general practice as an integral part of the health system
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General Practice as an Integral Part of the Health
System
Barbara Starfield, MD, MPH
16th Nordic Conference on General PracticeCopenhagen, Denmark
May 13-16, 2009
Life Expectancy Compared with GDP per Capita for Selected Countries
Source: Economist Intelligence Unit. Healthcare International. 4th quarter 1999. London, UK: Economist Intelligence Unit, 1999.
Country codes:AG=ArgentinaAU=AustraliaBZ=BrazilCH=ChinaCN=CanadaFR=FranceGE=GermanyHU=HungaryIN=IndiaIS=IsraelIT=ItalyJA=JapanMA=MalaysiaME=Mexico
Starfield 11/06IC 3493 n
NE=NetherlandsPO=PolandRU=RussiaSA=South AfricaSI=SingaporeSK=South KoreaSP=SpainSW=SwedenSZ=SwitzerlandTK=TurkeyTW=TaiwanUK=United KingdomUS=United States
Country* Clusters: Health Professional Supply and Child Survival
Starfield 07/07HS 3754 nSource: Chen et al, Lancet 2004; 364:1984-90.
De
ns
ity
(w
ork
ers
pe
r 1
00
0)
Child mortality (under 5) per 1000 live births3 5 9 50 100 250
25
15
10
5.0
2.5
1
*186 countries
Primary health care is primary care applied on a population level. As a population strategy, it requires the commitment of governments to develop a population-oriented set of primary care services in the context of other levels and types of services.
Starfield 07/07PC 3755 n
Primary care is the provision of first contact, person-focused, ongoing care over time that meets the health-related needs of people, referring only those too uncommon to maintain competence, and coordinates care when people receive services at other levels of care.
Starfield 07/07PC 3756 n
Why Is Primary Care Important?
Better health outcomes
Lower costs
Greater equity in health
Starfield 07/07PC 3757 n
Evidence for the benefits of primary care-oriented health systems is robust across a wide variety of types of studies:
• International comparisons
• Population studies within countries
– across areas with different primary care physician/population ratios
– studies of people going to different types of practitioners
• Clinical studies
– of people going to facilities/practitioners differing in adherence to primary care practices
Starfield 03/08PC 3971 nSource: Starfield et al, Milbank Q 2005; 83:457-502.
Primary Care Scores, 1980s and 1990s
1980s 1990s
BelgiumFrance*
GermanyUnited States
0.8-
0.50.2
0.40.30.40.4
AustraliaCanadaJapan*
Sweden
1.11.2
-1.2
1.11.20.80.9
DenmarkFinland
NetherlandsSpain*
United Kingdom
1.51.51.5
-1.7
1.71.51.51.41.9
*Scores available only for the 1990s Starfield 07/07ICTC 3758 n
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. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
Starfield 11/0202-405 sc
Starfield 11/02PC 2366 n
System Features Important to Primary Health Care
Starfield 11/06EQ 3500 n
Sources: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. van Doorslaer et al. Equity in the Finance and Delivery of Health Care: An International Perspective. Oxford U. Press, 1993.
*0=all regressive 1=mixed 2=all progressive**except Medicaid
Resource Allocation (Score)
Progressive Financing*
Cost Sharing
Compre-hensiveness
BelgiumFranceGermanyUS
0000
0010
0020
0000
AustraliaCanadaJapanSweden
1112
2222
2211
2211
DenmarkFinlandNetherlandsSpainUK
22222
22022
21222
22212
**
Key system factors in achieving primary health care in both developing and industrialized countries are:• Universal financial coverage, under
governmental control or regulation• Efforts to distribute resources equitably
(according to degree of need)• No or low co-payments• Comprehensiveness of services
Starfield 07/07GH 3794 n
Sources: Starfield & Shi, Health Policy 2002; 60:201-18. Gilson et al, Challenging Inequity through Health Systems (http://www.who.int/social_determinants/resources/csdh_media/hskn_final_2007_en.pdf; accessed March 17, 2009).
More Comprehensive Health Centres Have Better Vaccination Coveragea,b
Starfield 05/09COMP 4188
Source: World Health Organization. The World Health Report 2008: Primary Health Care – Now More than Ever. Geneva, Switzerland, 2008.
