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The Primacy of Primary Care in Health Services Systems

The Primacy of Primary Care in Health Services Systems. Barbara Starfield, MD, MPH November 2002. The Countries, Mid-1990s. Australia Belgium Canada Denmark Finland France Germany Japan Netherlands Spain Sweden United Kingdom United States. Starfield. Primary Care Specialists .

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The Primacy of Primary Care in Health Services Systems

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  1. The Primacy of Primary Care in Health Services Systems Barbara Starfield, MD, MPH November 2002

  2. The Countries, Mid-1990s Australia Belgium Canada Denmark Finland France Germany Japan Netherlands Spain Sweden United Kingdom United States Starfield

  3. Primary Care Specialists Reimbursement of Physicians** 1980s 1990s 1980s 1990s Belgium F F F F France F F F F Germany F F F F United States F F F F Australia F F F F Canada F F F F Japan F F F F Sweden S S S S Denmark C/F F/C S/F F Finland* S/C S/C S S Netherlands C/F C/F F S Spain S S S S United Kingdom C C/F S S Starfield 2000

  4. Are Specialists Limited to Hospital Practice? Early-Mid 1990s Starfield 2000

  5. Primary Care Orientation of Health Systems: Rating Criteria • Health System Characteristics • Type of system • Financing • Type of primary care practitioner • Percent active physicians who are specialists • Professional earnings of primary care physicians relative to specialists • Cost sharing for primary care services • Patient lists • Requirements for 24-hour coverage • Strength of academic departments of family medicine Source: Starfield, 1998. Starfield

  6. Primary Care Orientation of Health Systems: Rating Criteria • Practice Characteristics • First-Contact • Longitudinality • Comprehensiveness • Coordination • Family-centeredness • Community orientation Source: Starfield, 1998. Starfield

  7. 1980s Primary Care Scores, 1980s and 1990s 1990s Belgium 0.8 0.4 France* - 0.3 Germany 0.5 0.4 United States 0.2 0.4 Australia 1.1 1.1 Canada 1.2 1.2 Japan* - 0.8 Sweden 1.2 0.9 Denmark 1.5 1.7 Finland 1.5 1.5 Netherlands 1.5 1.5 Spain* - 1.4 United Kingdom 1.7 1.9 Starfield 10/02

  8. System and Practice CharacteristicsFacilitating Primary Care, Early-Mid 1990s GER FR BEL US SWE JAP CAN FIN AUS SP DK NTH UK Starfield 11/00

  9. Health Care Expenditures per Capita, 1996 Starfield 2000

  10. Primary Care Score vs. Health Care Expenditures, 1997 UK DK NTH FIN SP CAN AUS SWE JAP GER US BEL FR

  11. Primary Care OrientationandPopulation Health Status Starfield 10/02

  12. 5.9 6.7 5.0 6.2 Average Rankings* for Health Indicators in Infancy, for Countries Grouped by Primary Care Orientation Low Birth Weight (1993) Neonatal Mortality (1993) Postneonatal Mortality (1993) Infant Mortality (1996) Lowest (Belgium, France, Germany, US) 9.5 7.8 11.5 8.8 Middle (Australia, Canada, Japan, Sweden) 7.3 5.3 5.5 6.0 Highest (Denmark, Finland, Netherlands, Spain, UK**) 4.8 7.8 4.6 6.4 Starfield 04/01

  13. Average Rankings for Health Indicators, YPLL (Total and Suicide) in Countries Grouped by Primary Care Orientation All Except SuicideSuicide All Except External Female Male Female Male Female Male Lowest 9.510.8 7.3 8.3 8.8 10.8 (Belgium, France, Germany, US) Middle 3.8 2.8 7.0 7.3 3.8 3.5 (Australia, Canada, Japan, Sweden) Highest 7.6 7.4 6.8 5.8 8.2 7.0 (Denmark, Finland, Netherlands, Spain, UK) Source: OECD, 1998. Starfield 2000

  14. 7.1 6.6 6.6 5.9 6.7 6.8 Average Rankings* for Life Expectancy at Ages 40, 65, and 80, for Countries Grouped by Primary Care Orientation Age 40 Age 65 Age 80 Female Male Male Female Male Female Lowest (Belgium, France, Germany, US) 7.8 9.5 8.0 8.0 7.4 6.9 Middle (Australia, Canada, Japan, Sweden) 4.0 2.5 3.8 3.5 3.6 4.3 Highest (Denmark, Finland, Netherlands, Spain, UK**) 8.8 8.6 8.8 9.0 9.5 9.3 Starfield 04/01

