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General Practice as an Integral Part of the Health System. Barbara Starfield, MD, MPH 16 th Nordic Conference on General Practice Copenhagen, Denmark May 13-16, 2009. Life Expectancy Compared with GDP per Capita for Selected Countries. Country codes: AG=Argentina AU=Australia BZ=Brazil

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general practice as an integral part of the health system

General Practice as an Integral Part of the Health System

Barbara Starfield, MD, MPH

16th Nordic Conference on General Practice

Copenhagen, Denmark

May 13-16, 2009

life expectancy compared with gdp per capita for selected countries
Life Expectancy Compared with GDP per Capita for Selected Countries

Country codes:

AG=Argentina

AU=Australia

BZ=Brazil

CH=China

CN=Canada

FR=France

GE=Germany

HU=Hungary

IN=India

IS=Israel

IT=Italy

JA=Japan

MA=Malaysia

ME=Mexico

NE=Netherlands

PO=Poland

RU=Russia

SA=South Africa

SI=Singapore

SK=South Korea

SP=Spain

SW=Sweden

SZ=Switzerland

TK=Turkey

TW=Taiwan

UK=United Kingdom

US=United States

Source: Economist Intelligence Unit. Healthcare International. 4th quarter 1999. London, UK: Economist Intelligence Unit, 1999.

Starfield 11/06

IC 3493 n

country clusters health professional supply and child survival
Country* Clusters: Health Professional Supply and Child Survival

25

15

10

5.0

Density (workers per 1000)

2.5

1

3

5

9

50

100

250

Child mortality (under 5) per 1000 live births

*186 countries

Starfield 07/07

HS 3754 n

Source: Chen et al, Lancet 2004; 364:1984-90.

slide4

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 07/07

PC 3755 n

slide5

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 07/07

PC 3756 n

why is primary care important
Why Is Primary Care Important?

Better health outcomes

Lower costs

Greater equity in health

Starfield 07/07

PC 3757 n

slide7
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 03/08

PC 3971 n

Source: Starfield et al, Milbank Q 2005; 83:457-502.

primary care scores 1980s and 1990s
Primary Care Scores, 1980s and 1990s

*Scores available only for the 1990s

Starfield 07/07

ICTC 3758 n

primary care orientation of health systems rating criteria
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 11/02

PC 2366 n

Starfield 11/02

02-405 sc

system features important to primary health care
System Features Important to Primary Health Care

**

*0=all regressive

1=mixed

2=all progressive

**except Medicaid

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.

Starfield 11/06

EQ 3500 n

slide11
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

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).

Starfield 07/07

GH 3794 n

more comprehensive health centres have better vaccination coverage a b
More Comprehensive Health Centres Have Better Vaccination Coveragea,b

Starfield 05/09

COMP 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 criteria1
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 04/09

PC 4180 n

pc 4181
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 04/09

PC 4181

system phc and practice pc characteristics facilitating primary care early mid 1990s
System (PHC) and Practice (PC) Characteristics Facilitating Primary Care, Early-Mid 1990s

GER

FR

BEL

US

SWE

JAP

CAN

FIN

AUS

SP

DK

NTH

UK

*Best level of health indicator is ranked 1; worst is ranked 13; thus, lower average ranks indicate better performance.

Starfield 03/05

ICTC 3099 n

Based on data in Starfield & Shi, Health Policy 2002; 60:201-18.

primary care score vs health care expenditures 1997
Primary Care Score vs. Health Care Expenditures, 1997

UK

DK

NTH

FIN

SP

CAN

AUS

SWE

JAP

GER

US

BEL

FR

Starfield 11/06

ICTC 3495 n

primary care strength and premature mortality in 18 oecd countries
Primary Care Strength and Premature Mortality in 18 OECD Countries

10000

PYLL

Low PC Countries*

5000

High PC Countries*

0

1970

1980

1990

2000

Year

*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.

Starfield 11/06

IC 3496 n

Source: Macinko et al, Health Serv Res 2003; 38:831-65.

primary care oriented countries have
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 07/07

IC 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
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 03/08

GH 3992

Sources: IBRD/World Bank, April 8, 2008. King & Bertino, PLoS Negl Trop Dis 2008;2:e209.

state level analysis primary care and life expectancy
State Level Analysis:Primary Care and Life Expectancy

HI

MN

ND

IA

UT

NE

CO

ID

WI

MA

WA

CT

OR

SD

NH

RI

VT

ME

CA

AZ

NJ

IN

MO

NM

AR

MI

FL

PA

MT

OK

TX

WY

NY

OH

IL

VA

DE

TN

KY

MD

KS

NC

AL

WV

NV

GA

AK

MS

LA

SC

Starfield 04/09

WCUS 4178 n

Source: Shi, Int J Health Serv 1994;24:431-58.

primary care and infant mortality rates indonesia 1996 2000
Primary Care and Infant Mortality Rates, Indonesia, 1996-2000

*constant Indonesian rupiah, in billions

Source: Simms & Rowson, Lancet 2003; 361:1382-5.

