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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, FRCGP May 2002. The Countries, Mid-1990s. Starfield. Reimbursement of Physicians **. Primary Care Specialists . 1980s 1990s 1980s 1990s Belgium F F F F France F F F F Germany F F F F

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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, FRCGP May 2002

  2. The Countries,Mid-1990s Starfield

  3. Reimbursement of Physicians** Primary Care Specialists 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 F=Fee-for-Service C=Capitation S=Salary *but substantial private sector fee-for-service ** for those who work in community 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 adapted from Starfield B. Primary Care: Balancing Health Needs Services & Technology, 1998 (Chapter 15) Starfield

  6. Primary Care Orientation of Health Systems: Rating Criteria • Practice Characteristics • First-Contact • Longitudinality • Comprehensiveness • Coordination • Family-centeredness • Community orientation adapted from Starfield B. Primary Care: Balancing Health Needs Services & Technology, 1998 (Chapter 15) Starfield

  7. Primary Care Scores, 1980s and 1990s 1980s 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 2000

  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 Starfield 10/00

  11. 5.9 6.7 5.0 6.2 Average Rankings* for Health Indicators in Infancy, for Countries Grouped by Primary Care Orientation *Best level of health indicator is ranked 1; worst is ranked 13, thus, lower average ranks indicate better performance. **England and Wales only Starfield 04/01

  12. Average Rankings for Health Indicators, YPLL (Total and Suicide) in Countries Grouped by Primary Care Orientation All Except Suicide Suicide All Except External Female Male Female Male Female Male Lowest 9.5 10.8 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 Tapes, 1998 Starfield 2000

  13. 11.0 15.8 29.1 Average Rankings for Health Indicators for Countries Grouped by Primary Care Orientation: World Health Report, 2000 Source: Calculated from WHO, World Health Report (Health Systems: Improving Performance) 2000 DALE: Disability adjusted life expectancy (life lived in good health) Child survival: survival to age 5, 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 2000

  14. 6.7 5.9 6.6 6.6 6.8 7.1 Average Rankings* for Life Expectancy at Ages 40, 65, and 80, for Countries Grouped by Primary Care Orientation *Best level of health indicator is ranked 1; worst is ranked 13, thus, lower average ranks indicate better performance. **England and Wales only Starfield 04/01

  15. 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) Starfield 2000

  16. Ranking of Countries by Income Inequality 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 Starfield 2000

  17. 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

  18. 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

  19. 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., BMJ, 1999 Starfield 2000

  20. 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 Note: All variables are ecologic, not individual *Overall mortality; mortality from heart disease, mortality from cancer, neonatal mortality, life span, low birthweight. Source: Shi, 1994 Starfield 1999

  21. Rates of Avoidable Adult Hospitalization for 6 Conditions and Family Physicians-Internists per 10,000 Population Starfield 1999 Source: Parchman & Culler, 1994

  22. Rates of Avoidable Pediatric Hospitalization for Diabetes Mellitus and Pneumonia and Family Physicians-Pediatrician Physicians per 10,000 Population Starfield 1999 Source: Parchman & Culler, 1994

  23. Adjusted Odds Ratios for Severe, Uncontrolled Hypertension According to Various Risk Factors* No. of Patients Adjusted with Complete Odds Ratio Risk Factor Data (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 *Adjustment was made in each model for age, sex, race or ethnic group, educational level, and current smoking status, but not for other risk factors. Odds ratios are expressed as the risk of severe, uncontrolled hypertension for a patient with the risk without it. CI denotes confidence interval. †Categorized on a five-point scale. ‡In the past year. Starfield 1999 Source: Shea et al 1992

  24. 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

  25. Starfield 2000

  26. . . . 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. Starfield 03/02 Shi et al. Income, Inequality, Primary Care and Health Indicators. Journal of Family Practice. April 1999

  27. 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 *p<.05; **p<.01. Source: Shi, Starfield, Kennedy, Kawachi, JFP 1999

  28. 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 *p<.05; **p<.01. Source: Shi, Starfield, Kennedy, Kawachi, JFP 1999

  29. 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, IJHS, 2000 Starfield 2000

  30. 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, IJHS, 2000 Starfield 2000

  31. 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, IJHS, 2000 Starfield 2000

  32. Primary Care Practice Characteristics: Evidence-Based • 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

  33. Primary Care and Equity: Summary In areas with low social inequity, the additional effect of primary care is small. In areas of high social inequity, the additional effect of primary care is larger. Starfield 2000

  34. Ranking on 16 Health Indicators (Best to Worst), Mid 1990s Japan Sweden Canada France Australia Spain Finland Netherlands United Kingdom Denmark Belgium United States Germany Starfield 1999

  35. Ranking, World Health Report (13 Countries) Child Survival Health System Country DALE Equity Attainment Japan 1 2 1 Australia 2 6 7 France 3 4 3 Sweden 4 12 2 Spain 5 3 11 Canada 6 7 4 Netherlands 7 5 5 United Kingdom 8 1 6 Belgium 9 10 8 Finland 10 11 13 Germany 11 8 9 United States 12 13 10 Denmark 13 9 12 Source: World Health Report, 2000, Annex tables 9, 5 Starfield 2000

  36. Health System Attainment,World Health Organization Components and Weighting Level of health (DALEs) 25% Distribution of health 25% (equity of child survival) Level of responsiveness of system 12.5% Distribution of responsiveness 12.5% Fairness of financial contribution 25% Source: World Health Report, 2000, Annex table 9 Starfield 2000

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