  15. 11.0 15.8 29.1 Average Rankings for World Health Organization Health Indicators for Countries Grouped by Primary Care Orientation Source: Calculated from WHO, 2000. DALE: Disability adjusted life expectancy (life lived in good health) Child survival: survival to age 2, with a disparities component Overall health: DALE minus DALE in absence of a health system Maximum DALE for health expenditures minus same in absence of a health system Starfield 10/02

  16. Percentage of Individuals Who Smoke per Capita at Ages 15 and Older, Early-Mid 1990s* Female Male Belgium 21.0 31.0 France 20.0 38.0 Germany 21.5 36.8 United States 24.6 28.6 Australia 23.8 28.2 Canada 26.0 26.0 Japan 13.3 60.4 Sweden 26.6 25.2 Denmark 40.1 45.9 Finland 20.0 33.0 Netherlands 30.5 42.9 Spain 21.0 44.0 United Kingdom 28.0 29.0 *All countries 1992, except Canada (1991), Spain (1993)

  17. Earned Income Disposable Income Country (90/20 ratio) (Gini) Belgium 5 3 France 10 8 Germany 7 6 United States 11 13 Australia 12 10 Canada 9 7 Japan 1 11 Sweden 2 2 Denmark 8 4 Finland 6 1 Netherlands 4 5 Spain 3 9 United Kingdom 13 12 Ranking of Countries by Income Inequality Starfield 2000

  18. Primary Care Features Consistently Associated with Good/Excellent Primary Care • System features • Regulated resource distribution • Government-provided health insurance • No/low cost-sharing for primary care • Practice features • Comprehensiveness • Family orientation Starfield 10/01

  19. Primary Care Score and Health Outcomes Source: Macinko et al., 2002. Starfield 06/02

  20. Primary Care Score and Premature Mortality in 18 OECD Countries 10000 PYLL Low PC Countries* 5000 All Countries* High PC Countries* 0 1970 1980 1990 2000 Year Source: Macinko et al., 2002. Starfield 06/02

  21. Within-Country Studies • Ecological analyses: Effect of primary care doctor to population ratios (US, UK) • Case control studies (US) • Hospitalizations for avoidable conditions or complications (US, Spain) • Survey data on impact of affiliation with a primary care doctor (US, Spain) • Path analyses at state and local levels (US) Starfield 2000

  22. Factors Related to In-hospital Standardized Mortality, England (NHS Hospitals), 1991-2 to 1994-5 Regression Coefficient % of cases admitted as emergency 0.58 # hospital doctors/100 hospital beds -0.47 # GPs/100,000 population -0.67 Standardized admission ratio -0.15 % live discharges to home 1.61 % patients with co-morbidity 1.51 NHS facilities/100,000 population -1.12 Source: Jarman et al., 1999. Starfield 2000

  23. Rates of Avoidable Adult Hospitalizationfor 6 Conditions and Family Physiciansper 10,000 Population Starfield 10/02 Source: Parchman & Culler, 1994.

  24. Rates of Avoidable Pediatric Hospitalization for Diabetes Mellitus and Pneumonia and Family Physiciansper 10,000 Population Source: Parchman & Culler, 1994. Starfield 10/02

  25. Physician Supply and Odds Ratios*of Diagnosis of Late-StageColorectal Cancer *change in odds of late stage diagnosis with each 10 percentile increase in supply of physicians **significant at p<.01 Source: Roetzheim et al., 1999. Starfield 10/02

  26. Adjusted Odds Ratios for Severe, Uncontrolled Hypertension According to Various Risk Factors* No. of Patients Adjusted with Complete Odds Ratio Risk FactorData (95% CI) P Value No primary care 204 4.4 (2.2-8.9) <0.001 No medical insurance 204 2.2(1.0-4.6) 0.04 Noncompliance with antihypertensive 199 2.0 (1.5-2.7) <0.001 regimen† One or more alcohol-related problems 204 2.2 (0.8-6.3) 0.14 Illicit drug use‡ 204 1.3 (0.5-3.6) 0.60 †Categorized on a five-point scale. ‡In the past year. Source: Shea et al., 1992. Starfield 1999

  27. Health Care Expenditures and Mortality 5 Year Followup:United States, 1987-92 • Adults (age 25 and older) with a primary care physician rather than a specialist as their personal physician • had 33% lower cost of care • were 19% less likely to die (after controlling for age, gender, income, insurance, smoking, perceived health (SF-36) and 11 major health conditions) Source: Franks & Fiscella, 1998. Starfield 1999