Starfield 07/07

WC 3796 n

primary care score and self rated health petr polis brazil 2004
Primary Care Score and Self-Rated Health, Petrópolis, Brazil, 2004*

*1= excellent/ good health; 0=bad/fair/poor health

** standard errors adjusted for clustering by clinic

Starfield 07/07

WC 3768 n

Source: 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
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.

Starfield 10/06

WC 3457 n

Source: Macinko et al, J Epidemiol Community Health 2006; 60:13-19.

slide25

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.

Sources: Starfield et al, Milbank Q 2005;83:457-502. Macinko et al, J Ambul Care Manage 2009;32:150-71.

Starfield 09/04

04-167

Starfield 09/04

WC 2957

what we already know
What We Already Know

Improving health (improving effectiveness)

Keeping costs manageable (improving efficiency)

A primary care oriented system is important for

Starfield 09/05

PC 3316

slide28

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 07/07

WCUS 3770 n

Source: Shi et al, Soc Sci Med 2005; 61(1):65-75.

percentage reduction in under 5 mortality thailand 1990 2000
Percentage Reduction in Under-5 Mortality: Thailand, 1990-2000

Starfield 07/07

WC 3797 n

Source: Vapattanawong et al, Lancet 2007; 369:850-5.

why does primary care enhance equity in health
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 05/09

PC 4184

Source: Starfield et al, Milbank Q 2005;83:457-502.

why does primary care enhance effectiveness of health services
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 05/09

PC 4185

Source: Starfield et al, Milbank Q 2005;83:457-502.

primary health care oriented countries
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 11/05

IC 3326

primary care and health 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

Primary Care and Health: Evidence-Based Summary

Starfield 09/02

PC 2218 n

Starfield 09/02

02-437 sc

conclusion
Conclusion

Although 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 11/05

HS 3329

strategy for change in health systems
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 11/06

HS 3494 n

health workforce
Health Workforce

Starfield 10/07

WF 3901

slide37

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.

Above a certain level of specialist supply, the more specialists per population, the worse the outcomes.

Controlled only for income inequality

Source: Shi et al, J Am Board Fam Pract 2003; 16:412-22.

Starfield 11/06

SP 3499 n

percentage of people seeing at least one specialist in a year
Percentage of People Seeing at Least One Specialist in a Year

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.

Starfield 01/07

SP 3529 n

resource use controlling for morbidity burden
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.

*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.

Starfield 09/07

CMOS 3854

percent of patients reporting any error by number of doctors seen in past two years
Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two Years

Starfield 09/07

IC 3870 n

Source: Schoen et al, Health Affairs 2005; W5: 509-525.

slide41

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.

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.

Starfield 12/05

SP 3343

slide42
What is the right number of specialists?What do specialists do?What do specialists contribute to population health?

Starfield 01/06

SP 3354

enhancements to primary care
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

ALL REQUIRE EVALUATION.

Starfield 02/08

PC 3966

slide44

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 06/08

EVAL 4044

good primary care requires
Good Primary Care Requires

Health system POLICIES conducive to primary care practice

Health services delivery that achieves the important FUNCTIONS of primary care

Starfield 06/08

PC 4042

slide47

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 10/08

EVAL 4072

the health services system
The Health Services System

Personnel

Facilities and equipment

Range of services

Organization

Management and amenities

Continuity/information systems

Knowledge base

Accessibility

Financing

Population eligible

Governance

Community resources

CAPACITY

Cultural and

behavioral

characteristics

Provision

of care

Problem recognition

Diagnosis

Management

Reassessment

PERFORMANCE

People/practitioner interface

Receipt

of care

Utilization

Acceptance and satisfaction

Understanding

Participation

Social, political,

economic, and physical environments

HEALTH STATUS

(outcome)

Longevity

Comfort

Perceived well-being

Disease

Achievement

Risks

Resilience

Biologic endowment

and prior health

Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998.

Starfield 02/09

HS 4133 n

pcat primary care assessment tool
PCAT(Primary Care Assessment Tool)

First-contact (access and use)

Person-focused care over time

Comprehensiveness (services available and provided)

Coordination

Family centered

Community oriented

Culturally competent

Starfield 05/03

03-095

Starfield 05/03

PCM 2479

primary care scores by data source psf clinics
Primary Care Scores by Data Source, PSF Clinics

Resources Available

First Contact

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 05/06

WC 3421 n

slide52

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 06/08

PC 4046

primary care
Primary Care

Starfield 02/08

EVAL 3968 n

structural and process elements of the essential features of primary care
Structural and Process Elements of the Essential Features of Primary Care

Capacity

Essential Features

Performance

First-contact

Accessibility

Eligible population

Range of services

Continuity

Utilization

Person-focused

relationship

Longitudinality

Comprehensiveness

Problem recognition

Coordination

Starfield 04/97

EVAL 1108 n

Starfield 1997

97-194

structural and process elements of the essential features of primary care1
Structural and Process Elements of the Essential Features of Primary Care

Capacity

Essential Features

Performance

First-contact

Accessibility

Eligible population

Range of services

Continuity

Utilization

Person-focused

relationship

Longitudinality

Comprehensiveness

Problem recognition

Coordination

Starfield 10/08

EVAL 4071 n