INTRODUCTION
The Affordable Care Act (ACA) shifted US health policy to emphasize disease prevention by mandating full coverage of approved preventive services.1 However, there is considerable debate regarding the continued utility of preventive health exams (PHEs) in the era of new forms of primary care.2 To inform this debate, we sought to characterize the care delivered at the PHE. We compare the services provided during PHEs by primary care providers (PCPs) vs. non-primary care providers, and also examine the services provided at PHEs compared with those provided at visits for chronic and acute conditions.
METHODS
We performed a cross-sectional analysis using data from the 2011–2014 National Ambulatory Medical Care Survey (NAMCS). NAMCS is a nationally representative survey of visits to office-based physicians. We defined a visit as a PHE when the patient’s reason for visit was for a general examination, the physician’s reason for visit was preventive care, and the physician’s only coded diagnosis was a general examination. We identified visits for chronic and acute conditions if the physician’s reason for visit was defined as such on the NAMCS survey. We defined PCPs as providers within family/general practice, internal medicine, or pediatrics. Non-PCPs belonged to other medical specialties or obstetrics and gynecology (ob/gyn). We examined all 23 diagnostic and screening services and 7 counseling services included in the NAMCS survey. We calculated the weighted proportion of visits in which a patient received a particular service and compared proportions using χ2 testing.
RESULTS
Of the estimated 3,055,782,135 visits by adults between 2011 and 2014, 64,662,713 were for a PHE (2.1%; 95% CI, 1.9–2.3). The majority of PHEs were conducted in either solo or group private practices (90.22%; 95% CI, 87.5–92.4). In our comparison of services in PHEs conducted by PCPs vs. non-PCPs (Table 1), PCPs provided more dietary counseling (31.3% vs. 17.5%; p < 0.001), exercise counseling (29.1% vs. 15.0%; p < 0.001), depression screening (8.4% vs. 4.2%; p = 0.01), and colonoscopy referrals (5.6% vs. 2.8%; p = 0.004). PCPs also provided more screening CBCs (42.6% vs. 30.3%; p < 0.001) and EKGs (15.7% vs. 9.0%; p = 0.01) than non-PCPs. In our comparison of services across visit type (Table 2), we observed significantly higher rates of the following tests during PHEs: CBCs (11.8% in acute vs. 13.1% in chronic vs. 37.4% in PHE; p < 0.001), EKGs (3.1% in acute vs. 3.2% in chronic vs. 12.9% in PHE; p < 0.001), and urinalyses (8.1% in acute vs. 6.4% in chronic vs. 25.6% in PHE; p < 0.001).
Table 1.
Comparison of PHE Services by PCPs vs. Non-PCPs in 2011–2014 in Adults ≥ 18
| Non-PCP conducted visit | PCP conducted visit | p value | |
|---|---|---|---|
| No. of visits (weighted) | 27,186,400 | 37,476,313 | |
| Health education/counseling | |||
| Diet/nutrition | 17.5 | 31.3 | < 0.001 |
| Exercise | 15.0 | 29.1 | < 0.001 |
| Family planning/contraception | 3.3 | 1.3 | 0.03 |
| Tobacco use cessation | 3.3 | 7.1 | 0.004 |
| Weight reduction | 4.4 | 9.3 | 0.002 |
| Injury prevention | * | 6.0 | * |
| Imaging | |||
| Mammography | 11.9 | 7.8 | 0.02 |
| X-ray | 3.0 | 4.2 | 0.23 |
| Bone density | 3.0 | 3.5 | 0.55 |
| Blood tests | |||
| CBC | 30.3 | 42.6 | < 0.001 |
| PSA | 6.2 | 13.0 | < 0.001 |
| Lipid profile | 34.0 | 46.1 | < 0.001 |
| HbA1c | 10.2 | 14.8 | 0.11 |
| Glucose | 14.9 | 14.7 | 0.95 |
| Tests and procedures | |||
| Chlamydia test | 2.6 | 1.7 | 0.26 |
| Colonoscopy | 2.8 | 5.6 | 0.004 |
| EKG/ECG | 9.0 | 15.7 | 0.01 |
| PAP test | 21.1 | 7.2 | < 0.001 |
| Urinalysis | 23.5 | 27.2 | 0.52 |
| Screening | |||
| Depression screening | 4.2 | 8.4 | 0.01 |
*Fewer than 30 records were available, making the estimates unreliable
Table 2.
