Strong Primary Care Research Articles

Primary health care in the Region of the Americas 40 years after the Alma-Ata DeclarationAtenção primária à saúde na Região das Américas 40 anos após a Declaração de Alma-Ata

RESUMENEn este artículo se reseña la evolución de las propuestas y acuerdos regionales desde la Declaración de Alma-Ata (1978) hasta la Estrategia de Salud Universal y se destaca la vigencia de los planteamientos esenciales de la estrategia de atención primaria, que hoy se expresan en las propuestas de fortalecimiento del primer nivel de atención y la generación de redes integradas de servicios de salud. Se recuerda, también, el carácter contextual de la implementación de la estrategia en el marco de situaciones nacionales complejas a través de algunos hitos de los últimos 40 años. Se describen los factores que frenan la implementación de la atención primaria de salud (APS), así como los avances y desafíos emergentes que hoy en día enfrentan los sistemas de salud en varios países. Se reafirma que solo mediante un fuerte primer nivel articulador y resolutivo, cercano, inserto en la comunidad y accesible, es posible avanzar hacia el ejercicio del derecho a la salud para todos y se aboga por la generación de propuestas prácticas para relanzar la estrategia de APS a 40 años de la Declaración de Alma-Ata.

Long-term trends in supply and sustainability of the health workforce in remote Aboriginal communities in the Northern Territory of Australia

BackgroundInternational evidence suggests that a key to improving health and attaining more equitable health outcomes for disadvantaged populations is a health system with a strong primary care sector. Longstanding problems with health workforce supply and turnover in remote Aboriginal communities in the Northern Territory (NT), Australia, jeopardise primary care delivery and the effort to overcome the substantial gaps in health outcomes for this population. This research describes temporal changes in workforce supply in government-operated clinics in remote NT communities through a period in which there has been a substantial increase in health funding.MethodsDescriptive and Markov-switching dynamic regression analysis of NT Government Department of Health payroll and financial data for the resident health workforce in 54 remote clinics, 2004–2015. The workforce included registered Remote Area Nurses and Midwives (nurses), Aboriginal Health Practitioners (AHPs) and staff in administrative and logistic roles. Main outcome measures: total number of unique employees per year; average annual headcounts; average full-time equivalent (FTE) positions; agency employed nurse FTE estimates; high and low supply state estimates.ResultsOverall increases in workforce supply occurred between 2004 and 2015, especially for administrative and logistic positions. Supply of nurses and AHPs increased from an average 2.6 to 3.2 FTE per clinic, although supply of AHPs has declined since 2010. Each year almost twice as many individual NT government-employed nurses or AHPs are required for each FTE position.Following funding increases, some clinics doubled their nursing and AHP workforce and achieved relative stability in supply. However, most clinics increased staffing to a much smaller extent or not at all, typically experiencing a “fading” of supply following an initial increase associated with greater funding, and frequently cycling periods of higher and lower staffing levels.ConclusionsOverall increases in workforce supply in remote NT communities between 2004 and 2015 have been affected by continuing very high turnover of nurses and AHPs, and compounded by recent declines in AHP supply. Despite substantial increases in resourcing, an imperative remains to implement more robust health service models which better support the supply and retention of resident health staff.

Improving GP access to U/S – a multidimensional approach in collaboration with the Primary Care Division

Improving GP access to U/S – a multidimensional approach in collaboration with the Primary Care Division

