Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015
Association of Primary Care Physician Supply With Population Mortality in the United States, 2005-2015
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DOI：
10.1001/jamainternmed.2018.7624
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发表时间：
2019-04-01
影响因子：
39
通讯作者：
Phillips, Russell S.
中科院分区：
文献类型：
--
作者：
Basu, Sanjay;Berkowitz, Seth A.;Phillips, Russell S.
最近的美国医疗改革激励改善人口健康结果和初级保健功能。目前尚不清楚改善初级保健医生的供应能在多大程度上改善人口健康，独立于其他卫生保健和社会经济因素。这项流行病学研究评估了美国人口数据和个人-与2005年至2015年的死亡率相关的水平索赔数据，以及2005年至2015年初级保健和专科医生供应的变化。来自美国3142个县、7144个初级保健服务区和306个医院转诊地区的数据被用来调查初级保健医生供应与预期寿命变化和特定原因死亡率的相关性，调整后的健康护理、人口统计学、社会经济学和行为协变量。分析时间为2018年3月至7月。主要结局和指标包括标准化预期寿命、死因特异性死亡率和限制平均生存时间。结果初级保健医生供应从2005年的196 014名医生增加到2015年的204 419名。由于一些县初级保健医生的不成比例的损失和人口的增加，初级保健医生相对于人口规模的平均（SD）密度从每10万人口46.6人下降到每10万人口46.6人。（95% CI，0.0-114.6/100 000人口）至41.4/100 000人口（95% CI，0.0-108.6/100 000人口），农村地区的损失更大。在调整后的混合效应回归中，每10万人口中每增加10名初级保健医生，预期寿命就会增加51.5天（95% CI，29.5-73.5天;增加0.2%），而每10万人增加10名专科医生相当于增加19.2天（95% CI，7.0-31.3天）。每10万人口中增加10名初级保健医生，可使心血管、癌症和呼吸系统死亡率降低0.9%至1.4%。在不同的地理水平，使用工具变量回归，或在个人层面的分析发现类似的好处与初级保健supply.CONCLUSIONS和相关性更大的初级保健医生供应与较低的死亡率，但人均供应下降2005年至2015年。明确将更多资源用于初级保健医生供应的计划可能对人口健康很重要。
IMPORTANCE Recent US health care reforms incentivize improved population health outcomes and primary care functions. It remains unclear how much improving primary care physician supply can improve population health, independent of other health care and socioeconomic factors.OBJECTIVES To identify primary care physician supply changes across US counties from 2005-2015 and associations between such changes and population mortality.DESIGN, SETTING, AND PARTICIPANTS This epidemiological study evaluated US population data and individual-level claims data linked to mortality from 2005 to 2015 against changes in primary care and specialist physician supply from 2005 to 2015. Data from 3142 US counties, 7144 primary care service areas, and 306 hospital referral regions were used to investigate the association of primary care physician supply with changes in life expectancy and cause-specific mortality after adjustment for health care, demographic, socioeconomic, and behavioral covariates. Analysis was performed from March to July 2018.MAIN OUTCOMES AND MEASURES Age-standardized life expectancy, cause-specific mortality, and restricted mean survival time.RESULTS Primary care physician supply increased from 196 014 physicians in 2005 to 204 419 in 2015. Owing to disproportionate losses of primary care physicians in some counties and population increases, the mean (SD) density of primary care physicians relative to population size decreased from 46.6 per 100 000 population (95% CI, 0.0-114.6 per 100 000 population) to 41.4 per 100 000 population (95% CI, 0.0-108.6 per 100 000 population), with greater losses in rural areas. In adjusted mixed-effects regressions, every 10 additional primary care physicians per 100 000 population was associated with a 51.5-day increase in life expectancy (95% CI, 29.5-73.5 days; 0.2% increase), whereas an increase in 10 specialist physicians per 100 000 population corresponded to a 19.2-day increase (95% CI, 7.0-31.3 days). A total of 10 additional primary care physicians per 100 000 population was associated with reduced cardiovascular, cancer, and respiratory mortality by 0.9% to 1.4%. Analyses at different geographic levels, using instrumental variable regressions, or at the individual level found similar benefits associated with primary care supply.CONCLUSIONS AND RELEVANCE Greater primary care physician supply was associated with lower mortality, but per capita supply decreased between 2005 and 2015. Programs to explicitly direct more resources to primary care physician supply may be important for population health.