Association of Features of Primary Health Care With Coronary Heart Disease Mortality

Context The goal of US health care reform is to extend access. In England, with a universal access health system, coronary heart disease (CHD) mortality rates have decreased by more than two-fifths in the last decade, but variations in rates between local populations persist. Objective To identify which features of populations and primary health care explain variations in CHD mortality rates between the 152 primary care trust populations in England. Design, Setting, and Participants A cross-sectional study in England of all 152 primary care trusts (total registered population, 54.3 million in 2008) using a hierarchical regression model with age-standardized CHD mortality rate as the dependent variable, and population characteristics (index of multiple deprivation, smoking, ethnicity, and registers of individuals with diabetes) and service characteristics (level of provision of primary care services, levels of detected hypertension, pay for performance data) as candidate explanatory variables. Main Outcome Measures Age-standardized CHD mortality rates in 2006, 2007, and 2008. Results The mean age-standardized CHD mortality rates per 100 000 European Standard Population were 97.9 (95% confidence interval [CI], 94.9-100.9) in 2006, 93.5 (95% CI, 90.4-96.5) in 2007, and 88.4 (95% CI, 85.7-91.1) in 2008. In all 3 years, 4 population characteristics were significantly positively associated with CHD mortality (index of multiple deprivation, smoking, white ethnicity, and registers of individuals with diabetes), and 1 service characteristic (levels of detected hypertension) was significantly negatively associated with CHD mortality (adjusted r(2) = 0.66 in 2006, adjusted r(2) = 0.68 in 2007, and adjusted r(2) = 0.67 in 2008). Other service characteristics did not contribute significantly to the model. Conclusion In England, variations in CHD mortality are predominantly explained by population characteristics; however, greater detection of hypertension is associated with lower CHD mortality. JAMA. 2010;304(18):2028-2034 www.jama.com