A Participatory Model of the Paradox of Primary Care

Abstract

PURPOSEThe paradox of primary care is the observation that primary care is associated with apparently low levels of evidence-based care for individual diseases, but systems based on primary care have healthier populations, use fewer resources, and have less health inequality. The purpose of this article is to explore, from a complex systems perspective, mechanisms that might account for the effects of primary care beyond disease-specific care. METHODSIn an 8-session, participatory group model-building process, patient, caregiver, and primary care clinician community stakeholders worked with academic investigators to develop and refine an agent-based computer simulation model to test hypotheses about mechanisms by which features of primary care could affect health and health equity.RESULTS In the resulting model, patients are at risk for acute illness, acute lifechanging illness, chronic illness, and mental illness. Patients have changeable health behaviors and care-seeking tendencies that relate to their living in advantaged or disadvantaged neighborhoods. There are 2 types of care available to patients: primary and specialty. Primary care in the model is less effective than specialty care in treating single diseases, but it has the ability to treat multiple diseases at once. Primary care also can provide disease prevention visits, help patients improve their health behaviors, refer to specialty care, and develop relationships with patients that cause them to lower their threshold for seeking care. In a model run with primary care features turned off, primary care patients have poorer health. In a model run with all primary care features turned on, their conjoint effect leads to better population health for patients who seek primary care, with the primary care effect being particularly pronounced for patients who are disadvantaged and patients with multiple chronic conditions. Primary care leads to more total health care visits that are due to more disease prevention visits, but there are reduced illness visits among people in disadvantaged neighborhoods. Supplemental appendices provide a working version of the model and worksheets that allow readers to run their own experiments that vary model parameters. CONCLUSION This simulation model provides insights into possible mechanisms for the paradox of primary care and shows how participatory group model building can be used to evaluate hypotheses about the behavior of such complex systems as primary health care and population health. INTRODUCTIONM ultiple studies have found that primary care is associated with poorer quality care for individual diseases than is care provided by clinicians focused primarily on those diseases. [1][2][3][4][5][6] Yet, other evidence shows that systems based on primary care have better quality of care, better population health, greater equity, and lower cost. [7][8][9][10][11] This discrepancy between apparently poor disease-specific care and advantageous outcomes at the level of the whole person and system has been called t...

European Practical and Patient-Centred Guidelines for Adult Obesity Management in Primary Care

“…Finally, the management of chronic diseases by GPs is paradoxically associated with a low level of evidence-based care [65]. As a result, the authors fully acknowledge that not all GPs may be able to strictly and thoroughly follow all recommendations set out in this paper, due to time constraints or other factors.…”

Mapping the Dynamic Complexity of Chronic Disease Care in Singapore: Using Group Model Building in Knowledge Elicitation

“…Chronic disease care delivery is characterized by both detail complexity and dynamic complexity. The former refers to the complexity due to multiple stakeholders within the system—policymakers, providers, patients, funders and educators—each with disparate interests (Senge, , Ellis, , Homa et al ., ). The latter refers to complexity arising from interactions among the stakeholders, made more pertinent due to the public and private division, together with multiple payers in the system (Sterman, ).…”

“…Homa et al . () employed a participatory GMB process involving patients, caregivers and primary care clinicians to investigate the mechanisms that might account for the effect of primary care beyond disease‐specific care. Another study used an agent‐based computer simulation model developed with GMB to test plausible hypotheses about the primary care system (Homa et al ., ).…”

In This Issue: Generalist Care Around the World

“…In an attempt to understand the paradox of primary care, Homa and colleagues 5 developed a computerized simulation of neighborhoods and health care systems with input and collaboration from patients in similar real communities. The simulation-available for others to use and adapt-used examples of primary care and specialty care in fairly straightforward single illness conditions and in situations where a high degree of multimorbidity and complexity existed.…”