title: Does higher quality primary health care reduce stroke admissions? A national cross-sectional study.
abstract: BACKGROUND
  Hospital admission rates for stroke are strongly associated with population factors. The supply and quality of primary care services may also affect admission rates, but there is little previous research.
  
  
  OBJECTIVE
  To determine if the hospital admission rate for stroke is reduced by effective primary and secondary prevention in primary care.
  
  
  METHODS
  National cross-sectional study in an English population (52,763,586 patients registered with 7969 general practices in 152 primary care trusts).
  
  
  METHODS
  A combination of data on hospital admissions for 2006-2009, primary healthcare staffing, practice clinical quality and access indicators, census sources, and prevalence estimates was used. The main outcome measure was indirectly standardised hospital admission rates for stroke, for each practice population.
  
  
  RESULTS
  Mean (3 years) annual stroke admission rates per 100,000 population varied from zero to 476.5 at practice level. In a practice-level multivariable Poisson regression, observed stroke prevalence, deprivation, smoking prevalence, and GPs/100,000 population were all risk factors for hospital admission. Protective healthcare factors included the percentage of stroke or transient ischaemic attack patients whose last measured total cholesterol was ≤5 mmol/l (P<0.001), and ability to book an appointment with a GP (P<0.003). All effect sizes were relatively small.
  
  
  CONCLUSIONS
  Associations of stroke admission rates with deprivation and smoking highlight the need for smoking-cessation services. Of the stroke and hypertension clinical quality indicators examined, only reaching a total cholesterol target was associated with reduced admission rates. Patient experience of access to primary care may also be clinically important. In countries with well-developed primary healthcare systems, the potential to reduce hospital admissions by further improving the clinical quality of primary healthcare may be limited.
authors.affiliation: Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, UK. m.soljak@imperial.ac.uk
authors.forename: Michael
authors.initials: M
authors.lastname: Soljak
authors.forename: Amaia
authors.initials: A
authors.lastname: Calderon-Larrañaga
authors.forename: Pankaj
authors.initials: P
authors.lastname: Sharma
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Cecil
authors.forename: Derek
authors.initials: D
authors.lastname: Bell
authors.forename: Gerrard
authors.initials: G
authors.lastname: Abi-Aad
authors.forename: Azeem
authors.initials: A
authors.lastname: Majeed
mesh_terms: D003430:Cross-Sectional Studies; D004739:England / Q000453:epidemiology; D058006:General Practice / Q000592:standards*; D006297:Health Services Accessibility / Q000592:standards*; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D006973:Hypertension / Q000453:epidemiology / Q000517:prevention & control; D017063:Outcome Assessment, Health Care; D015995:Prevalence; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care; D012044:Regression Analysis; D020521:Stroke / Q000453:epidemiology / Q000517:prevention & control*