Association of primary care characteristics with variations in mortality rates in England: an observational study

PLoS One. 2012;7(10):e47800. doi: 10.1371/journal.pone.0047800. Epub 2012 Oct 24.


Background: Wide variations in mortality rates persist between different areas in England, despite an overall steady decline. To evaluate a conceptual model that might explain how population and service characteristics influence population mortality variations, an overall null hypothesis was tested: variations in primary healthcare service do not predict variations in mortality at population level, after adjusting for population characteristics.

Methodology/principal findings: In an observational study of all 152 English primary care trusts (geographical groupings of population and primary care services, total population 52 million), routinely available published data from 2008 and 2009 were modelled using negative binomial regression. Counts for all-cause, coronary heart disease, all cancers, stroke, and chronic obstructive pulmonary disease mortality were analyzed using explanatory variables of relevant population and service-related characteristics, including an age-correction factor. The main predictors of mortality variations were population characteristics, especially age and socio-economic deprivation. For the service characteristics, a 1% increase in the percentage of patients on a primary care hypertension register was associated with decreases in coronary heart disease mortality of 3% (95% CI 1-4%, p = 0.006) and in stroke mortality of 6% (CI 3-9%, p<0.0001); a 1% increase in the percentage of patients recalling being better able to see their preferred doctor was associated with decreases in chronic obstructive pulmonary disease mortality of 0.7% (CI 0.2-2.0%, p = 0.02) and in all cancer mortality of 0.3% (CI 0.1-0.5%, p = 0.009) (continuity of care). The study found no evidence of an association at primary care trust population level between variations in achievement of pay for performance and mortality.

Conclusions/significance: Some primary healthcare service characteristics were also associated with variations in mortality at population level, supporting the conceptual model. Health care system reforms should strengthen these characteristics by delivering cost-effective evidence-based interventions to whole populations, and fostering sustained patient-provider partnerships.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Age Factors
  • England / epidemiology
  • Humans
  • Models, Statistical
  • Models, Theoretical*
  • Mortality*
  • Observation
  • Primary Health Care / methods*
  • Primary Health Care / standards
  • Primary Health Care / statistics & numerical data*
  • Regression Analysis
  • Socioeconomic Factors

Grant support

The study formed part of the programme of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Research and Care (CLARHC) in Leicestershire, Northamptonshire and Rutland. The CLAHRC is funded by the NIHR. The views expressed in this paper do not necessarily reflect those of the NIHR. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.