Measuring the value of the Health Care Home

Introduction: The primary care environment is demanding new models of care driven by population and workforce demographics, but also by technology changing the way we live our lives and therefore our expectations of service delivery. The outcomes gained from a strong primary care system are well documented, however the sustainability of this sector, particularly in rural areas is under threat. The Pinnacle Midlands Health Network ‘Health Care Home’ (HCH) model of care transforms the role of general practice as the integrator within a community and health care system, whilst at the same time shifting the control of healthcare more towards the individual and their family. It shifts the primary health care eco-system from largely a reactive, provider-centric system to one that proactively plans and delivers care using the ‘one assessment, one plan and one team’ concept of care. Drives towards integrated care have often been hampered by concentration on one aspect of service delivery without making the necessary alignments to other elements of the system. Creating a HCH environment cracks the well-documented barriers to integrated care, building leadership and clinical capacity, changing professional custom and practice, expanding roles, establishing integrated patient information systems and aligning funding and contractual models. Pinnacle is partnering with other organisations around New Zealand to develop HCHs across the country. However the exact nature of what constitutes a HCH in the New Zealand setting, and what might form minimum standards for such are undefined. We sought to create a list of criteria that would define a HCH, and enable measurement of progress towards that status. Method: The literature was searched for all mentioned aspects of HCHs. The implementation documentation for each existing HCH in New Zealand was searched to identify all changed components. Each was mapped onto a four point scale, from no progress toward HCH to full implementation of HCH. These were tested and refined in workshops of HCH providers and commissioners covering a variety of implementation sites and HCH styles. The final version was then used by HCH providers to provide a historical score for their practices over time on each dimension. Results: The HCH Implementation Tool was successfully developed and deployed. Results from the deployment will be presented at the Congress. It has already proved useful for practices starting on their transformation to measure their progress and how far they have to go. Conclusions: The Health Care Home model demonstrates improved outcomes for patient experience, workforce satisfaction and system efficiency. It is possible to define and measure the changes leading to a primary care practice becoming a Health Care Home and the extent of its integration with other services, allowing quantification in addition to common qualitative measures

When Esophagus Met Bronchus: And Itʼs not a Love Story

Esophagopulmonary fistula is a devastating complication of advanced esophageal cancer (EC). Embryonically, the trachea and esophagus are derived from the foregut. When these structures meet again, they impact oral feeding and quality of life. This connection during development likely causes future malignant invasion into the respiratory tract. The incidence of stage T4, in which the tumor invades adjacent structures, is reported to be 8-30% among thoracic esophageal carcinomas.WhileEC accounts for 1% of all newly diagnosed cancers in the US, it is the 7th leading cause of cancer deaths among men. The 5-year survival rate of EC is 18% at diagnosis drops to 5% with stage IV disease, likely due to complications. We present one such complication, esophagopulmonary fistula, diagnosed with esophagogastroduodenoscopy (EGD). A 60-year-old Caucasian male presented with back pain, 10 lb. weight loss, and progressive dysphagia for 2 weeks. He had history of hypertension and a hiatal hernia, but denied heartburn. He was a former smoker, 1 pack/day for 5 years, with an average BMI. Barium esophagogram revealed a lobulated soft tissue mass near the GEJ. Contrast CT demonstrated a large heterogeneous enhancing esophageal soft tissue mass, as well as bilateral pulmonary nodules. Endoscopy revealed an esophageal mass from 29cm to the GEJ at 37cm, encompassing 75% of the lumen. Our advanced endoscopist was able to pass the endoscope into the stomach. While maneuvering around the mass, a pulmonary fistula was observed on the right side of the esophagus at 30cm. Given the location and the two lumens, this fistula was believed to connect to the right middle lobe bronchus. Biopsies were consistent with esophageal adenocarcinoma. He was palliatively treated with a covered stent, allowing him to eventually eat solids. ECs are aggressive and often diagnosed at later stages when complications are increased, namely esophagopulmonary fistulas. Making screening in this population is of utmost concern. Our patient adamantly denied heartburn or acid regurgitation. However, his wife reported that he had daily reflux and chronic cough, but declined to seek medical evaluation. This case serves to highlight the importance of strong patient and primary care provider relationships, to hopefully discover more EC cases in earlier stages. This case also affirms that covered expandable metallic stents allow for feeding, safely prevent aspiration from the fistula, and improve quality of life.Figure: Anatomical Reference - Esophagus cm from Incisors.Figure: Proximal Portion of Esophagopulmonary Fistula.Figure: Communication between Esophagus and Right Middle Lobe Bronchus.

