PCP Visits Before Emergency Surgery Tied to Lower Mortality in Older Adults

Visiting a primary care provider (PCP) in the year prior to emergency general surgery was associated with lower postoperative mortality among Medicare patients, according to a retrospective cohort study.

Compared with Medicare patients ages 66 and up who had not seen a PCP in the previous year, those who had seen a PCP had lower adjusted odds of:

• In-hospital mortality: OR 0.81 (95% CI 0.72-0.92)
• 30-day mortality: OR 0.73 (95% CI 0.67-0.80)
• 60-day mortality: OR 0.75 (95% CI 0.69-0.81)
• 90-day mortality: OR 0.74 (95% CI 0.69-0.81)
• 180-day mortality: OR 0.75 (95% CI 0.70-0.81)

“These findings suggest that primary care may be exerting a protective effect on postoperative morbidity and mortality,” wrote Sanford E. Roberts, MD, of the University of Pennsylvania in Philadelphia, and co-authors in JAMA Surgery.

Of note, Black patients with PCP exposure had similar adjusted odds of in-hospital mortality relative to patients with no PCP exposure (OR 1.09, 95% CI 0.75-1.57), while white patients with PCP exposure had a 21% decreased risk of in-hospital mortality compared with the same group (OR 0.79, 95% CI 0.70-0.90).

However, at 30, 60, 90, and 180 days post-surgery, both Black and white patients who had visited a PCP had significantly lower adjusted odds of mortality compared with those who had not seen a PCP, with no significant differences in the interactions between race and PCP exposure for mortality.

“All together, patients who saw their PCP had 25% lower mortality after surgery. That’s a huge effect,” Roberts said in an email to MedPage Today. “And I think one of the most exciting aspects is that it’s an intervention that is effective for Black and white patients. So, often we see disparities in many aspects of treatment — but seeing a PCP was beneficial no matter the patient’s race in our study.”

The authors noted that while primary care visits have been used to help predict mortality in broader models, “the direct impact of primary care on surgical outcomes has yet to be studied.” Limited access to and use of primary care services, they reasoned, may be behind the higher number of comorbidities and more advanced disease stages that Black patients enter surgery with, especially older patients.

While primary care “aids in identifying and managing a patient’s comorbidities,” they wrote, an association between PCP use and lower mortality could be due to a patient’s overall healthier habits like exercise and good nutrition — and not necessarily just this management.

Caroline E. Reinke, MD, MSHP, and David C. Slawson, MD, of the Carolinas Medical Center in Charlotte, North Carolina, echoed this idea in an invited commentary. “What remains unanswered is whether the PCP visit itself is the causative factor … or if seeing a PCP on an annual basis is a marker of the patient possessing some other ‘magic sauce’ that improves outcomes?”

Adherence to medical treatments can dramatically improve patient outcomes, they noted, but adherence requires “at least 2 critical components beyond the interaction with a PCP: a fundamental conceptual framework that maintenance matters and the tangible resources to achieve the goals.”

Social determinants of health can directly affect the resources available to patients, and in turn, how easy it is for them to stick with a medical treatment. “Future evaluations of the interaction between PCP visits and social determinants of health may shed light on how to achieve the greatest impact,” Reinke and Slawson added.

Roberts told MedPage Today that “having easy access to appointments, finding a provider you trust, having insurance — there are many, many factors that go into getting routine care and, unfortunately, many of these factors are more difficult for many minority patients because of a long history of structural racism is the U.S.”

He said that though research beyond an observational study would help solidify these findings, “bottom line, I think this reinforces the need for preventive care in our system. The more we can do to keep people healthy before there is a problem, the better they will fare during the event.”

Ideas for applying this research to clinical practice include setting alerts in medical records for patients who have gone over a year without a PCP appointment, or facilitating use of patient navigators more frequently, he said.

This study used CMS Master Beneficiary Summary File, Inpatient, Carrier (Part B), and Durable Medical Equipment files for patients ages 66 and older with a principal diagnosis of an emergency general surgery condition. Patients who had undergone a general surgery operation — including colorectal, general abdominal, hepatopancreatobiliary, hernia, intestinal obstruction, resuscitation, and upper gastrointestinal surgeries — from July 2015 to June 2018 were included.

A total of 102,384 patients met inclusion criteria, of which 8.4% were Black and 91.6% were white. Patients who had seen a PCP in the previous year had a mean age of 73.8, and 54.8% were women. Among the patients who had not seen a PCP, mean age was 71, and 48.5% were women.

Roberts and colleagues cited several limitations to their study, including its restrospective design, and the use of claims database data. They also noted the potential for confounding from the possible tendency of patients who visit a PCP to have other beneficial health and lifestyle habits. Alternately, patients who avoid PCPs may also avoid coming to the emergency department for operations, which could worsen outcomes.

Furthermore, “only Black and white patients were included in this study. Additional work will be needed to see if similar trends occur in other racial and ethnic groups,” they wrote.