Chapter 10: Primary Care: Physicians, Nurses, and Pharmacists

THE CASE FOR PRIMARY CARE

Chapter 3 distinguished primary from secondary and tertiary care. Primary care has been defined as core functions that patients receive from their usual source of care. The World Health Organization (WHO) recognized the important role played by primary care. Similar to the Institute of Medicine’s 6 dimensions of quality (STEEEP, see Chapter 5), the WHO stated that primary care should be comprehensive, integrated, continuous, team-based, patient empowering, health promoting, and bridging of personal and family and community health.¹

Other researchers have distilled 5 elements of primary care that, when collectively present, distinguish it from specialty-oriented care: first-contact accessibility, continuity, comprehensiveness, coordination, and whole-person accountability.² The definitions for these 5 elements are presented in Figure 10-1. Research has shown the positive impact on important patient outcomes by (1) accessibility: hospitalization rates, emergency department (ED) visits, and patient satisfaction; (2) continuity: hospitalization rates, complication rates, ED visits, total costs, and adherence to provider recommendations; (3) comprehensiveness: hospitalization rates, better health outcomes at lower cost, and self-reported health outcomes; (4) coordination: less duplication of services, better patient outcomes, and greater satisfaction; and (5) accountability: patient self-management for chronic conditions and adherence to provider recommendations.

Primary care has long been viewed as essential to maintaining and promoting the health status of the population, improving the patient’s experience of care, and controlling per-capita costs (ie, the triple aim). Historically, it has also been viewed as critical to improving access to care and quality of care and lowering the cost of care (ie, the iron triangle).³ Analysts suggest that primary care benefits both population and personal health by improving health status, lowering utilization of care, increasing use of preventive services, reducing disease and death rates, and reducing the negative health effects of income inequality on health and mortality, especially in areas where income inequality is greatest.⁴

Two recent studies published in the medical literature lend credence to these claims. They indicate that the availability of primary care is associated with higher health status (as measured by patient mortality), higher quality of care (as measured by clinical process measures), and higher patient experience measures.