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THE PRIMARY SOLUTION:The Case for Primary (Health) Care

THE PRIMARY SOLUTION:The Case for Primary (Health) Care. Barbara Starfield, MD, MPH Presented at RNZCGP Annual Quality Symposium, Wellington NZ, February 13, 2009. Life Expectancy Compared with GDP per Capita for Selected Countries. Country codes: AG=Argentina AU=Australia BZ=Brazil

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THE PRIMARY SOLUTION:The Case for Primary (Health) Care

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  1. THE PRIMARY SOLUTION:The Case for Primary (Health) Care Barbara Starfield, MD, MPH Presented at RNZCGP Annual Quality Symposium, Wellington NZ, February 13, 2009

  2. 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

  3. 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 Country* Clusters: Health Professional Supply and Child Survival *186 countries Starfield 07/07 HS 3754 n Source: Chen et al, Lancet 2004; 364:1984-90.

  4. 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

  5. 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

  6. Why Is Primary Care Important? Better health outcomes Lower costs Greater equity in health Starfield 07/07 PC 3757 n

  7. 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.

  8. 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

  9. Primary Care Orientation of Health Systems: Rating Criteria • Practice Characteristics • First-contact • Longitudinality • Comprehensiveness • Coordination • Family-centeredness • Community orientation Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 11/02 PC 2367 n Starfield 11/02 02-406 sc

  10. Primary Care Scores, 1980s and 1990s *Scores available only for the 1990s Starfield 07/07 ICTC 3758 n

  11. 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

  12. GER FR BEL US SWE JAP CAN FIN AUS SP DK NTH UK System (PHC) and Practice (PC) Characteristics Facilitating Primary Care, Early-Mid 1990s *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.

  13. 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

  14. 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. Starfield 11/06 IC 3496 n Source: Macinko et al, Health Serv Res 2003; 38:831-65.

  15. 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.

  16. Is Primary Care as important within countries as it is among countries? Starfield 07/07 WC 3765 n

  17. . . . 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 Starfield 07/07 WCUS 3766 n Source: Shi et al, J Fam Pract 1999; 48:275-84.

  18. 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

  19. Percentage Reduction in Under-5 Mortality: Thailand, 1990-2000 Starfield 07/07 WC 3797 n Source: Vapattanawong et al, Lancet 2007; 369:850-5.

  20. 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.

  21. 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.

  22. 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 09/04 04-167 Starfield 09/04 WC 2957 Source: Starfield B. www.pitt.edu/~super1/lecture/lec8841/index.htm

  23. What We Already Know A primary care oriented system is important for • Improving health (improving effectiveness) • Keeping costs manageable (improving efficiency) Starfield 09/05 PC 3316

  24. Does primary care reduce inequity in health? Starfield 07/07 EQ 3769 n

  25. 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.

  26. 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 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

  27. 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 Starfield 09/02 PC 2218 n Starfield 09/02 02-437 sc

  28. 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

  29. 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 Starfield 11/06 HS 3494 n

  30. Health Workforce Starfield 10/07 WF 3901

  31. 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

  32. 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

  33. 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. The effect is independent of the number of generalist visits. *Using the Johns Hopkins Adjusted Clinical Groups (ACGs) Source: Starfield et al, Ambulatory specialist use by patients in US health plans: correlates and consequences. Submitted 2008. Starfield 09/07 CMOS 3854

  34. 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.

  35. 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

  36. What is the right number of specialists?What do specialists do?What do specialists contribute to population health? Starfield 01/06 SP 3354

  37. 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

  38. 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

  39. 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

  40. 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 The Health Services System Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 02/09 HS 4133 n

  41. 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

  42. Resources Available First Contact 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 05/06 WC 3421 n

  43. 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

  44. Primary Care Starfield 02/08 EVAL 3968 n

  45. 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

  46. 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

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