Increasing PCP density could ‘substantially improve’ life expectancy

United States residents in counties with fewer primary care physicians to serve their population could potentially see sizeable increases in life expectancy with the addition of more PCPs, researchers wrote.

“A major question has been how much we can expect to achieve in population health improvements with our current workforce,” Sanjay Basu, MD, PhD, director of research for the Center for Primary Care at Harvard Medical School, told Healio Primary Care. “We wanted to understand how the concentration of the workforce within high‐density areas affects that problem, and therefore how we might need to focus our efforts on lower‐availability settings.”

Basu and colleagues wrote in Annals of Internal Medicine that federal and state efforts to increase PCP density have been unsuccessful. Instead, there has been a decrease in PCP density over the past decade, they added.

The researchers conducted a study using generalized additive models, mixed-effects models and generalized estimating equations to assess how reducing PCP shortages could affect age-modified life expectancy, all-cause mortality and death from cancer, CVD, infectious disease, injury, respiratory disease and substance use among residents of 3,104 counties in the United States from 2010 to 2017.

According to the researchers, the mean life expectancy of residents in areas with fewer than one physician for each 3,500 people — which the Health Resources and Services Administration (HRSA) defines as a “primary health care shortage area” — in 2017 (number of counties = 1,218) was 310.9 days shorter compared with residents of areas who had more PCPs.

Basu and colleagues also reported that if these 1,218 counties added 17,651 physicians to their population — roughly 14.5 more physicians for each county with a PCP shortage — it could boost the mean life expectancy of their residents by 22.4 days (median = 19.4 days; 95% CI, 0.9-45.6). If the 2,636 counties with fewer than one physician for each 1,500 residents added 95,754 physicians — or approximately 36.3 more physicians for each county with a shortage — the life expectancy of those residents would rise 56.3 days (median = 55.6 days; 95% CI, 4.2-105.6).

The researchers concluded that increasing PCP density could “substantially improve life expectancy.”

“The study is fairly robust in the sense that we found similar results using multiple different statistical approaches, and inferred our results based on how counties themselves experienced a particular history of increased or decreased providers — rather than extrapolating from one county to a different one,” Basu said.

The results underscore the need for more physician recruitment efforts such as loan-repayment programs, according to Basu.

“We also hope to look upstream by encouraging more educational opportunities in rural and low‐availability settings, and coordinating with national corps of service providers to increase PCP density through early education programs that help build a workforce passionate about care for the underserved,” he added.

In a press release, the researchers provided other suggestions to encourage more PCPs to practice in rural areas, such as boosting salaries and supporting efforts to increase the number of medical trainees from underserved areas. Other efforts to improve primary care access include complementing the existing workforce with physician assistants and nurse practitioners and gauging the role of telehealth, according to the researchers.

The study also raises the question of whether PCP shortage areas should be defined by the current HRSA designation or a recommendation from an expert panel that proposed “widening the definition of low‐availability areas,” Basu said.

“By following the expert panel, we find a bigger portion of inequalities in our nation's population health are exposed, and so the take-home message becomes one of marrying the need for more primary care providers with the need for a broader agenda to address population health inequalities that are so stark within our country,” he said.