"Enticing case study" or "celebrated anomaly"? Policy learning from the Cuban health system.

Cuba is regarded as having achieved very good health outcomes for its level of economic development. It has adopted policies and programs that focus on prevention, universal access to healthcare, a strong primary care system, the integration of health in all policies, and public participation in health. It has also established a strong and accessible system of medical education and provides substantial medical aid and support to other countries. Why then, it may be asked, has the Cuban experience not had greater influence on health policies and reforms elsewhere? This article, based on a literature review and new primary sources, analyzes various factors highlighted in the policy transfer literature to explain this. It also notes other factors that have created greater awareness of Cuban health achievements in some countries and which provide a basis for learning lessons from its policies.

Health Care Home - what is it?

Introduction: The primary care environment is demanding new models of care driven by population and workforce demographics, but also by technology changing the way we live our lives and therefore our expectations of service delivery. The outcomes gained from a strong primary care system are well documented, however the sustainability of this sector, particularly in rural areas is under threat. The Pinnacle Midlands Health Network ‘Health Care Home’ (HCH) model of care transforms the role of general practice as the integrator within a community and health care system, whilst at the same time shifting the control of healthcare more towards the individual and their family. It shifts the primary health care eco-system from largely a reactive, provider-centric system to one that proactively plans and delivers care using the ‘one assessment, one plan and one team’ concept of care. Drives towards integrated care have often been hampered by concentration on one aspect of service delivery without making the necessary alignments to other elements of the system. Creating a HCH environment cracks the well-documented barriers to integrated care, building leadership and clinical capacity, changing professional custom and practice, expanding roles, establishing integrated patient information systems and aligning funding and contractual models. Pinnacle MHN has 14 practices who have adopted the model and another seven in the immediate pipeline with one locality delivering an integrated health and social care model. Pinnacle is partnering with other organisations around New Zealand to develop HCHs across the country. However the exact nature of what constitutes a HCH in the New Zealand setting, and what might form minimum standards for such are undefined. We sought to create a list of criteria that would define a HCH, and enable measurement of progress towards that status. Method: The literature was searched for all mentioned aspects of HCHs. The implementation documentation for each existing HCH in New Zealand was searched to identify all changed components. Each was mapped onto a four point scale, from no progress toward HCH to full implementation of HCH. These were tested and refined in workshops of HCH providers and commissioners covering a variety of implementation sites and HCH styles. The final version was then used by HCH providers to provide a historical score for their practices over time on each dimension. Results: The HCH Implementation Tool was successfully developed and deployed. Results from the deployment will be presented at the Congress. It has already proved useful for practices starting on their transformation to measure their progress and how far they have to go. Conclusions: It is possible to define and measure the changes leading to a primary care practice becoming a Health Care Home and the extent of its integration with other services, allowing quantification of an otherwise qualitative measure

Enhanced skills in global health and health equity: Guidelines for curriculum development

Global health addresses health inequities in the care of underserved populations, both domestic and international. Given that health systems with a strong primary care foundation are the most equitable, effective and efficient, family medicine is uniquely positioned to engage in global health. However, there are no nationally recognized standards in Canada for postgraduate family medicine training in global health. To generate consensus on the essential components of a Global Health/Health Equity Enhanced Skills Program in family medicine. A panel comprised of 34 experts in global health education and practice completed three rounds of a Delphi small group process. Consensus (defined as ≥ 75% agreement) was achieved on program length (12 months), inclusion of both domestic and international components, importance of mentorship, methods of learner assessment (in-training evaluation report, portfolio), four program objectives (advocacy, sustainability, social justice, and an inclusive view of global health), importance of core content, and six specific core topics (social determinants of health, principles and ethics of health equity/global health, cultural humility and competency, pre and post-departure training, health systems, policy, and advocacy for change, and community engagement). Panellists agreed on a number of program components forming the initial foundation for an evidence-informed, competency-based Global Health/Health Equity Enhanced Skills Program in family medicine.

