Objectives: To identify features of primary care quality
improvement associated with improved health outcomes
using premature coronary heart disease (CHD) mortality
as an example, and to determine impacts of different
modelling approaches.
Design: Cross-sectional study of mortality rates in 229
general practices.
Setting: General practices from three East Midlands
primary care trusts.
Participants: Patients registered to the practices above
between April 2006 and March 2009.
Main outcome measures: Numbers of CHD deaths in
those aged under 75 (premature mortality) and at all
ages in each practice.
Results: Population characteristics and markers of
quality of primary care were associated with variations in
premature CHD mortality. Increasing levels of
deprivation, percentages of practice populations on
practice diabetes registers, white, over 65 and male were
all associated with increasing levels of premature CHD
mortality. Control of serum cholesterol levels in those
with CHD and the percentage of patients recalling access
to their preferred general practitioner were both
associated with decreased levels of premature CHD
mortality. Similar results were found for all-age mortality.
A combined measure of quality of primary care for CHD
comprising 12 quality outcomes framework indicators
was associated with decreases in both all-age and
premature CHD mortality. The selected models suggest
that practices in less deprived areas may have up to 20%
lower premature CHD mortality than those with median
deprivation and that improvement in the CHD care quality
from 83% (lower quartile) to 86% (median) could reduce
premature CHD mortality by 3.6%. Different modelling
approaches yielded qualitatively similar results.
Conclusions: High-quality primary care, including
aspects of access to and continuity of care, detection and
management, appears to be associated with reducing
CHD mortality. The impact on premature CHD mortality is
greater than on all-age CHD mortality. Determining the
most useful measures of quality of primary care needs
further consideration.