Primary care, race, and mortality in US states

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Abstract

This study used US state-level data from 1985 to 1995 to examine the relationship of primary care resources and income inequality with all-cause mortality within the entire population, and in black and white populations. The study is a pooled ecological design with repeated measures using 11 years of state-level data (n=549). Analyses controlled for socioeconomic and demographic characteristics. Contemporaneous and time-lagged covariates were modeled, and all analyses were stratified by race/ethnicity. In all models, primary care was associated with lower mortality. An increase of one primary care doctor per 10,000 population was associated with a reduction of 14.4 deaths per 100,000. The magnitude of primary care coefficients was higher for black mortality than for white mortality. Income inequality was not associated with mortality after controlling for state-level sociodemographic covariates. The study provides evidence that primary care resources are associated with population health and could aid in reducing socioeconomic disparities in health.

Section snippets

Background

In the past decade, substantial literature suggested a significant association between income inequality and mortality both in the US and abroad (Blakely, Lochner, & Kawachi, 2002; Wilkinson, 1996; Kennedy, Kawachi, & Prothrow-Stith, 1996; Lochner, Pamuk, Makuc, Kennedy, & Kawachi, 2001; Lynch et al., 1998; McLaughlin & Stokes, 2002; Subramanian, Blakely, & Kawachi, 2003). The greater the gap in income distribution between the rich and poor in a given area, the higher the mortality rate for the

Data and measures

Data for this study came from a variety of sources including the Compressed Mortality Files (US Department of Health and Human Services National Center for Health Statistics, 2000), the US Department of Commerce and the Census Bureau (1985), US Department of Commerce and the Census Bureau (1986), US Department of Commerce and the Census Bureau (1987), US Department of Commerce and the Census Bureau (1988), US Department of Commerce and the Census Bureau (1989), US Department of Commerce and the

Results

During 1985–1995, there was a decline in all-cause mortality. The mean state age-adjusted mortality rate dropped from 821 to 762 per 100,000 population (Fig. 1, Panel 1). In the same period, there was a steady increase in primary care physicians, from 5.02 to 6.04 per 10,000 population (Fig. 1, Panel 2). Income inequality within states fluctuated during the period with an overall worsening trend: the mean of the Gini coefficient among states increased from 0.41 to 0.43 during the period (Fig. 1

Discussion

This study confirmed earlier findings that primary care was associated with lower mortality and partially mediated the association between socioeconomic variables and mortality (Shi, Starfield, Kennedy, & Kawachi (1999), Shi, Starfield, Politzer, & Regan (2002); Shi & Starfield (2001), Shi, Starfield, Kennedy, & Kawachi (1999)). These findings are significant because they provide more robust evidence of a relationship between primary care physicians and lower state mortality than was possible

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