Primary Care Orientation of Health Systems: Rating Criteria
• Practice Characteristics– First-contact – Person-focus over time – Comprehensiveness – Coordination – Family-centeredness – Community orientation
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
Starfield 04/09PC 4180 n
PC 4181
• First contact avoids unnecessary specialist visits.
• Person-focus over time avoids disease-focused care (makes care more effective).
• Comprehensiveness avoids referrals for common needs (makes care more efficient).
• Coordination avoids duplication and conflicting interventions (makes care less dangerous).
Starfield 04/09PC 4181
0123456789
101112
0 1 2 3 4 5 6 7 8 9 10 11 12 13
System Characteristics (Rank*)
Pra
ctic
e C
ha
ract
eri
stic
s (R
an
k*)
UK
NTH
SP
FIN CANAUS
SWE JAP
GER FRBEL
US
DK
*Best level of health indicator is ranked 1; worst is ranked 13; thus, lower average ranks indicate better performance.
Based on data in Starfield & Shi, Health Policy 2002; 60:201-18.
System (PHC) and Practice (PC) Characteristics Facilitating Primary Care, Early-Mid 1990s
Starfield 03/05ICTC 3099 n
0
0.5
1
1.5
2
1000 1500 2000 2500 3000 3500 4000
Per Capita Health Care Expenditures
Pri
ma
ry C
are
Sco
re
Primary Care Score vs. Health Care Expenditures, 1997
US
NTH
CANAUS
SWEJAP
BEL FRGER
SP
DK
FIN
UK
Starfield 11/06ICTC 3495 n
Primary Care Strength and Premature Mortality in 18 OECD Countries
*Predicted PYLL (both genders) estimated by fixed effects, using pooled cross-sectional time series design. Analysis controlled for GDP, percent elderly, doctors/capita, average income (ppp), alcohol and tobacco use. R2(within)=0.77.
Source: Macinko et al, Health Serv Res 2003; 38:831-65.
Year
High PC Countries*
Low PC Countries*
10000
PYLL
1970 1980 1990 2000
0
5000
Starfield 11/06IC 3496 n
Primary Care Oriented Countries Have
• Fewer low birth weight infants• Lower infant mortality, especially postneonatal• Fewer years of life lost due to suicide• Fewer years of life lost due to “all except
external” causes• Higher life expectancy at all ages except at
age 80
Starfield 07/07IC 3762 n
Sources: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield & Shi, Health Policy 2002; 60:201-18.
The global imperative is to organize health systems around strong, patient-centered, i.e., Primary Care.
A disease-by-disease approach will not address the most serious shortfall in achieving the health-related Millennium Development Goals. It will also worsen global inequities. Those exposed to a variety of interacting influences are vulnerable to many diseases. Eliminating diseases one by one will not materially reduce the chances of others.
Starfield 03/08GH 3992
Sources: IBRD/World Bank, April 8, 2008. King & Bertino, PLoS Negl Trop Dis 2008;2:e209.
Is Primary Care as important within
countries as it is among countries?