Comparison of Services in PHEs, Visits for Acute Problems, and Visits for Chronic Care in 2011–2014 in Adults ≥ 18
| Acute | Chronic | PHE | p value† | |
|---|---|---|---|---|
| No. of visits (weighted) | 1,337,206,061 | 1,094,361,868 | 64,662,713 | |
| Health education/counseling | ||||
| Diet/nutrition | 7.0 | 11.0 | 25.5 | < 0.001 |
| Exercise | 4.7 | 8.2 | 23.2 | < 0.001 |
| Family planning/contraception | 0.7 | 0.4 | 2.2 | < 0.001 |
| Stress management | 1.3 | 2.4 | 2.5 | 0.50 |
| Tobacco use cessation | 2.0 | 2.4 | 5.5 | < 0.001 |
| Weight reduction | 2.4 | 4.0 | 7.2 | < 0.001 |
| Injury prevention | 2.4 | 1.0 | 4.3 | 0.01 |
| Imaging | ||||
| CT scan | 3.3 | 1.5 | * | * |
| Echocardiogram | 1.4 | 1.2 | 0.9 | 0.22 |
| Mammography | 0.9 | 1.0 | 9.5 | < 0.001 |
| MRI | 1.99 | 1.48 | * | * |
| X-ray | 10.9 | 3.7 | 3.7 | < 0.001 |
| Bone density | 0.4 | 0.5 | 3.2 | < 0.001 |
| Blood tests | ||||
| CBC | 11.8 | 13.1 | 37.4 | < 0.001 |
| PSA | 1.9 | 2.1 | 10.1 | < 0.001 |
| Lipid profile | 6.8 | 9.9 | 41.1 | < 0.001 |
| HbA1c | 4.6 | 6.4 | 12.9 | < 0.001 |
| Glucose | 5.0 | 5.5 | 14.8 | < 0.001 |
| Tests and procedures | ||||
| Cardiac stress test | 0.9 | 0.9 | * | * |
| Chlamydia test | 0.7 | 0.1 | 2.1 | < 0.001 |
| Colonoscopy | 2.0 | 1.0 | 4.4 | < 0.001 |
| EKG/ECG | 3.1 | 3.2 | 12.9 | < 0.001 |
| PAP test | 1.03 | 0.35 | 13.1 | < 0.001 |
| Urinalysis | 8.1 | 6.4 | 25.6 | < 0.001 |
| Screening | ||||
| Depression screening | 2.0 | 3.1 | 6.6 | < 0.001 |
†p values are comparing both acute and chronic visits to the PHE
*Fewer than 30 records were available, making the estimates unreliable
DISCUSSION
Our findings help characterize the strengths and weaknesses of PCPs during the PHE and provide a broader look into the delivery of services during ambulatory visits.
Our results indicate that PCPs provided higher rates of counseling, depression screening, and colonoscopy referrals than non-PCPs during the PHE. Similar trends have been previously observed and are likely due to the trust established by the continuity of the PCP-patient relationship, and the training that generalist physicians receive that emphasizes preventive intervention.3 Non-PCPs provided higher rates of mammograms and Pap smears, which is unsurprising given our classification of ob/gyns as non-PCPs.
Compared with non-PCPs, PCPs also provided more tests that the United States Preventive Services Task Force (USPSTF) recommends against during a PHE, such as screening CBCs and EKGs. Despite the lack of evidence for mass screening with such tests as a means of prevention, many PCPs believe that screening laboratory tests detect subclinical illness in asymptomatic patients.4 We observed similarly high rates of CBCs, EKGs, and urinalyses during PHEs than during visits for acute and chronic conditions, which may be due to misaligned incentives in our fee-for-service healthcare model.
Our study has several potential limitations. It is possible that some of the non-recommended screening tests were indicated to investigate issues that arose during the PHE, but were not documented in the chart. There is also the possibility of misclassification and underreporting of visit content on the NAMCS survey.
Hopefully, recent policy initiatives to improve primary care access through changed reimbursement strategies, such as the medical home model, will lead to stronger PCP-patient relationships and improved quality of care through counseling and recommended screening tests.5 However, these policy initiatives will not suffice and will only thrive with concurrent efforts to bridge the gap between data-driven recommendations by organizations such as the USPSTF and providers’ attitudes towards preventive screening.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they do not have a conflict of interest.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.The Patient Protection and Affordable Care Act, P.L. 111–148, 23 March 2010.
- 2.Mehrotra A, Prochazka A. Improving value in health care—against the annual physical. N Engl J Med. 2015;373(16):1485–7. doi: 10.1056/NEJMp1507485. [DOI] [PubMed] [Google Scholar]
- 3.Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q. 2005;83(3):457–502. doi: 10.1111/j.1468-0009.2005.00409.x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Prochazka AV, Lundahl K, Pearson W, Oboler SK, Anderson RJ. Support of evidence-based guidelines for the annual physical examination: a survey of primary care providers. Arch Intern Med. 2005;165(12):1347–52. doi: 10.1001/archinte.165.12.1347. [DOI] [PubMed] [Google Scholar]
- 5.Rittenhouse DR, Shortell SM. The patient-centered medical home: will it stand the test of health reform? JAMA. 2009;301(19):2038–40. doi: 10.1001/jama.2009.691. [DOI] [PubMed] [Google Scholar]