starfield. benefits of primary care: evidence from international comparisons of 13 industrialized...
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Starfield
Benefits of Primary Care:Evidence from International
Comparisons of 13 Industrialized Countries
Starfield 09/02
The Countries, Mid-1990s
Australia (AUS)Belgium (BEL)Canada (CAN)Denmark (DK)Finland (FIN)France (FR)
Germany (GER)Japan (JAP)
Netherlands (NTH)Spain (SP)
Sweden (SWE)United Kingdom (UK)
United States (US)
Starfield
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
Primary Care Orientation of Health Systems: Rating Criteria
• Practice Characteristics– First-Contact – Longitudinality – Comprehensiveness – Coordination – Family-centeredness – Community orientation
StarfieldSource: Starfield, 1998.
Primary Care Scores, 1980s and 1990s
Belgium 0.8 0.4 France - 0.3
Germany 0.5 0.4United States 0.2 0.4
Australia 1.1 1.1Canada 1.2 1.2
Japan - 0.8Sweden 1.2 0.9
Denmark 1.5 1.7Finland 1.5 1.5
Netherlands 1.5 1.5Spain - 1.4
United Kingdom 1.7 1.9
1980s 1990s
Starfield 2000
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*)
System and Practice CharacteristicsFacilitating Primary Care, Early-Mid 1990s
UK
NTH
SP
FIN CANAUS
SWE JAP
GER FRBEL
US
DK
Starfield 11/00
Health Care Expenditures per Capita, 1996
BelgiumFrance
GermanyUnited States
--------------------
1693197822223708
AustraliaCanada
JapanSweden
--------------------
1776200215811405
DenmarkFinland
NetherlandsSpain
United Kingdom
-------------------------
14301389175611311304 Starfield 2000
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
Starfield 10/00
US
NTH
CANAUS
SWEJAP
BEL FRGER
SP
DK
FIN
UK
International Comparisons:Birth Outcomes and Primary Care Score
9.5
11.5
7.3
5.54.8 4.6
0
2
4
6
8
10
12
14
Low BirthWeight Post NeonatalMortality
R= -.38 NS
Ave
rage
Ran
king
s
Low Med High
Source: Starfield & Shi, 2002.
Primary Care Score
Low: BEL, FR, GER, USMed: AUS, CAN, JAP, SWEHigh: DEN, FIN, NTH, SP, UK
R= -.74; p<.001
Starfield 09/02
Countries with weak primary care infrastructures have poorer health performance.
Average Rankings for Health Indicators, YPLL (Total and Suicide) in Countries Grouped by Primary Care Orientation
Starfield 2000
All Except Suicide Suicide All Except ExternalFemale 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, 1998.
Average Rankings for World Health OrganizationHealth Indicators for Countries Grouped
by Primary Care Orientation
31.615.216.0Highest* (Denmark, Finland, Netherlands, Spain, UK)
26.016.5 4.8Middle* (Australia, Canada, Sweden, Japan)
36.322.516.3Lowest (Belgium, France, Germany, US)
Overall Health
Child Survival Equity DALEs
Source: Calculated from WHO, 2000.Starfield 10/02
11.0 29.115.8
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
Benefits of Primary Care: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 09/02
Rates of Avoidable Pediatric Hospitalization for Diabetes Mellitus and Pneumonia and Family
Physicians per 10,000 Population
Starfield 10/02Source: Parchman & Culler, 1994.
State Level Analysis:Primary Care and Life Expectancy
PC physicians/population positively associated with longer life expectancy.
Source: Shi et al., 1999.
71
72
73
74
75
76
77
78
4.00 4.50 5.00 5.50 6.00 6.50 7.00 7.50
Primary Care Physicians/10,000 Population
Lif
e E
xpec
tan
cy
.LA
SC.
.GA
.NV
.MS
.AL
.WV
.DE .
NC
.KY
.KS
.TN
. ID
.MI
.TX
.IA
.UT .
NY
.CA
.MD
.ND
.WI
.NM
.AZ
.NE
.MA
. CT
. HI.MN
.AK
.IL
.VA
.PA
.
FL
.MT
.OR
.NJ
ME.NH
.SD
.ID
.AR
.
.WA
.RI
R=.54
P<.05
Starfield 03/02
TotalMortality
InfantMortality
Income Inequality(Robin Hood Index)
Primary CarePhysicians
LifeExpectancy
Low Birthweight
.41** -.17
-.29*
-.33*
.58**-.37**
.42** .35*
-.36**
Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990
Starfield*p<.05; **p<.01.Source: Shi et al., 1999.
TotalMortality
NeonatalMortality
Income Inequality(GINI COEFFICIENT)
Primary CarePhysicians
Stroke Mortality
Postneonatal Mortality
-.38** -.33*
-.18
-.33*
.18.16
.39** .40**
-.38**
Path Coefficients for the Effects of Income Inequality and Primary Care on Health Outcome: 50 US States, 1990
*p<.05; **p<.01.
Life Expectancy
Life Expectancy
-.35**
.42**
StarfieldSource: Shi et al., 1999.
Reductions in Inequality in Health by Primary Care: Self-Reported Health,
60 US Communities, 1996Percent 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
Starfield 2000Based on data in Shi & Starfield, 2000.
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 mortalityLow primary care resources 1.9% increase in mortality
Areas with high income inequality
High primary care resources 17.1% decrease in mortalityLow primary care resources 6.9% increase in mortality
*compared with population mean
Based on data in Shi & Starfield, 2000. Starfield 2000
Low Birthweight among US Rural, Urban, and Health Center Infants
Source: Politzer et al., 2001. Starfield 09/02
8.8
7.5
6.8
6.0
13.6
10.4
13.0
7.4
US urban infants
Urban health center infants infants
US rural infants
Rural health center infants
African American urban infants
African American urban health center infants
African American rural infants
African American rural health center infants
14.00.0 12.010.02.0 4.0 6.0 8.0
Geo
grap
hic
area
Rac
ial c
ompo
sitio
n
• 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 09/02
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 09/02
Primary Care and Equity: Evidence-Based Summary