Healthcare is variably organized across the world. In some places, people attend medical specialists such as cardiologists and urologists directly. In other places, people attend primary care physicians for most health problems and, if necessary, they refer to medical specialists. Common sense may suggest that primary care is less expensive, but also less effective than medical specialist care. Scientific research actually found the opposite to be true, at least for large parts of the population. Nevertheless, the investments in medical care are largely directed to medical specialist care in most countries.

Primary healthcare is provided by physicians with a broad medical training (e.g. general practice or family medicine) and their teams, usually in office-based ambulatory practices. The strength of primary healthcare varies across the world. Strong primary healthcare is easily accessible, continuous, comprehensive, person-centred, and guided by consolidated biomedical knowledge. We evaluated the impacts of a programme that implemented many of these features in Baden-Wuerttemberg, a German state with about 11 million inhabitants. At the start of the programme, the strength of primary care in this part of the world was mixed, and overall moderate.

The programme was launched in 2008 and our study focused on the years 2012 to 2016, in which about 1 million individuals had enrolled in the programme. Participation in the programme was voluntarily for both physicians and patients. Patients were requested to attend a primary care physician before any other physician in case they needed medical care. The primary care physicians provided structured care for chronic diseases, they attended educational meetings in which they received data-based feedback on their prescribing of medication, and they received computerized decision support for prescribing. The adoption of these items was enhanced by a somewhat better payment than usual for the physicians. The AOK Baden-Wuerttemberg (the largest health insurer and purchaser of healthcare in the state) supported the programme from its start.

As intended, the enrolled patients had more visits in primary care and fewer uncoordinated visits to other physicians compared to a similar population of other patients from the same region. The mortality of the enrolled patients during the observed period of 5 years was slightly lowered. Providing structured care for patients with chronic diseases (such as diabetes) seemed to be an important factor in the beneficial impact on mortality.

It remains to be examined, how the impacts were exactly achieved. The present study highlighted the mediating role of structured care for chronic diseases, but other explanations may be equally true. Strong primary care implies that a patient usually attend the same physician, which is known to have positive effects on the quality and outcomes of healthcare. Other research on the programme in Baden-Wuerttemberg found that that programme reduced the numbers of hospital admissions, which is in line with the lowered mortality. Finally, the physicians in the programme were exposed to types of education and practice support of proven effectiveness.

This large study in a naturalistic setting confirmed the beneficial impact of strong primary care on population health outcomes. Strong primary healthcare is the cornerstone of any healthcare system.

Michel Wensing, Joachim Szecsenyi, Gunter Laux
Heidelberg University Hospital, Department of General Practice and Health Services Research, Germany

Publication

Strong primary care and patients’ survival
Wensing M, Szecsenyi J, Kaufmann-Kolle P, Laux G
Sci Rep. 2019 Jul 26

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