Paper of the Week: 10th December 2019
This week’s blog is brought to you by: Dr Joe McManners
Full reference and title from the journal:
Association Between a Temporary Reduction in Access to Health Care and Long-term Changes in Hypertension Control Among Veterans After a Natural Disaster Aaron Baum, PhD; Michael L. Barnett,MD, MS; Juan Wisnivesky,MD, DrPH; Mark D. Schwartz, MD.
JAMA Network Open. 2019;2(11):e1915111. doi:10.1001/jamanetworkopen.2019.15111 (Reprinted) November 13, 2019
https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2755309
Authors conclusion:
The authors used the temporary closure of a primary healthcare facility as a natural experiment to examine the association between a temporary decrease in health care access and long-term control of hypertension, diabetes, and hypercholesterolemia.
The period of decreased access to healthcare services was associated with increased rates of uncontrolled hypertension, but not with increased rates of uncontrolled diabetes or hyperlipidemia, more than 1 year after the Manhattan facility reopened. Temporary gaps in access to health care may be associated with long-term increases in uncontrolled blood pressure among patients with hypertension.
3V bottom line
In universal health systems access to primary care, for the effective management of long-term conditions, should be equitable. However, in practice, even in the UK, access to primary care is worse depending on where you live and sadly worse for those living in deprived areas. This study provides evidence for worse outcomes when access to primary care is reduced.
The effect of loss of access to primary care is similar whether caused by natural disaster or by structural inequity in healthcare provision.
3VH – Implications for value
In this study we see a real life unintended ‘experiment’ following super-storm Sandy in New York state; a large cohort lost access to primary care. Around 19,000 patients were exposed to loss of their primary care facility. The authors compared this cohort to those not exposed to this and found they were 25% more likely to have uncontrolled blood pressure. This effect persisted 2 years later.
The study demonstrates an example of what happens with even temporary loss of access to primary care. If poor access is permanent this will inevitably adversely affect lifelong health. Even in a short time scale, loss of access contributed to uncontrolled hypertension, we can imagine that a permanent poor access would result in long term uncontrolled hypertension with the well evidenced outcomes of ischaemic heart disease, stroke and dementia worsening (not taking into account other effects of lack of access to primary care to other health conditions and causal factors).
In reality access to primary care is very variable, even within health systems with good general access. Inequitable access is a recognised phenomenon and is usually a long-term situation.
In universal health systems, such as the UK, access to primary care, for the effective management of long-term conditions (and the rest of comprehensive health care), is assumed to be equitable. This should mean that good access doesn’t depend on who you are, where you live or your particular problems. However, in practice, even in the UK, access to primary care is worse depending on where you live and sadly worse for those living in deprived areas (the ‘inverse care law’)[i]. Figures for 2018 show this trend is worsening, with the number of patients per GP higher in more deprived areas and lower in more affluent areas. [ii][iii] There is also evidence that for certain groups of people, effective access is reduced, for example for those with poor English, those with mental health problems or Learning Disabilities. Looking at patient access questions, one in seven people in the poorest areas were unable to get a GP appointment, compared to one in ten in the richest areas[iv]. This pattern is repeated over and over and again.
Linking this pattern with evidence of worsening outcomes with poor access, such as the evidence of this study, which looks at poor access to primary care due to an emergency, we can draw parallels with poor access to primary care due to deprivation and inequity, and the resulting deterioration in health outcomes caused by this. The effect of loss of access to primary care is similar whether caused by natural disaster or by structural inequity in healthcare provision. In health services, equity matters as if the service is inequitable there is the likelihood that the service will make inequality worse.
3VH definition of equity is worth revisiting:
‘Equity in health can be defined as the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/disadvantage—that is, different positions in a social hierarchy.’[v]
By this definition, access to primary care is inequitable. And as we have seen, it matters.
If we are going to address inequity, we need to measure it. We need to measure and identify when we have inequity, such as in access to primary care and if we want to improve the health of our population fairly, we then need to reduce that inequity.
[i] https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(71)92410-X/fulltext
[ii] https://www.health.org.uk/news-and-comment/blogs/a-worrying-cycle-of-pressure-for-gps-in-deprived-areas
[iii] https://www.gponline.com/gp-workforce-falling-50-faster-deprived-areas-official-data-show/article/1465701
[iv] https://www.nuffieldtrust.org.uk/news-item/poor-areas-left-behind-on-standards-of-gp-care-research-reveals
[v] https://ovsp.net/essential-glossary/equity-equality-and-health-inequalities/