Starfield 07/07WC 3765 n
State Level Analysis:Primary Care and Life Expectancy
Source: Shi, Int J Health Serv 1994;24:431-58. Starfield 04/09WCUS 4178 n
71
72
73
74
75
76
77
78
4.0 4.5 5.0 5.5 6.0 6.5 7.0 7.5
Primary care physicians per 10,000 population
Life
exp
ecta
ncy
at b
irth
ME
NHVT
MA
RI
CT
NY
NJ
PA
OH
IN
IL
MI
WI
MN
IA
MO
ND
SD
NE
KSDE MDVA
WV NC
SC
GA
FL
KYTN
AL
MS
AR
LA
OK TX MT
ID
WY
CO
NMAZ
UT
NV
WAOR
CA
AK
HI
Primary Care and Infant Mortality Rates, Indonesia, 1996-2000
1996-19971997-1998
1998-1999 1999-2000
Primary care spendingper capita*
10.3 9.6 8.5 8.2
Hospital spendingper capita*
4.1 4.4 4.6 5.3
Infant mortality
20% improvement(all provinces)(1990-96)
14% worsening(22 of 26 provinces)
*constant Indonesian rupiah, in billions
Source: Simms & Rowson, Lancet 2003; 361:1382-5. Starfield 07/07WC 3796 n
Primary Care Score and Self-Rated Health, Petrópolis, Brazil, 2004*
(n=455) Odds Ratio 95% CI**
Primary care score (0-5) 1.452 1.073, 1.966
Age (years) 0.969 0.957, 0.981
Chronic disease (yes/no) 0.578 0.360, 0.927
Recent illness (yes/no) 0.176 0.098, 0.316
Household wealth (scale 1-8) 1.219 1.007, 1.476
Completed primary school 0.733 0.374, 1.437
Clinic type (0=traditional; 1=PSF) 0.998 0.594, 1.679
*1= excellent/ good health; 0=bad/fair/poor health** standard errors adjusted for clustering by clinic
Starfield 07/07WC 3768 nSource: Macinko, Almeida, de Sá, Health Policy Plan 2007; 22:167-77.
Impact of PSF Coverage on Infant Mortality in Brazilian States, 1990-2002: Marginal Effects*
*Based on 2-way fixed effects model of Brazilian states, 1990-2002, n=351 R^2=0.90. Non-significant (p>0.05) control variables, including physician and nurse supply and sewage not shown.
Marginal effect (% change in IMR with 10% increase in variable)-5 0 5 10 15
Hospital beds
Fertility rate
Clean water
PSF coverage
Illiteracy(women)
Source: Macinko et al, J Epidemiol Community Health 2006; 60:13-19.Starfield 10/06WC 3457 n
Many other studies done WITHIN countries, both industrialized and developing, show that areas with better primary care have better health outcomes, including total mortality rates, heart disease mortality rates, and infant mortality, and earlier detection of cancers such as colorectal cancer, breast cancer, uterine/cervical cancer, and melanoma. The opposite is the case for higher specialist supply, which is associated with worse outcomes.
Starfield 09/0404-167
Sources: Starfield et al, Milbank Q 2005;83:457-502. Macinko et al, J Ambul Care Manage 2009;32:150-71.
Starfield 09/04WC 2957
What We Already Know
• Improving health (improving effectiveness)
• Keeping costs manageable (improving efficiency)
A primary care oriented system is important for
Starfield 09/05PC 3316
Does primary care reduce inequity in
health?
Starfield 07/07EQ 3769 n
Source: Shi et al, Soc Sci Med 2005; 61(1):65-75.
In the United States, an increase of 1 primary care doctor is associated with 1.44 fewer deaths per 10,000 population.
The association of primary care with decreased mortality is greater in the African-American population than in the white population.
Starfield 07/07WCUS 3770 n
Percentage Reduction in Under-5 Mortality: Thailand, 1990-2000
Starfield 07/07WC 3797 n
Poorest quintile (1) 44
(2) 41
(3) 22
(4) 23
Richest quintile (5) 13
Rate ratio (Q1/Q5) 55
Absolute difference (Q1-Q5)
61
Policy changes:
1989 At least one primary care health center for each rural village
1993 Government medical welfare scheme: all children less than 12, elderly, disabled
2001 Entire adult population insured
Activities of Rural Doctors’ Society
Source: Vapattanawong et al, Lancet 2007; 369:850-5.
Why Does Primary Care Enhance Equity in Health?
• Greater comprehensiveness of services (especially important in the presence of multi-morbidity)
• Person-focused care over time (better knowledge of patient and better recognition of problems)
• Greater accessibility of services• Better coordination, thus facilitating care for people
of limited flexibility • Better person-focused prevention
Starfield 05/09PC 4184Source: Starfield et al, Milbank Q 2005;83:457-502.
Why Does Primary Care Enhance Effectiveness of Health Services?
• Greater accessibility• Better person-focused prevention• Better person-focused quality of clinical care• Earlier management of problems (avoiding
hospitalizations)• The accumulated benefits of the four
features of primary care
Starfield 05/09PC 4185Source: Starfield et al, Milbank Q 2005;83:457-502.