  28. Primary Care Reform, 1984-90 to 1994-96 Percent Decline in Mortality - Various Causes, Barcelona, Spain 45 E = 40 M = 38 40 M = 35 L = 35 35 30 % Decline E = 23 25 20 15 10 L = 6 5 0 Perinatal Hypertension E = Early Implementation M = Later Implementation L = Late Implementation Source: Villalbi et al., 1999. Starfield 2000

  29. Major Determinants of Outcomes*:50 US States Specialty Physicians: More: all outcomes worse Primary Care Physicians: Fewer: all outcomes worse Hospital Beds: More: higher total, heart disease, and neonatal mortality Education: No relationship Income: Lower: higher heart and cancer mortality Unemployment: Higher: higher total mortality, lower life span, more low birthweight Urban: Lower mortality (all), longer life span Pollution: Higher total mortality Life Style: Worse: higher total and cancer mortality, lower life span Minority: Higher total mortality, neonatal mortality, low birthweight, lower life span

  30. . . . HI . . MN . . CT WA . ND MA . . . . NE . SD ID . OR CA . . ME . NH . . . AZ RI . . ID . . NM . MT . IA UT . NJ . . TN . . FL . WI KS NY . . TX AR . PA . MI DE KY . WV . . NC VA AL MD . IL MS . . NV . AK R=.54 P<.05 GA SC LA State Level Analysis:Primary Care and Life Expectancy PC physicians/population positively associated with longer life expectancy. Source: Shi et al., 1999. Starfield 03/02

  31. Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990 Total Mortality Infant Mortality .42** .35* -.36** -.29* Income Inequality (Robin Hood Index) -.33* Primary Care Physicians -.37** .58** Life Expectancy Low Birthweight .41** -.17 Source: Shi et al., 1999. *p<.05; **p<.01. Starfield

  32. Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990 Life Expectancy Total Mortality Neonatal Mortality .39** .40** -.35** -.38** -.18 Income Inequality (GINI COEFFICIENT) -.33* Primary Care Physicians .16 .18 .42** Stroke Mortality Postneonatal Mortality -.38** -.33* Life Expectancy Source: Shi et al., 1999. *p<.05; **p<.01. Starfield

  33. Does Primary Care Reduce Disparities in Health across Population Subgroups? Starfield 10/02

  34. Reductions* in Inequality in Health by Primary Care: Postneonatal Mortality,50 US States, 1990 Areas with low income inequality High primary care resources 0.8% decrease in mortality Low primary care resources 1.9% increase in mortality Areas with high income inequality High primary care resources 17.1% decrease in mortality Low primary care resources 6.9% increase in mortality *compared with population mean Based on data in Shi & Starfield, 2000. Starfield 2000

  35. Reductions* in Inequality in Health by Primary Care: Stroke Mortality,50 US States, 1990 Areas with low income inequality High primary care resources 1.3% decrease in mortality Low primary care resources 2.3% increase in mortality Areas with high income inequality High primary care resources 2.3% decrease in mortality Low primary care resources 1.1% increase in mortality *compared with population mean Based on data in Shi & Starfield, 2000. Starfield 2000

  36. Reductions in Inequality in Health by Primary Care: Self-Reported Health,60 US Communities, 1996 • Percent reporting fair or poor health • Areas with low income inequality • No effect of primary care resources* • Areas with moderate income inequality • 16% increase in areas with low primary care resources* • Areas with high income inequality • 33% increase in areas with low primary care resources* • *compared with median # of primary care physicians to population ratios Based on data in Shi & Starfield, 2000. Starfield 2000

  37. Primary Care Practice Characteristics: Evidence-Based Summary • Countries with strong primary care • have lower overall costs • generally have healthier populations • Within countries • areas with higher primary care physician availability (but NOT specialist availability) have healthier populations • more primary care physician availability reduces the adverse effects of social inequality Starfield 1999

  38. Primary Care Practice Characteristics: Evidence-Based Summary • Countries with strong primary care • have lower overall costs • generally have healthier populations • Within countries • areas with higher primary care physician availability (but NOT specialist availability) have healthier populations • more primary care physician availability reduces the adverse effects of social inequality Starfield 1999

  39. Conclusions Both international comparisons and studies within countries document the beneficial impact of primary care on effectiveness (health outcomes), on efficiency (lower costs), and on equity of health outcomes (reducing disparities across population subgroups). Health policy should be directed toward strengthening the primary care orientation of health systems.

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