Patients' Financially Driven Delay of GP Visits: Is It Less Likely to Occur in Stronger Primary Care Systems?

Available evidence has suggested that strong primary care (PC) systems are associated with better outcomes. This study aims to investigate whether PC strength is specifically related to the prevalence of patients' financially driven postponement of general practitioner (GP) care. Therefore, data from a cross-sectional multicountry study in 33 countries among GPs and their patients were analyzed using multilevel logistic regression modelling. According to the results, the variation between countries in the levels of patients' postponement of seeking GP care for financial reasons was large. More than one third of these cross-country differences could be explained by characteristics of the health care system and the GP practices. In particular, PC systems with good accessibility and those systems that offer comprehensive care were associated with lower levels of financially driven delay. Consequently, we can conclude that well-organized PC systems can compensate for the negative influence of individual characteristics (socioeconomic position) on the care-seeking behaviors of patients.

The stronger primary care, the lower financially driven postponement of care?

The stronger primary care, the lower financially driven postponement of care?

Typologies of Individuals Attending an Addiction Rehabilitation Center Based on Diagnosis of Mental Disorders

ObjectivesThis study aimed to: (1) identify clusters based on the diagnostic status of mental disorders among individuals with problematic substance use treated in an addiction rehabilitation center (ARC), and (2) characterize these clusters according to socio-demographic variables, neighborhood characteristics, and health service utilization. MethodsData were compiled for 4526 individuals with problematic substance use who received services from an ARC in 2004. The data were compiled by merging four databases: the ARC data registry, the Quebec Health Insurance Board database, the Quebec provincial database for hospitalizations, and the Quebec National Institute of Public Health database. A two-step cluster analysis was performed to generate distinct groups based on diagnostic categories of mental disorders. Complementary comparative analyses were conducted to test differences among the clusters. ResultsThree clusters were identified. The first cluster consisted of individuals who did not receive any diagnosis of a mental disorder, including substance use disorders (SUDs), and who were low users of health services. The second cluster was composed of individuals who received a diagnosis of mental disorder, but not of SUD, and who primarily used mental health services. The third cluster included individuals who had a dual diagnosis (co-occurring SUD and mental disorder), and who were high users of acute care services. ConclusionsThis study highlights the heterogeneity of individuals with problematic substance use treated in an ARC. Treatment will be more effective, overall, if tailored to the varying needs of individuals with problematic substance use. Recommendations of the study geared toward improving the effectiveness of care for this population include systematic diagnostic screening for SUDs by physicians, developing strong primary care for individuals with problematic substance use, and ensuring a continuing care model for individuals with a dual diagnosis.

Patient experiences and the association with organizational factors in general practice: results from the Norwegian part of the international, multi-centre, cross-sectional QUALICOPC study.

BackgroundGeneral practitioners (GPs) constitute a vital part of a strong primary health care system. We need further knowledge concerning factors that may affect the patients’ experiences in their meetings with the GPs. We investigated to what degree organizational factors and GP characteristics are associated with patients’ communicative experiences in a consultation.MethodsWe used data from the Norwegian part of the international, multi-center study Quality and Costs of Primary Care in Europe (QUALICOPC). We included 198 Norwegian GPs and 1529 patients. The patients completed a survey concerning experiences in a consultation with a GP on the inclusion day. The GPs completed a survey regarding organizational aspects of their own practice. Main outcome measures were seven statements concerning how the patients experienced the communication with the GP during the consultation. A generalized estimating equation logistic regression model was used to identify variations in patient experiences associated with characteristics of the GPs and their practices.ResultsThe patients reported overall positive experiences with their GP consultations. Patients who consulted a GP with a short patient list were less likely than patients who consulted a GP with a medium sized list to regard the GP as polite (Odds Ratio (OR) 0.2; 95 % CI 0.1–0.7), to report that the GP asked questions about their health problems (OR 0.6; 0.4–1.0) or that the GP used sufficient time (OR 0.5; CI 0.3–0.9). Patients who consulted a GP with a long patient list compared to patients who consulted a GP with a medium sized list were less likely to feel that they could cope better after the GP visit (OR 0.5; 0.3–0.9) and more likely to feel that the GP hardly looked at them while talking (OR 1.8; 1.0–3.0). No associations with patient experiences were found with the average duration of the consultations, whether the GP worked in a fee-for-service model or whether the GP was the patient’s regular doctor.ConclusionsNorwegian patients report predominantly positive experiences when consulting a GP. Positive communication experiences are most likely to be reported when the GP has a medium sized patient list.