• Have more equitable resource distributions• Have health insurance or services that are provided
by the government• Have little or no private health insurance• Have no or low co-payments for health services• Are rated as better by their populations• Have primary care that includes a wider range of
services and is family oriented• Have better health at lower costs
Primary health care oriented countries
Sources: Starfield and Shi, Health Policy 2002; 60:201-18. van Doorslaer et al, Health Econ 2004; 13:629-47. Schoen et al, Health Aff 2005; W5: 509-25.
Starfield 11/05IC 3326
• 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
Primary Care and Health: Evidence-Based Summary
Starfield 09/0202-437 sc
Starfield 09/02PC 2218 n
ConclusionAlthough sociodemographic factors undoubtedly influence health, a primary care oriented health system is a highly relevant policy strategy because its effect is clear and relatively rapid, particularly concerning prevention of the progression of illness and effects of injury, especially at younger ages.
Starfield 11/05HS 3329
Strategy for Change in Health Systems
• Achieving primary care• Avoiding an excess supply of specialists• Achieving equity in health• Addressing co- and multi-morbidity• Responding to patients’ problems• Coordinating care• Avoiding adverse effects• Adapting payment mechanisms• Developing information systems that serve
care functions as well as clinical information
Starfield 11/06HS 3494 n
Health Workforce
Starfield 10/07WF 3901
In 35 US analyses dealing with differences between types of areas (7) and 5 rates of mortality (total, heart, cancer, stroke, infant), the greater the primary care physician supply, the lower the mortality for 28. The higher the specialist ratio, the higher the mortality in 25.
Controlled only for income inequality
Source: Shi et al, J Am Board Fam Pract 2003; 16:412-22. Starfield 11/06SP 3499 n
Above a certain level of specialist supply, the more specialists per population, the worse the outcomes.
Percentage of People Seeing at Least One Specialist in a Year
Starfield 01/07SP 3529 n
US 40% of total population; 54% of patients (users)
Canada(Ontario)
31% of population (68% at ages 65 and over)
UK about 15% of patients (at ages under 65)
Spain 30% of population; 40% of patients (users)
Sources: Peterson S, AAFP (personal communication, January 30, 2007). Jaakkimainen et al. Primary Care in Ontario. ICES Atlas. Toronto, CA: Institute for Clinical Evaluative Sciences, 2006. Sicras-Mainar et al, Eur J Public Health 2007; 17:657-63. Starfield et al, submitted 2008.
Resource Use, Controlling for Morbidity Burden*
• More DIFFERENT specialists seen: higher total costs, medical costs, diagnostic tests and interventions, and types of medication
• More DIFFERENT generalists seen: higher total costs, medical costs, diagnostic tests and interventions
• More generalists seen (LESS CONTINUITY): more DIFFERENT specialists seen among patients with high morbidity burdens. The effect is independent of the number of generalist visits. That is, the benefits of primary care are greatest for people with the greatest burden of illness.
Starfield 09/07CMOS 3854
*Using the Johns Hopkins Adjusted Clinical Groups (ACGs)
Source: Starfield et al, Ambulatory specialist use by patients in US health plans: correlates and consequences. J Ambul Care Manage 2009 forthcoming.
Percent of Patients Reporting Any Error by Number of Doctors Seen
in Past Two Years
Starfield 09/07IC 3870 nSource: Schoen et al, Health Affairs 2005; W5: 509-525.
Country One doctor 4 or more doctors
Australia 12 37
Canada 15 40
Germany 14 31
New Zealand 14 35
UK 12 28
US 22 49
There are large variations in both costs of care and in frequency of interventions. Areas with high use of resources and greater supply of specialists have NEITHER better quality of care NOR better results from care.
Starfield 12/05SP 3343
Sources: Fisher et al, Ann Intern Med 2003; Part 1: 138:273-87; Part 2: 138:288-98. Baicker & Chandra, Health Aff 2004; W4:184-97. Wennberg et al, Health Aff 2005; W5:526-43.
What is the right number of specialists?
What do specialists do?
What do specialists contribute to population health?
