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 BetterHow Primary Care Will Improve Health Care and Save the WorldRichard G. Roberts, MD, JDWonca PresidentProfessor of Family Medicine, University of WisconsinTEL:
2 U.S. Healthcare System 1,300 payers1 4,919 hospitals2 764,000 physicians33,119,000 nurses4302,000,000 people51http://www.ahip.org/2http://www.aha.org/aha/research-and-trends/health-and-hospital-trends/2006.html3http://bhpr.hrsa.gov/healthworkforce/reports/behindrnprojections/2.htm4Dionne 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. October5http://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 capita1 in 4 without any or enough insurance22000 World Health Report3:ranked 37th for system performanceranked 72nd for health outcomes1https://www.cms.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage2http://www.census.gov/prod/2006pubs/p pdf3http://www.who.int/whr/2000/en/whr00_en.pdf
4 Healthcare services U.S., 2005 Physician office visits 963,617,000 Emergency dept visits 115,223,000Hospital outpatient dept visits 90,393,000Hospital discharges ,667,000Source: National Ambulatory Medical Care Survey, 2005
6 Visit rates by setting type: United States, 1995 and 2005 197% change+22%162Visits per 100 persons696556+23%48+35%40373126+8%+19%Sources: National Ambulatory Medical Care Survey and National HospitalAmbulatory 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 WHA62.12Geneva, 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 careResponsible for total health needs75% of complaints are self-limited80% < 65 years; 40% > 65 yearsTime and relationship as diagnostic and therapeutic tools
11 Primary Care Score vs. Health Care Expenditures, 1997 07 Malaysia PC trends Feb3/25/2017Primary Care Score vs. Health Care Expenditures, 1997UKDKNTHFINSPCANAUSSWEJAPGERUSBELFR
12 Relationship between Strength of Primary Care and Combined Outcomes 07 Malaysia PC trends Feb3/25/2017Relationship between Strength of Primary Care and Combined OutcomesUSAGERBELAUSSWESPCANFINUKNTHDK*1=best11=worst
13 Primary Care Strength and Premature Mortality in 18 OECD Countries 07 Malaysia PC trends Feb3/25/2017Primary Care Strength and Premature Mortality in 18 OECD CountriesYearHigh PC Countries*Low PC Countries*10000PYLL19701980199020005000Source: 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:
16 Mortality OutcomesPrimary 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 Mortality70% improvement in % worsening inall provinces of 28 provinces*constant Indonesian rupiah per capita, in billionsSimms et al. Lancet 2003;361:
18 Personal physician: primary care vs specialist 33% lower cost of care19% less likely to dieFrank et al. J Fam Pract 1998;47:105-9
19 Increasing physicians 1 per 10,000 population SpecialistsDecrease 9 states in qualityIncrease costs $526/beneficiaryPrimary careIncrease 10 states in qualityDecrease costs $684/beneficiaryBaicker et al. Health Affairs 2004;W4:
20 Equity effects of primary care Improves self-rated healthReduces disparitiesReduces effects of income inequalityStarfield 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 bleed1Late stage diagnosis of breast2or colorectal3 cancerExcessive utilization4Handoff or communication errors5Weingarten 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<1592507501000Taken 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 studies7 (16%) found effects stronger than those of subsequent studies20 (44%) were replicated11 (24%) remained largely unchallengedSource: 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 convincingTo a reasonable degreeMedicine2 standard deviations (p<.05)Engineering6 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 services3Patient 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% totalStange KC, et al. J Fam Pract 1998;46(5):363-8.
30 PersonalProfessionalPrimary Health CarePublicPopulation
31 Primary Health Care Personal Professional Tar Wars Counseling, medicationPrimary Health CareTobacco-related diseasePublicPopulationTobacco controlRegistry, immunization
32 Predictors for success Provide ready accessPrevent & manage chronic conditionsProve & improve performance
33 Aims & Assets of Primary Health Care ContinuityComprehensive
34 More important than knowing the disease is knowing the person with the dis-ease.