Improving Obesity Prevention and Management in Primary Care in Canada.

Obesity is a major risk factor for chronic diseases with significant morbidity, mortality and health care cost. There is concern due to the dramatic increase in overweight and obesity in Canada in the last 20years. The causes of obesity are multifactorial, with underestimation by patients and healthcare providers of the long-term nature of the condition, and its complexity. Solutions related to prevention and management will require multifaceted strategies involving education, health policy, public health and health systems across the care continuum. We believe that to support such strategies we need to have a strong primary care workforce equipped with appropriate knowledge, skills and attitudes to support persons at risk for, or with, obesity. To achieve this end, significant skills building is required to improve primary care obesity prevention and management efforts. This review will first examine the current state, and then will outline how we can improve.

Trends towards stronger primary care in three western European countries; 2006-2012.

BackgroundStrong primary care systems are believed to have an important role in dealing with healthcare challenges. Strengthening primary care systems is therefore a common policy goal for many countries. This study aims to investigate whether the Netherlands, the UK and Germany have strengthened their primary care systems in 2006-2012.MethodFor this cross-sectional study, data from the International Health Policy surveys of the Commonwealth Fund in 2006, 2009 and 2012 were used. The surveys represent the experiences and perspectives of primary care physicians with their primary care system. The changes over time were researched in three areas: organization of primary care processes, use of IT in primary care and use of benchmarking and financial incentives for performance improvement.ResultsRegarding organization of primary care processes, in all countries the use of supporting personnel in general practice increased, but at the same time practice accessibility decreased. IT services were most advanced in the UK. The UK and the Netherlands showed increased use of performance feedback information. German GPs were least satisfied with how their system works across the 2006-2012 timeframe.ConclusionAll three countries show trends towards stronger primary care systems, although in different areas. Coordination and comprehensive care through the assignment of assisting personnel and use of disease management programs improved in all countries. In the Netherlands and the UK, informational continuity is in part ensured through better IT services. All countries showed increasing difficulties upholding primary care accessibility.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0458-3) contains supplementary material, which is available to authorized users.

Nurse practitioners, canaries in the mine of primary care reform

A strong and effective primary care capacity has been demonstrated to be crucial for controlling costs, improving outcomes, and ultimately enhancing the performance and sustainability of healthcare systems. However, current challenges are such that the future of primary care is unlikely to be an extension of the current dominant model. Profound environmental challenges are accumulating and are likely to drive significant transformation in the field. In this article we build upon the concept of “disruptive innovations” to analyze data from two separate research projects conducted in Quebec (Canada). Results from both projects suggest that introducing nurse practitioners into primary care teams has the potential to disrupt the status quo. We propose three scenarios for the future of primary care and for nurse practitioners’ potential contribution to reforming primary care delivery models. In conclusion, we suggest that, like the canary in the coal mine, nurse practitioners’ place in primary care will be an indicator of the extent to which healthcare system reforms have actually occurred.

