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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.

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Presentation on theme: "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."— Presentation transcript:

1 We Can Do Better How Primary Care Will Improve Health Care and Save the World Richard G. Roberts, MD, JD Wonca President Professor of Family Medicine, University of Wisconsin TEL:

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 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/p 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 ,667,000 Source: National Ambulatory Medical Care Survey, 2005

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:

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.

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

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; : Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quar 2005;83: 9

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
07 Malaysia PC trends Feb 3/25/2017 Primary Care Score vs. Health Care Expenditures, 1997 UK DK NTH FIN SP CAN AUS SWE JAP GER US BEL FR

12 Relationship between Strength of Primary Care and Combined Outcomes
07 Malaysia PC trends Feb 3/25/2017 Relationship between Strength of Primary Care and Combined Outcomes USA GER BEL AUS SWE SP CAN FIN UK NTH DK *1=best 11=worst

13 Primary Care Strength and Premature Mortality in 18 OECD Countries
07 Malaysia PC trends Feb 3/25/2017 Primary Care Strength and Premature Mortality in 18 OECD Countries Year High PC Countries* Low PC Countries* 10000 PYLL 1970 1980 1990 2000 5000 Source: Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within Organization for Economic Cooperation and Development (OECD) countries, Health Serv Res 2003; 38(3): *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:

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15 Family Doctors Personal Health Community Health

16 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:

17 Indonesia Infant Mortality
Primary care* Hospital* Infant Mortality 70% improvement in % worsening in all provinces of 28 provinces *constant Indonesian rupiah per capita, in billions Simms et al. Lancet 2003;361:

18 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

19 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:

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

21 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.

22 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: Ferrante et a. J Am Board Fam Pract 2000;13: Rotezheim et al. J Fam Pract 1999;48: Greenfield et al. JAMA 1992;367: Skinner et al. Health Affairs 2006;25:w34-w37.

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

24 How good is the evidence?
Design: Review of all original clinical research in 3 major general clinical journal or high-impact specialty journals from 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:

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

26 Is there something wrong with the scientific method?
The Truth Wears Off. Is there something wrong with the scientific method? Lehrer J. The New Yorker. December 13, 2010, p. 52 ff.

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

28 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: Tsai et al. Am J Man Care 2005;11: Yarnall KHS. AJPH 2003;43: Bodenheimer T. NEJM 2006:355:

29 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.

30 Personal Professional Primary Health Care Public Population

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

32 Predictors for success
Provide ready access Prevent & manage chronic conditions Prove & improve performance

33 Aims & Assets of Primary Health Care
Continuity Comprehensive

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

35 It’s the RELATIONSHIP!

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