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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.

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Presentation on theme: "General Practice as an Integral Part of the Health System Barbara Starfield, MD, MPH 16 th Nordic Conference on General Practice Copenhagen, Denmark May."— Presentation transcript:

1 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

2 Life Expectancy Compared with GDP per Capita for Selected Countries Source: Economist Intelligence Unit. Healthcare International. 4th quarter 1999. London, UK: Economist Intelligence Unit, 1999. 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 Starfield 11/06 IC 3493 n 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

3 Country* Clusters: Health Professional Supply and Child Survival Starfield 07/07 HS 3754 n Source: Chen et al, Lancet 2004; 364:1984-90. Density (workers per 1000) Child mortality (under 5) per 1000 live births 35950100250 25 15 10 5.0 2.5 1 *186 countries

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 Scores, 1980s and 1990s 1980s1990s Belgium France* Germany United States 0.8 - 0.5 0.2 0.4 0.3 0.4 Australia Canada Japan* Sweden 1.1 1.2 - 1.2 1.1 1.2 0.8 0.9 Denmark Finland Netherlands Spain* United Kingdom 1.5 - 1.7 1.5 1.4 1.9 *Scores available only for the 1990s Starfield 07/07 ICTC 3758 n

9 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 02-405 sc Starfield 11/02 PC 2366 n

10 System Features Important to Primary Health Care Starfield 11/06 EQ 3500 n 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. *0=all regressive 1=mixed 2=all progressive **except Medicaid Resource Allocation (Score) Progressive Financing* Cost Sharing Compre- hensiveness Belgium France Germany US 00000000 00100010 00200020 00000000 Australia Canada Japan Sweden 11121112 22222222 22112211 22112211 Denmark Finland Netherlands Spain UK 2222222222 2202222022 2122221222 2221222212 **

11 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 Starfield 07/07 GH 3794 n Sources: Starfield & Shi, Health Policy 2002; 60:201-18. Gilson et al, Challenging Inequity through Health Systems ( /hskn_final_2007_en.pdf; accessed March 17, 2009). /hskn_final_2007_en.pdf

12 More Comprehensive Health Centres Have Better Vaccination Coverage a,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.

13 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

14 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

15 UK NTH SP FIN CAN AUS SWE JAP GER FR BEL US DK *Best level of health indicator is ranked 1; worst is ranked 13; thus, lower average ranks indicate better performance. Based on data in Starfield & Shi, Health Policy 2002; 60:201-18. System (PHC) and Practice (PC) Characteristics Facilitating Primary Care, Early-Mid 1990s Starfield 03/05 ICTC 3099 n

16 Primary Care Score vs. Health Care Expenditures, 1997 US NTH CAN AUS SWE JAP BELFR GER SP DK FIN UK Starfield 11/06 ICTC 3495 n

17 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; 38:831-65. Year High PC Countries* Low PC Countries* 10000 PYLL 1970198019902000 0 5000 Starfield 11/06 IC 3496 n

18 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.

19 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.

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

21 State Level Analysis: Primary Care and Life Expectancy Source: Shi, Int J Health Serv 1994;24:431-58. Starfield 04/09 WCUS 4178 n ME NH VT MA RI CT NY NJ PA OH IN IL MI WI MN IA MO ND SD NE KS DE MD VA WV NC SC GA FL KY TN AL MS AR LA OK TX MT ID WY CO NM AZ UT NV WA OR CA AK HI

22 Primary Care and Infant Mortality Rates, Indonesia, 1996-2000 1996-1997 1997- 1998 1998- 19991999-2000 Primary care spending per capita* Hospital spending per capita* Infant mortality 20% improvement (all provinces) (1990-96) 14% worsening (22 of 26 provinces) *constant Indonesian rupiah, in billions Source: Simms & Rowson, Lancet 2003; 361:1382-5. Starfield 07/07 WC 3796 n

23 Primary Care Score and Self-Rated Health, Petrópolis, Brazil, 2004* (n=455)Odds Ratio95% CI** Primary care score (0-5)1.4521.073, 1.966 Age (years)0.9690.957, 0.981 Chronic disease (yes/no)0.5780.360, 0.927 Recent illness (yes/no)0.1760.098, 0.316 Household wealth (scale 1-8)1.2191.007, 1.476 Completed primary school0.7330.374, 1.437 Clinic type (0=traditional; 1=PSF)0.9980.594, 1.679 *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.

