Greater Black PCP representation improves survival outcomes for Black patients

Key takeaways:

• A 10% increase in Black primary care physician representation increased the life expectancy of Black patients by about 1 month.
• Enhanced life expectancy was greatest in counties with high poverty.

Greater representation of Black primary care physicians was associated with improved life expectancy among Black patients and reduced disparities in all-cause mortality rates, according to researchers.

“Life expectancy disparities between Black and white individuals have persisted for decades and have improved only modestly over time,” John E. Snyder, MD, MS, MPH, director of the division of data governance and strategic analysis at HHS Health Resources and Services Administration, and colleagues wrote. “While primary care availability appears to be important for everyone, some studies stratified by race suggest that there may be a more powerful inverse association between access and mortality for Black individuals.”

The researchers conducted a cohort study to determine the association between Black PCP workforce representation and survival outcomes over three time points: 2009, 2014 and 2019. The analysis included 1,618 counties in the United States that had at least one Black PCP.

Overall, the number of counties with at least one Black PCP was 1,198 in 2009, 1,260 in 2014 and 1,308 in 2019, “consistently less than half of all 3,142 Census-defined U.S. counties as of 2014,” the researchers wrote in JAMA Network Open.

While percentages of Black PCPs in each year were lower than the percentages of Black patients in the U.S. county-level population, there was still an overall 9.8% increase in the number of counties with at least one Black PCP from 2009 to 2019.

Regarding patient outcomes, Snyder and colleagues estimated that a 10% increase in Black representation in the PCP workforce was associated with a:

• higher life expectancy among Black individuals of 30.61 days (95% CI, 19.13-42.44);
• lower all-cause mortality among Black individuals by 12.71 deaths per 100,000 (95% CI, -14.77 to -10.66); and
• a 1.2% lower disparity between Black and white all-cause mortality rates (95% CI, -1.29% to -1.05%)

Improvements in life expectancy were greatest in counties with high poverty, according to the researchers.

However, they did not find an association between the total proportion of PCPs and positive health outcomes among Black individuals.

“Taken together, these findings suggest that Black PCP workforce representation levels are relevant to and potentially affect Black population health,” they wrote.

Snyder and colleagues concluded that the findings support the need to increase the diversity of the PCP workforce. However, they also noted that building a more diverse workforce should not result in care segregation or lessen the need for cultural understanding among all physicians.

In a related editorial, Monica E. Peek, MD, MPH, MSc, an associate professor of medicine in the section of general internal medicine at the University of Chicago, said the positive associations found may not just be exclusively the result of health care delivery.

“While there is evidence to support potential mechanisms by which Black physicians working within the health care system can improve health outcomes for Black patients (eg, increased shared decision-making and patient-centered care, culturally concordant care, increased quality of care), there is also evidence that Black physicians are more likely than physicians from other racial or ethnic groups to engage in health-related work outside the health care system to be politically involved in health-related matters at the local, state, or

national level; and to encourage medical organizations to advocate public health,” she wrote. “This community involvement and advocacy by Black physicians may change the social drivers of health for the populations most vulnerable to their health effects.”

Peek also referred to the lack of association between the total PCP proportion and survival outcomes as a “chasm” between non-Black physicians and Black patients created by structural racism and other abuses.

“Overcoming this chasm, establishing trustworthy institutions, and engaging with

and truly seeing Black patients in their full humanity will take an extraordinary, transformative, and sustained commitment of time, infrastructure and action,” she wrote.

Ultimately, considering the study findings, “it should be a national priority to ensure that Black populations in the U.S. have access to Black PCPs within their counties and to increase the representation of Black PCPs within existing counties,” Peek wrote.

References:

• Peek M. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.6687
• Snyder J, et al. JAMA Netw Open. 2023;doi:10.1001/jamanetworkopen.2023.6678