Presentation on theme: "We Can Do Better Richard G. Roberts, MD, JD Wonca President 2010-2013 Professor of Family Medicine, University of Wisconsin TEL: +1 608 263 3598 Email:"— Presentation transcript:
We Can Do Better Richard G. Roberts, MD, JD Wonca President Professor of Family Medicine, University of Wisconsin TEL:
U.S. Healthcare System 1,300 payers 1 4,919 hospitals 2 764,000 physicians 3 3,119,000 nurses 4 302,000,000 people Dionne 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
U.S. Healthcare System 2009 National Health Expenditures (NHE) National Health Expenditures (NHE) % of GDP (Switzerland 11%); largest sector 17.6% of GDP (Switzerland 11%); largest sector $2,500 billion $2,500 billion $8086 NHE per capita $8086 NHE per capita 1 in 4 without any or enough insurance 21 in 4 without any or enough insurance World Health Report 3 :2000 World Health Report 3 : ranked 37 th for system performance ranked 37 th for system performance ranked 72 nd for health outcomes ranked 72 nd for health outcomes 1 https://www.cms.gov/NationalHealthExpendData/02_NationalHealthAcco untsHistorical.asp#TopOfPage 2 3
Healthcare services U.S., 2005 U.S., 2005 Physician office visits963,617,000 Emergency dept visits115,223,000 Hospital outpatient dept visits 90,393,000 Hospital discharges 34,667,000 Source: National Ambulatory Medical Care Survey, 2005
U.S. Physician Office Visits Excludes anesthesiology, pathology & radiology. Source: 216 Million 22%17% 168 Million 129 Million 13% 512 Million 53% 451 Million 47%
Visit rates by setting type: United States, 1995 and Sources: National Ambulatory Medical Care Survey and National Hospital Ambulatory Care Survey. Visits per 100 persons % change +22% +23% +35% +19% +8%
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 Dr Margaret Chan, Director General, WHO A world that is greatly out of balance in matters of health is neither stable nor secure... 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 brings balance back to health care, and puts families and communities at the hub of the health system.
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.
Rosenthal TG. The medical home: growing evidence to support a new approach to primary care. JABFM 2008; 21: Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Quar 2005;83:
Family Physicians Doctors of first & last resort – e.g., cancerDoctors of first & last resort – e.g., cancer Continuous & comprehensive careContinuous & comprehensive care Responsible for total health needsResponsible for total health needs 75% of complaints are self-limited75% of complaints are self-limited –80% 65 years Time and relationship as diagnostic and therapeutic toolsTime and relationship as diagnostic and therapeutic tools
Primary Care Score vs. Health Care Expenditures, 1997 US NTH CAN AUS SWE JAP BELFR GER SP DK FIN UK
Relationship between Strength of Primary Care and Combined Outcomes USA GER BEL AUS SWE SP CAN FIN UK NTH DK *1=best 11=worst
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. R 2 (within)=0.77. Source: Macinko et al, Health Serv Res 2003; 38: Year High PC Countries* Low PC Countries* PYLL
CommunityHealth Personal Health Personal Health
Mortality Outcomes Primary care physicians: 1 per 10,000 (20%) more primary care physicians decreases mortality by 40 per 100,000 (5% fewer deaths).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). 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).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:
Indonesia Infant Mortality Primary care* Hospital* Infant Mortality % improvement in 14% worsening in all provinces of 28 provinces * constant Indonesian rupiah per capita, in billions Simms et al. Lancet 2003;361:
Personal physician: primary care vs specialist 33% lower cost of care33% lower cost of care 19% less likely to die19% less likely to die Frank et al. J Fam Pract 1998;47:105-9
Increasing physicians 1 per 10,000 population SpecialistsSpecialists Decrease 9 states in quality Decrease 9 states in quality Increase costs $526/beneficiary Increase costs $526/beneficiary Primary carePrimary care Increase 10 states in quality Increase 10 states in quality Decrease costs $684/beneficiary Decrease costs $684/beneficiary Baicker et al. Health Affairs 2004;W4:
Equity effects of primary care Improves self-rated healthImproves self-rated health Reduces disparitiesReduces disparities Reduces effects of income inequalityReduces effects of income inequality Starfield B et al. Milbank Quar 2005;83:
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.
Why do people worse with specialists? Outside area of expertise:Outside area of expertise: CAP, AMI, CHF, UGI bleed 1 Late stage diagnosis of breast 2Late stage diagnosis of breast 2 or colorectal 3 cancer Excessive utilization 4Excessive utilization 4 Handoff or communication errors 5Handoff or communication errors 5 1.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.
Pyramid of Care < Taken from White KL, et al. N Engl J Med 1961;265: and Green LR, et al. N Engl J Med 2001;344:
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%) contradicted by subsequent studies 7 (16%) found effects stronger than those of subsequent studies 7 (16%) found effects stronger than those of subsequent studies 20 (44%) were replicated 20 (44%) were replicated 11 (24%) remained largely unchallenged 11 (24%) remained largely unchallenged Source: Ioannidis JPA. JAMA 2005;294:
Case of Hemoglobin A1c ACCORD (N=10,251) NEJM 2008;358: ACCORD (N=10,251) NEJM 2008;358: ADVANCE (N=11,140) NEJM 2008;358: ADVANCE (N=11,140) NEJM 2008;358: VA Trial (N=1791) NEJM 2009;360: VA Trial (N=1791) NEJM 2009;360:
The Truth Wears Off. Is there something wrong with the scientific method? Lehrer J. The New Yorker. December 13, 2010, p. 52 ff.
Epistemology LawLaw Beyond a reasonable doubt Beyond a reasonable doubt Clear and convincing Clear and convincing To a reasonable degree To a reasonable degree MedicineMedicine 2 standard deviations (p<.05) 2 standard deviations (p<.05) EngineeringEngineering 6 SD (p< ; 2 per billion) 6 SD (p< ; 2 per billion) Six Sigma: <3.4 defects per million opportunities Six Sigma: <3.4 defects per million opportunities
Time Requirements 10.6 hrs/day – chronic conditions 1, hrs/day – chronic conditions 1, hrs/day – preventive services 37.4 hrs/day – preventive services 3 Patient agenda?Patient agenda? Acute care?Acute care? Administrative issues?Administrative issues? 1.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:
Complexity Average visit: 1.4 – 8 problemsAverage visit: 1.4 – 8 problems Diagnoses:Diagnoses: ologist: top 5 = 90% ologist: top 5 = 90% family doctor: top 25 = 60% total family doctor: top 25 = 60% total Stange KC, et al. J Fam Pract 1998;46(5):363-8.
PersonalProfessional PopulationPublic Primary Health Care
PersonalProfessional Population Public Tar WarsCounseling, medication Registry, immunization Tobacco control Tobacco-related disease