24 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. Source: Macinko et al, J Epidemiol Community Health 2006; 60:13-19. Starfield 10/06 WC 3457 n

25 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 Sources: Starfield et al, Milbank Q 2005;83:457-502. Macinko et al, J Ambul Care Manage 2009;32:150-71. Starfield 09/04 WC 2957

26 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

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

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

29 Percentage Reduction in Under-5 Mortality: Thailand, 1990-2000 Starfield 07/07 WC 3797 n Poorest quintile (1)44 (2)41 (3)22 (4)23 Richest quintile (5)13 Rate ratio (Q1/Q5)55 Absolute difference (Q1-Q5) 61 Policy changes: 1989At least one primary care health center for each rural village 1993Government medical welfare scheme: all children less than 12, elderly, disabled 2001Entire adult population insured Activities of Rural Doctors Society Source: Vapattanawong et al, Lancet 2007; 369:850-5.

30 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.

31 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.

32 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

33 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 02-437 sc Starfield 09/02 PC 2218 n

34 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

35 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

36 Health Workforce Starfield 10/07 WF 3901

37 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. Controlled only for income inequality Source: Shi et al, J Am Board Fam Pract 2003; 16:412-22. Starfield 11/06 SP 3499 n Above a certain level of specialist supply, the more specialists per population, the worse the outcomes.

38 Percentage of People Seeing at Least One Specialist in a Year Starfield 01/07 SP 3529 n US40% of total population; 54% of patients (users) Canada (Ontario) 31% of population (68% at ages 65 and over) UKabout 15% of patients (at ages under 65) Spain30% of population; 40% of patients (users) 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.

39 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. Starfield 09/07 CMOS 3854 *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.

40 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. CountryOne doctor4 or more doctors Australia1237 Canada1540 Germany1431 New Zealand1435 UK1228 US2249

41 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. Starfield 12/05 SP 3343 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.

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

43 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 Starfield 02/08 PC 3966 ALL REQUIRE EVALUATION.

44 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 peoples health problems) Breadth of services Coordination (enhanced problems/needs recognition over time) Starfield 06/08 EVAL 4044

45 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


47 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

48 The Health Services System Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 02/09 HS 4133 n Longevity Comfort Perceived well-being Disease Achievement Risks Resilience CAPACITY PERFORMANCE HEALTH STATUS (outcome) Provision of care Receipt of care Personnel Facilities and equipment Range of services Organization Management and amenities Continuity/information systems Knowledge base Accessibility Financing Population eligible Governance People/practitioner interface Cultural and behavioral characteristics Social, political, economic, and physical environments Biologic endowment and prior health Problem recognition Diagnosis Management Reassessment Utilization Acceptance and satisfaction Understanding Participation Community resources

49 PCAT (Primary Care Assessment Tool) Starfield 05/03 03-095 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 PCM 2479

50 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 First Contact Resources Available


52 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

53 Primary Care Starfield 02/08 EVAL 3968 n First ContactAccessibility Use by people for each new problem LongitudinalRelationship between a facility and its population Use by people over time regardless of the type of problem; person-focused character of provider/patient relationship ComprehensiveBroad range of services Recognition of situations where services are needed CoordinationMechanism for achieving continuity Recognition of problems that require follow-up

54 Structural and Process Elements of the Essential Features of Primary Care Essential FeaturesPerformance Utilization Person-focused relationship Capacity Accessibility Eligible population Range of services Continuity First-contact Longitudinality Comprehensiveness Coordination Problem recognition Starfield 1997 97-194 Starfield 04/97 EVAL 1108 n

55 Structural and Process Elements of the Essential Features of Primary Care Essential FeaturesPerformance Utilization Person-focused relationship Capacity Accessibility Eligible population Range of services Continuity First-contact Longitudinality Comprehensiveness Coordination Problem recognition Starfield 10/08 EVAL 4071 n

56 Welcome to the 16th Nordic Congress of General Practice

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