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We Can Do Better

We Can Do Better. How Primary Care Will Improve Health Care and Save the World. Richard G. Roberts, MD, JD Wonca President 2010-2013 Professor of Family Medicine, University of Wisconsin TEL: +1 608 263 3598 Email: richard.roberts@fammed.wisc.edu. U.S. Healthcare System.

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We Can Do Better

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  1. We Can Do Better How Primary Care Will Improve Health Care and Save the World Richard G. Roberts, MD, JD Wonca President 2010-2013 Professor of Family Medicine, University of Wisconsin TEL: +1 608 263 3598 Email: richard.roberts@fammed.wisc.edu

  2. U.S. Healthcare System 1,300 payers1 4,919 hospitals2 764,000 physicians3 3,119,000 nurses4 302,000,000 people5 1http://www.ahip.org/ 2http://www.aha.org/aha/research-and-trends/health-and-hospital-trends/2006.html 3http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/2.htm 4Dionne M, Moore J, Armstrong D, and Martiniano R. The United States Health Workforce Profile. Rensselaer, NY: Center for Health Workforce Studies, School of Public Health, SUNY Albany. October 2006. http://chws.albany.edu. 5http://www.census.gov/

  3. U.S. Healthcare System • 2009 National Health Expenditures (NHE)1 • 17.6% of GDP (Switzerland 11%); largest sector • $2,500 billion • $8086 NHE per capita • 1 in 4 without any or enough insurance2 • 2000 World Health Report3: • ranked 37th for system performance • ranked 72nd for health outcomes 1https://www.cms.gov/NationalHealthExpendData/02_NationalHealthAcco untsHistorical.asp#TopOfPage 2http://www.census.gov/prod/2006pubs/p60-231.pdf 3http://www.who.int/whr/2000/en/whr00_en.pdf

  4. Healthcare services U.S., 2005 Physician office visits 963,617,000 Emergency dept visits 115,223,000 Hospital outpatient dept visits 90,393,000 Hospital discharges 34,667,000 Source: National Ambulatory Medical Care Survey, 2005 http://www.cdc.gov/nchs/data/ad/ad387.pdf

  5. U.S. Physician Office Visits 20051 512 Million 451 Million 53% 47% 216 Million 168 Million 129 Million 22% 17% 13% 1Excludes anesthesiology, pathology & radiology. Source: http://www.cdc.gov/nchs/data/ad/ad387.pdf

  6. Visit rates by setting type: United States, 1995 and 2005 197 % change +22% 162 Visits per 100 persons 69 65 56 +23% 48 +35% 40 37 31 26 +8% +19% Sources: National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey. http://www.cdc.gov/nchs/data/ad/ad388.pdf

  7. “A world that is greatly out of balance in matters of health is neither stable nor secure. . . “ “Primary health care brings balance back to health care, and puts families and communities at the hub of the health system. “ “Primary health care also offers the best way of coping with the ills of life in the 21st century: the globalization of unhealthy lifestyles, rapid unplanned urbanization, and the ageing of populations.” Dr Margaret Chan, Director General, WHO - 2008

  8. Primary Health Care, including health systems strengthening. World Health Assembly adopted a resolution urging member states to “accelerate action towards universal access to primary health care” and “to train and retain adequate numbers of health workers . . . including . . . family physicians. . .” World Health Assembly Resolution WHA62.12 Geneva, World Health Organization, May 2009.

  9. Rosenthal TG. The medical home: growing evidence to support a new approach to primary care. JABFM 2008; 21:427-440. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quar 2005;83:457-502.

  10. Family Physicians • Doctors of first & last resort – e.g., cancer • Continuous & comprehensive care • Responsible for total health needs • 75% of complaints are self-limited • 80% < 65 years; 40% > 65 years • Time and relationship as diagnostic and therapeutic tools

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

  12. USA GER BEL AUS SWE CAN SP NTH DK FIN UK *1=best 11=worst Relationship between Strength of Primary Care and Combined Outcomes

  13. 10000 PYLL Low PC Countries* 5000 High PC Countries* 0 1970 1980 1990 2000 Year 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.

  14. Family Doctors Personal Health Community Health

  15. Mortality Outcomes • Primary care physicians: 1 per 10,000 (20%) more primary care physicians decreases mortality by 40 per 100,000 (5% fewer deaths). Family Physicians: 1 per 10,000 (33%) more family physicians results decreases mortality by 70 per 100,000 (9% fewer deaths). • Specialists: 1 per 10,000 (8%) more specialists increases mortality by 16 per 100,000 (2% more deaths). Shi. J Am Board Fam Pract 2003;16:412-22.

