Explaining variations in mortality rates at general practice level

This thesis aims to identify features of primary care associated with improved health outcomes using premature coronary heart disease (CHD) mortality as an example. Impacts of different modelling approaches are also explored. A cross-sectional study of 229 general practices in the East Midlands was undertaken. The main outcome measure was numbers of premature CHD deaths in patients registered at the practices (April 2006 to March 2009). Publicly available data describing both population characteristics and aspects of primary care were utilised. A novel method of estimating smoking prevalence in practice populations was described and differing methods of describing the performance of primary care in detecting hypertension were evaluated. Population characteristics and markers of quality of primary care were associated with variations in premature CHD mortality. Increases in: the percentage of practice populations on practice diabetes registers, the proportion who were over 65, the proportion who were male, and the estimated smoking prevalence in patients with chronic conditions 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, a measure of continuity of care, were both associated with decreased counts of premature CHD mortality. Increasing levels of undiagnosed hypertension prevalence were associated with increased levels of premature CHD mortality. Similar results were found for all-age mortality; there is less evidence that continuity of care is associated with all-age CHD mortality. High-quality primary care, including aspects of access to and continuity of care, disease detection and management, appear to be associated with reduced CHD mortality. Data gathered as part of the Health Checks initiative has the potential to improve studies of this type, particularly if published by age group. Determining the most useful measures of quality of primary care needs further consideration.