Our findings lend support to the national movement that is encouraging primary care practice redesign into patient-centered medical homes and highlights first contact access as a characteristic that predicts increases in most preventive services. In our study, the addition of first-contact access for patients who already had continuity of care with a primary care physician was associated with higher receipt of preventive services when compared to having continuity of care alone. Specifically, we found that patients who reported highly rated first-contact access to care had improved receipt of prostate exams, flu shots, and cholesterol tests as compared to those with continuity of care with a primary care physician alone. Rates of receipt of mammograms were not significantly different among those with highly rated first-contact access versus those without this additional PCMH characteristic.
Our study population, which consisted of 69% of the surviving original cohort who responded to the survey in 2003 to 2006, had relatively high rates of preventive service use as compared to the national population at the time of the study. For example, in the prior 12 months, 83% of our sample had received a mammogram, as compared to 77% nationally43
; 78% had received a prostate exam, as compared to 50% nationally44
; 90% had received a cholesterol test, as compared to 85–88%45
; and 63% had received an influenza vaccination, as compared to 50% nationally.46
Even in this relatively well-educated population with excellent continuity of care and high receipt of preventive services, the addition of first-contact accessibility increased the odds of individuals receiving flu shots, prostate exams and cholesterol screening. Although the increase in odds of preventive services receipt was small in some cases, when translated to national health indicators, these small increases have potentially large payoffs.
Our findings also have implications for the ongoing discussion regarding the relationship between continuity of care with a personal physician and access to care.47–50
Continuity of care is difficult to achieve in open access models with part-time providers.51, 52
There has been a shift away from personal continuity53, 54
and an increase in primary care providers that practice part-time, though this may be offset by other strategies.55
Our findings imply that provider continuity and access to care jointly benefit receipt of preventive services. This suggests that primary care office models that can balance these two areas and also develop advanced systems that can adapt to the changing demographics of the provider workforce are needed. In addition, further research is needed to explore how patients perceive first-contact access to their continuity physician in regards to receiving individual preventive services, and how this may vary according to different types of preventive services.
Similar to other studies that have examined the associations between receipt of preventive services and continuity of care,21, 33
mammography receipt did not increase with first-contact access. One explanation is that the effects of first-contact access on preventive services may not extend beyond the point of care. Mammograms are the only service we examined generally not completed in the primary care office. Alternatively, the mammography screening rate in our population was quite high. Given mammogram receipt is dependent on provider and patient characteristics, and the logistics of another imaging site11, 33
it may be difficult for primary care clinics to further improve this rate.
Despite strengths of this comprehensive data, these findings should be considered in light of several limitations. This sample represents individuals who attended Wisconsin high schools in the 1950s and therefore is limited in geographical and racial/ethnic diversity. However, WLS graduates are generally representative of non-Hispanic white women and men with a high school education, constituting approximately 67% of Americans aged 60 to 64.56
We also restricted the sample to individuals with insurance and continuity of care in order to test the additional effect of first-contact access on preventive service receipt. Therefore, our sample is not generalizable to all patients seen in primary care. Receipt of preventive services was measured using self-report, which when compared to the medical record has been found to be overestimated.57–60
However, there is no reason to believe any estimation differences would be different for those with and without desirable first-contact accessibility. It is possible that individuals who received better preventive care were more likely to perceive access to care more positively. We used clinical preventive service guideline age cutoffs that were in place at the time of data collection, which have changed recently for certain preventive services. In particular, prostate cancer screening is no longer recommended for men over age seventy-five61
and influenza vaccination is now recommended over the age of six months.62
Annual prostate exam in the current clinical environment may be considered an example of overutilization. Lastly, influenza vaccination was available in public clinics and drug stores during the years of the study. Therefore, it is difficult to know if individuals received these immunizations in their primary care clinic. However, a principle of the medical home is that such care should be delivered and tracked through the primary care system, which will become increasingly important as accountable care organizations track and measure the delivery of high-quality care.
In conclusion, our findings suggest that first-contact accessibility adds benefit beyond continuity of care with a physician to improve receipt of preventive services in the primary care patient-centered medical home. Amid increasing primary care demands and limited primary care resources, studies examining the impact of specific components of the PCMH may help redesign efforts. There is need for further studies of the interplay between specific PCMH principles and how they perform in practice.