  16. Indonesia Infant Mortality 1996-19971997-19981998-19991999-2000 Primary care* 10.3 9.6 8.5 8.2 Hospital* 4.1 4.1 4.6 5.3 Infant Mortality 70% improvement in 14% worsening in all provinces 1990-1996 22 of 28 provinces *constant Indonesian rupiah per capita, in billions Simms et al. Lancet 2003;361:1382-5.

  17. Personal physician: primary care vs specialist • 33% lower cost of care • 19% less likely to die Frank et al. J Fam Pract 1998;47:105-9

  18. Increasing physicians 1 per 10,000 population • Specialists • Decrease 9 states in quality • Increase costs $526/beneficiary • Primary care • Increase 10 states in quality • Decrease costs $684/beneficiary Baicker et al. Health Affairs 2004;W4:184-197

  19. Equity effects of primary care • Improves self-rated health • Reduces disparities • Reduces effects of income inequality Starfield B et al. Milbank Quar 2005;83:457-502

  20. People do better with primary care. Starfield B, Shi L, Grover A, Macinko J. The Effects of Specialist Supply on Populations’ Health: Assessing the Evidence. http://content.healthaffairs.org/cgi/content/full/hlthaff.w5.97/DC1

  21. Why do people worse with specialists? • Outside area of expertise: CAP, AMI, CHF, UGI bleed1 • Late stage diagnosis of breast2 or colorectal3 cancer • Excessive utilization4 • Handoff or communication errors5 • Weingarten et al. Arch Int Med 2002;162:527-532. • Ferrante et a. J Am Board Fam Pract 2000;13:408-414. • Rotezheim et al. J Fam Pract 1999;48:850-858. • Greenfield et al. JAMA 1992;367:1024-1030. • Skinner et al. Health Affairs 2006;25:w34-w37.

  22. <1 5 9 250 750 1000 Pyramid of Care Taken from White KL, et al. N Engl J Med 1961;265:885-92 and Green LR, et al. N Engl J Med 2001;344:2021-25.

  23. How good is the evidence? Design: Review of all original clinical research in 3 major general clinical journal or high-impact specialty journals from 1990-2003 that were cited more than 1000 times. Results: Of 49 highly cited studies, 45 claimed that the intervention was effective. • 7 (16%) contradicted by subsequent studies • 7 (16%) found effects stronger than those of subsequent studies • 20 (44%) were replicated • 11 (24%) remained largely unchallenged Source: Ioannidis JPA. JAMA 2005;294:218-228.

  24. Case of Hemoglobin A1c • ACCORD (N=10,251) NEJM 2008;358:2545-59. • ADVANCE (N=11,140) NEJM 2008;358:2560-72. • VA Trial (N=1791) NEJM 2009;360:129-39.

  25. The Truth Wears Off. Is there something wrong with the scientific method? Lehrer J. The New Yorker. December 13, 2010, p. 52 ff. http://www.newyorker.com/reporting/2010/12/13/101213fa_fact_lehrer

  26. Epistemology • Law • Beyond a reasonable doubt • Clear and convincing • To a reasonable degree • Medicine • 2 standard deviations (p<.05) • Engineering • 6 SD (p<.00000002; 2 per billion) • Six Sigma: <3.4 defects per million opportunities

  27. Time Requirements • 10.6 hrs/day – chronic conditions1, 2 • 7.4 hrs/day – preventive services3 • Patient agenda? • Acute care? • Administrative issues? • Østbye T. Ann Famed Med 2005; 3:209-214. • Tsai et al. Am J Man Care 2005;11:478-88. • Yarnall KHS. AJPH 2003;43:635-641. • Bodenheimer T. NEJM 2006:355:861-864.

  28. Complexity • Average visit: 1.4 – 8 problems • Diagnoses: • “ologist”: top 5 = 90% • family doctor: top 25 = 60% total Stange KC, et al. J Fam Pract 1998;46(5):363-8.

  29. Personal Professional Primary Health Care Public Population

  30. Personal Professional Tar Wars Counseling, medication Primary Health Care Tobacco-related disease Public Population Tobacco control Registry, immunization

  31. Predictors for success • Provide ready access • Prevent & manage chronic conditions • Prove & improve performance

  32. Aims & Assets of Primary Health Care • Continuity • Comprehensive

  33. More important than knowing the disease is knowing the person with the dis-ease.

  34. It’s the RELATIONSHIP!

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