Transforming primary care

Last week saw two important publications on primary care in the UK. The General Practice Forward View, published by NHS England and developed in partnership with the Royal College of General Practitioners and Health Education England, sets out a plan to transform general practice over the next 5 years. Backed by an extra £2·4 billion a year, the plan outlines steps to increase the number of general practitioners (GPs) and co-workers, as well as measures to reduce workload stresses, develop infrastructure, and support care redesign to enable increased access to GPs.The second report, Primary Care, by the House of Commons Health Committee, emphasises the need for increased funding of general practice to improve access to care and services for patients, such as extending the traditional 10 minute appointment time.Both reports acknowledge the unprecedented strain on today's GPs, with rising demand from more patients, many of whom have increasingly long-term complex medical conditions. Getting an appointment with a GP is becoming ever more difficult for patients in many areas, while GPs themselves are retiring early, moving abroad, or unable to recruit to fill vacancies.Primary care is the backbone of the NHS. 90% of all NHS patient contacts take place within primary care. Moreover, as Florian Stigler and co-authors outline in Correspondence this week, primary care builds an effective health-care system through its core principles of first contact, continuous, comprehensive, and coordinated care. For countries aspiring to universal health coverage, a strong primary care system is an essential underlying framework. For the NHS, urgent repair, support, and investment into primary care is needed to rebuild and strengthen its backbone. Recruitment from countries with weaker health systems than the NHS is not the answer; training more doctors in the UK, encouraging a career in general practice, improving retention, and increasing task sharing with co-workers (such as pharmacists) are far better solutions. Transforming general practice into a career that is once more desirable and rewarding is essential for the NHS to survive. Last week saw two important publications on primary care in the UK. The General Practice Forward View, published by NHS England and developed in partnership with the Royal College of General Practitioners and Health Education England, sets out a plan to transform general practice over the next 5 years. Backed by an extra £2·4 billion a year, the plan outlines steps to increase the number of general practitioners (GPs) and co-workers, as well as measures to reduce workload stresses, develop infrastructure, and support care redesign to enable increased access to GPs. The second report, Primary Care, by the House of Commons Health Committee, emphasises the need for increased funding of general practice to improve access to care and services for patients, such as extending the traditional 10 minute appointment time. Both reports acknowledge the unprecedented strain on today's GPs, with rising demand from more patients, many of whom have increasingly long-term complex medical conditions. Getting an appointment with a GP is becoming ever more difficult for patients in many areas, while GPs themselves are retiring early, moving abroad, or unable to recruit to fill vacancies. Primary care is the backbone of the NHS. 90% of all NHS patient contacts take place within primary care. Moreover, as Florian Stigler and co-authors outline in Correspondence this week, primary care builds an effective health-care system through its core principles of first contact, continuous, comprehensive, and coordinated care. For countries aspiring to universal health coverage, a strong primary care system is an essential underlying framework. For the NHS, urgent repair, support, and investment into primary care is needed to rebuild and strengthen its backbone. Recruitment from countries with weaker health systems than the NHS is not the answer; training more doctors in the UK, encouraging a career in general practice, improving retention, and increasing task sharing with co-workers (such as pharmacists) are far better solutions. Transforming general practice into a career that is once more desirable and rewarding is essential for the NHS to survive. No universal health coverage without primary health careUniversal health coverage is currently the aspiration of many countries worldwide. We commend Michael Reich and colleagues1 for analysing lessons learned from different country experiences, but we believe there is a crucial element neglected within the ongoing universal health coverage debate. Full-Text PDF

Nursing competency standards in primary health care: an integrative review.