Starfield 01/06SP 3354
Enhancements to Primary Care• Health information systems: primary care/system-wide• Analysis of variations in care
– with variations in use of secondary care– with variations in type of payment– with focus on patients versus diseases (P4P)
• Subspecialization in primary care• Patient-centered primary care (poorly conceptualized)• “Chronic care model”: self-management support;
delivery system design; decision support; clinical; information systems
Starfield 02/08PC 3966
ALL REQUIRE EVALUATION.
Any evaluation of enhancements to clinical primary care must consider the extent to which they better achieve the evidence-based primary care functions:• First contact for new needs/problems
• Person (not disease) focused care (enhanced recognition of people’s health problems)
• Breadth of services
• Coordination (enhanced problems/needs recognition over time)
Starfield 06/08EVAL 4044
Good Primary Care Requires
• Health system POLICIES conducive to primary care practice
• Health services delivery that achieves the important FUNCTIONS of primary care
Starfield 06/08PC 4042
The impact of a health services intervention should not be evaluated on the basis of a structural element of health systems alone. The value of health system structures lies only in the behaviors that they engender. In order to understand why and how things have an impact, it is necessary to evaluate the impact of structures on processes of care. That is why evaluations of structures such as type or number of practitioners, electronic health records, and the Chronic Care Model (CCM) have inconsistent results.
Starfield 10/08EVAL 4072
The Health Services System
Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.
Starfield 02/09HS 4133 n
LongevityComfortPerceived well-beingDiseaseAchievementRisksResilience
CAPACITY
PERFORMANCE
HEALTH STATUS(outcome)
Provisionof care
Receiptof care
PersonnelFacilities and equipmentRange of servicesOrganizationManagement and amenitiesContinuity/information systemsKnowledge baseAccessibilityFinancingPopulation eligibleGovernance
People/practitioner interface
Cultural andbehavioral
characteristics
Social, political,economic, and
physical environments
Biologic endowmentand prior health
Problem recognitionDiagnosisManagementReassessment
UtilizationAcceptance and satisfactionUnderstandingParticipation
Community resources
PCAT(Primary Care Assessment Tool)
Starfield 05/0303-095
• First-contact (access and use)• Person-focused care over time• Comprehensiveness (services available
and provided)• Coordination
• Family centered• Community oriented• Culturally competent
Starfield 05/03PCM 2479
Primary Care Scores by Data Source, PSF Clinics
Source: Almeida & Macinko. [Validation of a Rapid Appraisal Methodology for Monitoring and Evaluating the Organization and Performance of Primary Health Care Systems at the Local Level]. Brasília: Pan American Health Organization, 2006.
Starfield 05/06WC 3421 n
0
1
2
3
4
5Access
Longitudinal
Gatekeeping
Comprehensive
CoordinationFamily focus
Community
Providers
Total Score
PSF (users) PSF (providers) PSF (managers)
First ContactResources Available
There is no such thing as a “primary care service”. There are only primary care functions and “specialty care” functions. We know what the primary care functions are; they are evidence-based. Payment should be based on their achievement over a period of time. Any payment system that rewards specific services will distort the main purpose of medical care: to deal with health problems effectively, efficiently, and equitably.
Starfield 06/08PC 4046
Primary Care
Starfield 02/08EVAL 3968 n
First Contact • Accessibility• Use by people for each new problem
Longitudinal • Relationship between a facility and its population
• Use by people over time regardless of the type of problem; person-focused character of provider/patient relationship
Comprehensive • Broad range of services• Recognition of situations where services are
needed
Coordination • Mechanism for achieving continuity• Recognition of problems that require follow-up
Structural and Process Elements of the Essential Features of Primary Care
Essential Features Performance
Utilization
Person-focused relationship
Capacity
Accessibility
Eligible population
Range of services
Continuity
First-contact
Longitudinality
Comprehensiveness
Coordination
Problem recognition
Starfield 199797-194
Starfield 04/97EVAL 1108 n
Structural and Process Elements of the Essential Features of Primary Care
Essential Features Performance
Utilization
Person-focused relationship
Capacity
Accessibility
Eligible population
Range of services
Continuity
First-contact
Longitudinality
Comprehensiveness
Coordination
Problem recognition
Starfield 10/08EVAL 4071 n
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