a pretty compelling argument that by just changing the mix of providers in a community, you can have a demonstrable influence on what the mortality looks like in that community," he told Medscape Medical News.

Sanjay Basu, MD, PhD, director of research at Harvard Medical School's Center for Primary Care, Boston, Massachusetts, and colleagues found that in 2017, among people living in US counties with fewer than 1 PCP per 3500 people, the average life expectancy was 310.9 days shorter than the life expectancy among people living in counties with higher PCP-to-patient ratios.

Basu told Medscape Medical News that increasing life expectancy is particularly critical now, inasmuch as the United States saw a full year's drop in life expectancy, from 78.8 to 77.8 years, in the first half of 2020, largely due to COVID-19.

This analysis shows that adding PCPs, particularly in targeted areas, could be a powerful tool in reversing that trend, Basu says.

Where Would Adding Doctors Have the Most Impact?

The researchers assessed data for adults and children in 3104 US counties from 2010 to 2017 and evaluated age-adjusted life expectancy, all-cause mortality, and mortality attributed to cardiovascular disease, infectious disease, cancer, respiratory disease, substance use, or injury.

Basu's team sought to determine where adding PCPs would matter most. The current federal threshold for defining a shortage area is 1 PCP per 3500 people, but there has been much discussion about whether the bar should be much lower ― at 1 PCP per 1500 people.

Basu noted that the definition is important because it drives funding for more physicians and helps determine future workforce needs.

The researchers evaluated how many additional PCPs would be required to achieve the 1:1500 goal as opposed to the 1:3500 goal. They also assessed how much difference it would make in life span were that goal to be achieved.

In the 2636 counties with the lowest density (fewer than 1 PCP per 1500 people), reaching the 1:1500 ratio would require 95,754 more physicians collectively, or 36.3 more for each county that has a shortage.

It is expected that reaching that 1:1500 bar would increase life span by an average of 56.3 days (median, 55.6 days; 95% CI, 4.2 – 105.6 days).

To put that in context, "There's practically nothing in medicine that we do that makes more than a day of difference in life expectancy on the whole population," Basu said.

He said that the 56-day improvement in life span represents an effect similar historically to the benefit of smoking cessation and is higher than the effect of seat belts.

Reframing Goal Could Save 7000 Lives a Year

In addition, the researchers projected that ensuring that regions with the most critical shortages reach the 1:1500 ratio could prevent a total of 7272 deaths per year in those areas.

That effect was much greater than the effect of adding enough PCPs to reach the 1:3500 threshold. Although fewer physicians would need to be added to reach that bar (17,651 more physicians, vs 95,754, or about 14.5 more physicians per shortage county), it is expected that the additions would increase average life expectancy by only 22.4 days (median, 19.4 days; 95% CI, 0.9 – 45.6 days) instead of 56.3 gained by achieving the 1:1500 threshold.

That finding indicates that focusing on getting more PCPs into the areas with the most critical shortages would make the biggest difference in increasing population longevity and that funding would in this way have the most impact, he said.

McMahon notes that in order to entice physicians to practice in primary care and to have PCPs practice in areas of highest need, primary care needs to be redesigned.

Hours taken up by electronic medical records and administrative tasks have made primary care increasingly unattractive over the past decade, he said. In a recent article, McMahon and colleagues described why the primary care system "is designed to fail."

He told Medscape Medical News that the traditional model in which PCPs spend 32 hours seeing patients and 8 hours working on lab results, charting, and performing associated tasks is a fictional scenario born in the 1990s.

"We surveyed our faculty," he said, "and we found that in addition to the 32 hours, there's an additional 20 hours they're doing in the medical record. That's untenable, which is why 70% of our faculty work part time.

"In essence, it means they're taking a pay cut to do a full-time job, because they can't really do the job the way it's structured now," McMahon said. "That undermines people's interest in going into primary care."

It's even worse in rural communities, he said. In rural areas, most of the economics are centered on the patient visit. A doctor supports a nurse and the office from payments made for patient visits and a small facility fee.

In contrast, in the practice of surgery, nurses and staff are hired by the hospital, and the hospital gets substantial facility fees.

The metrics need to be redistributed, McMahon says.

"Maybe the physicians in underserved areas get a substantial increase in the doctors' office part of the bucket so they can afford to hire nurses and clerks and social workers to help them to do the job they're asked to do," he said.

"I think it's not acceptable that we try to rely on indentured physicians to man this," he said.

Helping to pay for the education of students interested in primary care won't work if the environment they enter does not have a solid infrastructure, he added.

"There are some kinds of services we need to provide that don't fit a business model," he said. "Rural health in underserved populations is one of those areas."

The study received no funding. McMahon has disclosed no relevant financial relationships. Coauthors' financial relationships are listed in the original article. Basu has received personal fees from Collective Health, HealthRight 360, PLOS Medicine and The New England Journal of Medicine outside the submitted work.

Ann Intern Med. Published online March 23, 2021. Abstract

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick.

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