This paper reports an integrative review of the literature on nursing competency standards for nurses working in primary health care and, in particular, general practice. Internationally, there is growing emphasis on building a strong primary health care nursing workforce to meet the challenges of rising chronic and complex disease. However, there has been limited emphasis on examining the nursing workforce in this setting. Integrative review. A comprehensive search of relevant electronic databases using keywords (e.g. 'competencies', 'competen*' and 'primary health care', 'general practice' and 'nurs*') was combined with searching of the Internet using the Google scholar search engine. Experts were approached to identify relevant grey literature. Key websites were also searched and the reference lists of retrieved sources were followed up. The search focussed on English language literature published since 2000. Limited published literature reports on competency standards for nurses working in general practice and primary health care. Of the literature that is available, there are differences in the reporting of how the competency standards were developed. A number of common themes were identified across the included competency standards, including clinical practice, communication, professionalism and health promotion. Many competency standards also included teamwork, education, research/evaluation, information technology and the primary health care environment. Given the potential value of competency standards, further work is required to develop and test robust standards that can communicate the skills and knowledge required of nurses working in primary health care settings to policy makers, employers, other health professionals and consumers. Competency standards are important tools for communicating the role of nurses to consumers and other health professionals, as well as defining this role for employers, policy makers and educators. Understanding the content of competency standards internationally is an important step to understanding this growing workforce.

Adjusted Clinical Groups Method (ACG) to allocate resources according to the disease burden of each health center

Health care must be provided with strong primary health care models, emphasizing prevention and a continued, integrated and interdisciplinary care. Tools should be used to allow a better planning and more efficient use of resources. To assess risk adjustment methodologies, such as the Adjusted Clinical Groups (ACG) developed by The Johns Hopkins University, to allow the identification of chronic condition patterns and allocate resources accordingly. We report the results obtained applying the ACG methodology in primary care systems of 22 counties for three chronic diseases, namely Diabetes Mellitus, Hypertension and Heart Failure. The outcomes show a great variability in the prevalence of these conditions in the different health centers. There is also a great diversity in the use of resources for a given condition in the different health care centers. This methodology should contribute to a better distribution of health care resources, which should be based on the disease burden of each health care center.

Population characteristics, mechanisms of primary care and premature mortality in England: a cross-sectional study

ObjectivesHealth systems with strong primary care tend to have better population outcomes, but in many countries demand for care is growing. We sought to identify mechanisms of primary care that...

The impact of primary care organization on avoidable hospital admissions for diabetes in 23 countries

Objective: Diabetes is a so-called ambulatory care sensitive condition. It is assumed that by appropriate and timely primary care, hospital admissions for complications of such conditions can be avoided. This study examines whether differences between countries in diabetes-related hospitalization rates can be attributed to differences in the organization of primary care in these countries. Design: Data on characteristics of primary care systems were obtained from the QUALICOPC study that includes surveys held among general practitioners and their patients in 34 countries. Data on avoidable hospitalizations were obtained from the OECD Health Care Quality Indicator project. Negative binomial regressions were carried out to investigate the association between characteristics of primary care and diabetes-related hospitalizations. Setting: A total of 23 countries. Subjects: General practitioners and patients. Main outcome measures: Diabetes-related avoidable hospitalizations. Results: Continuity of care was associated with lower rates of diabetes-related hospitalization. Broader task profiles for general practitioners and more medical equipment in general practice were associated with higher rates of admissions for uncontrolled diabetes. Countries where patients perceive better access to care had higher rates of hospital admissions for long-term diabetes complications. There was no association between disease management programmes and rates of diabetes-related hospitalization. Hospital bed supply was strongly associated with admission rates for uncontrolled diabetes and long-term complications. Conclusions: Countries with elements of strong primary care do not necessarily have lower rates of diabetes-related hospitalizations. Hospital bed supply appeared to be a very important factor in this relationship. Apparently, it takes more than strong primary care to avoid hospitalizations.Key pointsCountries with elements of strong primary care do not necessarily have lower rates of diabetes-related avoidable hospitalization.Hospital bed supply is strongly associated with admission rates for uncontrolled diabetes and long-term complications.Continuity of care was associated with lower rates of diabetes-related hospitalization.Better access to care, broader task profiles for general practitioners, and more medical equipment in general practice was associated with higher rates of admissions for diabetes.