Primary care makes significant impact on health care
Primary care does, indeed, make a difference in health outcomes. In areas where major diseases can be prevented — like cervical cancer or breast cancer, which can be screened for, caught early or even vaccinated against in the case of cervical cancer — improving access to primary care shows a significant decrease in mortality rates.
That was the message of Dr. George Rust, professor of family medicine and director of the National Center for Primary Care at the Morehouse School of Medicine in Atlanta and the most recent guest speaker at the Distinguished Speaker Series at the UNT Health Science Center.
For example, from 1950 to 1994, there was a 70 percent decline in age-adjusted cervical cancer mortality rates in America, he said.
Despite that radical decline, there is still a significant gap between the mortality rates of white women and black women. The same goes for breast cancer. When HIV and AIDS were wreaking havoc on black and white populations and wiping out potential years of life due to premature death, five times as many black years of life were lost than white. Protease inhibitors were introduced and slowed down the death rates, but not equally: Nine times as many black years were lost, he said.
Health disparities are a major concern for the United States, Rust said, but research into disparities is useless unless there are equitable health outcomes. Lowering death rates from a disease is a worthy goal, but unless all groups are equally affected by any changes, research has failed, he said.
To make equal change requires a different approach to research, something the medical community is beginning to accept but funding agencies are more reluctant to support because the data may be harder to interpret, Rust explained. Historically, medical studies have focused on one disease at a time, and patients with other diseases or conditions or who donÂ’t meet strict criteria are not allowed to participate. However, this is not an accurate representation of an American population made up of patients who may have two or three (or more) diseases at once, like diabetes, heart disease, high blood pressure and depression.
“That isn’t my patient population. That isn’t my practice,” he said. “. . .Most of my patients don’t have one thing. They have a paper bag with a bunch of different bottles in it.”
Additionally, diseases arenÂ’t the only things playing into a patientÂ’s health. Social, economic and cultural factors are also key, like health beliefs, money issues, access to transportation to get to medical care and language barriers, to name a few.
“The complexities that are medical are the easy ones,” Rust said.
Spending years studying a very weeded-out patient population, spending a year or two trying to interpret the data and publish it in a journal, and then returning to the population to attempt to help solve problems is not an effective way to do research, Rust said, and doesnÂ’t affect health outcomes well because the whole process moves so slowly that new problems can arise by the time the first issues are addresses. Instead, the medical research community needs to focus on teaming with the community to create research teams that mirror the diversity of the patient population and include a variety of health and social professionals, address complex comorbidities in the study population, use members of the community to help gather and disseminate information, and continually analyze data throughout the study and make appropriate changes as the study progresses, instead of waiting until the end.
While this approach may have a harder time getting funding because data is not so pure — “Sometimes what I do is sort of mucking up the research,” Rust said — the patients will benefit more from this approach, which is what really matters.
Dr. Roberto Cardarelli, executive director and founder of the Primary Care Research Institute and NorTex at the Health Science Center, acted as moderator at the event and raised the problem of the nationwide shortage of primary care physicians and how that will affect research and the work to eliminate health disparities through equitable outcomes and equal access to care.
“If we open access to care, I’m just concerned we won’t be able to handle it,” he said.
“All the financial incentives are aligned against us from succeeding in that model,” Rust acknowledged. However, states could look at incentives, like cutting down on student debt to certain students, to urge more medical students to turn to primary care or much-needed specialties, like pediatric psychology, Rust said.
Additionally, there is always an institution or group that benefits financially from better primary care, Rust said, like a hospital seeing fewer emergency department visits when a local clinic offers more care. Those organizations should be included in the research and should be shown the benefits in exchange for investing in the research, he said.
Mark DeHaven, division chief of community health services at UT Southwestern Medical Center and a panelist during the discussion part of the event, said achieving equitable outcomes requires a long-term commitment to a community that goes beyond one grant or one study. It may be difficult to convince administrators or funding partners that this is necessary, but history has already shown that something needs to change in order to make people healthier. Taking cautious steps — such as research that has been done until recently — isn’t in the best interest of patients.
“We have a choice between incrementalism and a radical departure,” he said.
