Among patients who receive healthcare at the same family physician practice, those who live close to each other fare better with respect to cardiovascular health, mortality, and healthcare costs than those who live farther apart, an analysis suggests.
In a retrospective study of data for more than 2 million adults, the rate of cardiovascular events was 24% higher among patients who lived farthest from each other than among those who lived closest to each other. Patient proximity also was associated with lower mortality and per-patient healthcare costs.
“The study was prompted by repeated examples of patients of mine helping each other,” author William Hogg, MD, a clinician investigator at the University of Ottawa in Ontario, Canada, told Medscape Medical News. “The significant improvement in all-cause mortality is quite possibly caused by patients helping each other.”
The study was published online September 13 in Canadian Family Physician.
Closer Seems Better
The investigators analyzed data for 2,690,482 adult patients cared for by 1710 family physicians and calculated the geographic distance between patients who received care from the same practice. They used distance between patients in a practice to stratify physicians into quintiles of panel proximity and compared outcomes from close-proximity practices with those from more-distant-proximity practices.
The main outcome was the occurrence of a major cardiovascular event during a 5-year follow-up period (2008 to 2012).
Patients in the closest-proximity quintile lived an average of 3.9 km from the 10 closest patients in the practice. Patients in the distant-proximity quintile lived an average of 12.4 km from the 10 closest patients in the practice.
In addition, close-proximity panels had more female physicians, more international medical graduates, and larger rosters. Patients in close-proximity panels were more likely to be women or immigrants, live in low-income neighborhoods, and be in poorer health.
After adjustment for age, sex, cardiac risk factors, income, ethnicity, physician characteristics, and patient-to-physician distance, the rate of major cardiovascular events was 24% higher among patients in the most-distant-proximity practices than among those in the closest-proximity practices (adjusted hazard ratio,1.24).
Age- and sex-standardized all-cause mortality and total per-patient healthcare costs were lowest in the closest-proximity quintile. Furthermore, patients in close-proximity practices visited their doctor more often and received more preventive care, according to the authors.
Results were similar in sensitivity analyses that were restricted to large urban communities and to White long-term residents.
“The better cardiovascular outcomes observed in close-proximity panels may be related to a previously unrecognized mechanism of social connectedness that extends the effectiveness of primary care practitioners,” write the investigators.
They acknowledge, however, that they were unable to consider confounding variables, such as family history, the built environment, and lifestyle factors, and that they were unable to confirm whether patients in a particular practice knew or supported each other.
“It is too soon to promote spatial proximity,” said Hogg. “The study findings should give pause to jurisdictions that restrict allowing patients the right to choose their physician. There may also be implications in terms of how to pay physicians equitably.”
His next steps for future research include surveying patients in family physician practices to document how often they know a neighbor who sees the same family physician and whether and how they have ever assisted each other.
Commenting on the study for Medscape, Michael Goyfman, MD, chief of cardiology and director of echocardiography at Long Island Jewish Forest Hills Hospital, part of Northwell Health in New York, said, “There are numerous possible confounding variables that the researchers were unable to address. For example, were some patients more likely than others to have heart attacks because of a strong family history of heart attacks, or perhaps because they had lower rates of exercise and healthy lifestyle practices?”
Patients with higher incomes tend to have better health outcomes, he added. “The researchers were able to assess the average income of a neighborhood but did not know the incomes of individual patients.”
In addition, it is unclear whether other factors motivated a patient to seek primary care at a location further from other patients, said Goyfman. “Perhaps the patient was medically complex, not satisfied with the care he or she received from nearby physicians, and therefore had to travel further than his or her neighbors to see a different physician. In this case, the distant-proximity group may merely be a marker for preexisting poor health or some other unassessed confounding variable.
“It may be, as the authors suggest, that neighbors help to care for one another, ensure that they are compliant with appointments, testing, medication, etc, all of which may improve outcomes,” he said. “Or this may all be merely a coincidence because the patients who are in the distant-proximity group are sicker or have other underlying health conditions that were not assessed.”
Only a randomized controlled trial can assess for causality, so if specific patients were randomly assigned to specific physicians and were followed for several years, a clearer picture would emerge, Goyfman concluded.
No commercial funding for the study was disclosed. The authors and Goyfman have disclosed no relevant financial relationships.
Can Fam Physician. Published online September 13, 2022. Full text
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