The Vision for Primary Care Realizing Renewing and

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The Vision for Primary Care: Realizing, Renewing, and Supporting Barbara Starfield, MD, MPH San The Vision for Primary Care: Realizing, Renewing, and Supporting Barbara Starfield, MD, MPH San Francisco, California April 2006

Global Health Chart Source: Karolinska Institute: www. whc. ki. se/index. php. Starfield 10/04 09/04 Global Health Chart Source: Karolinska Institute: www. whc. ki. se/index. php. Starfield 10/04 09/04 IC 2941 04 -198

Country* Clusters: Health Professional Supply and Child Survival 25 15 Density (workers per 1000) Country* Clusters: Health Professional Supply and Child Survival 25 15 Density (workers per 1000) 10 5. 0 2. 5 1 3 *186 countries 5 9 50 100 Child mortality (under 5) per 1000 live births Source: Chen et al, Lancet 2004; 364: 1984 -90. 250 Starfield 12/04 HS 3083

Life Expectancy Compared with GDP per Capita for Selected Countries Country codes: AG=Argentina AU=Australia 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 Source: Economist Intelligence Unit. Healthcare International. 4 th quarter 1999. London, UK: Economist Intelligence Unit, 1999. 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 Starfield 07/05 IC 3228

Primary care is the provision of first contact, person-focused ongoing care over time that 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 09/04 PC 2943 04 -132

Why Is Primary Care Important? Better health outcomes Lower costs Greater equity in health Why Is Primary Care Important? Better health outcomes Lower costs Greater equity in health Starfield 09/04 PC 2945 04 -134

Evidence of the Benefits of a Primary Care-Oriented Health System Starfield 09/04 PC 2946 Evidence of the Benefits of a Primary Care-Oriented Health System Starfield 09/04 PC 2946 04 -136

Primary Care Scores, 1980 s and 1990 s 1980 s 1990 s Belgium France* Primary Care Scores, 1980 s and 1990 s 1980 s 1990 s 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 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 1990 s Starfield 10/02 IC 2238 02 -185

Primary Care Score vs. Health Care Expenditures, 1997 UK DK NTH SP FIN AUS Primary Care Score vs. Health Care Expenditures, 1997 UK DK NTH SP FIN AUS SWE CAN JAP GER BEL FR US Starfield 10/00 IC 1731 00 -133

Primary Care Strength and Premature Mortality in 18 OECD Countries 10000 PYLL Low PC Primary Care Strength and Premature Mortality in 18 OECD Countries 10000 PYLL Low PC Countries* 5000 High PC Countries* 0 1970 1980 Year 1990 2000 *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. Starfield 10/04 09/04 Source: Macinko et al, Health Serv Res 2003; 38: 831 -65. IC 2953 04 -247

Health in the US Relative* to 13 Other Large Industrialized Countries 1980 s 2000 Health in the US Relative* to 13 Other Large Industrialized Countries 1980 s 2000 Life expectancy (LE) At birth At age 60 Potential years of life lost*** 13 13 7 12 4 -7 12 Healthy life expectancy (HLE) At birth - 12 At age 60 - 12 - *1 = best rank **age-adjusted ***at age 70 12 Percentage of HLE Cancer death rate** Cancer incidence Ischemic heart disease death rate** Sources: OECD. Health at a Glance, 2003. WHO. World Health Report 2004. 12 of 12 4 of 7 10 -11 of 12 Starfield 03/05 IC 3125

Is US Health Really the Best in the World? In a comparison of 13 Is US Health Really the Best in the World? In a comparison of 13 countries, * the US rankings were: • • • 13 th (last) for low-birth-weight percentages 13 th for neonatal mortality and infant mortality overall 11 th for postneonatal mortality 13 th for years of potential life lost (excluding external causes) 11 th for life expectancy at 1 year for females, 12 th for males 10 th for life expectancy at 15 years for females, 12 th for males 10 th for life expectancy at 40 years for females, 9 th for males 7 th for life expectancy at 65 years for females, 7 th for males 3 rd for life expectancy at 80 years for females, 3 rd for males 10 th for age-adjusted mortality *Australia, Belgium, Canada, Denmark, Finland, France, Germany, Japan, Netherlands, Spain, Sweden, United Kingdom, United States Source: Starfield, JAMA 2000; 284: 483 -5. Starfield 03/06 IC 3382

Community surveys in industrialized countries show that primary care oriented countries (Australia, Canada, New Community surveys in industrialized countries show that primary care oriented countries (Australia, Canada, New Zealand, United Kingdom) are rated higher than other countries (US and Germany) on many aspects of care, including • view of the health care system as NOT needing complete rebuilding • finding the regular physician’s advice helpful • coordination of care The United States rates the poorest on ALL aspects of experienced care, including access, person-focused care over time, unnecessary tests, polypharmacy, adverse effects, and rating of medical care received. Source: Schoen et al, Health Aff 2005; W 5: 509 -25. Starfield 11/05 IC 3325

An orientation to primary care reduces sociodemographic and socioeconomic disparities (inequities) • in access An orientation to primary care reduces sociodemographic and socioeconomic disparities (inequities) • in access to health services • in population health Starfield 03/06 IC 3383

Of 21 OECD countries, the United States is, by far, the most socially inequitable Of 21 OECD countries, the United States is, by far, the most socially inequitable (poor versus non-poor) in terms of the annual probability of visiting a physician. It is one of less than a handful of countries that does not collect information on visits to primary care physicians and specialists in population-based surveys. Source: van Doorslaer et al, CMAJ 2006; 174: 177 -83. Starfield 03/06 IC 3384

Overall, primary care oriented countries • Have more equitable resource distributions • Have health Overall, primary 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; W 5: 509 -25. Starfield 11/05 IC 3326

Is Primary Care as Important within Countries as It Is among Countries? Starfield 09/04 Is Primary Care as Important within Countries as It Is among Countries? Starfield 09/04 WC 2955 04 -138

Health Care Expenditures and Mortality 5 Year Followup: United States, 1987 -92 • Adults Health Care Expenditures and Mortality 5 Year Followup: United States, 1987 -92 • Adults (age 25 and older) with a primary care physician rather than a specialist as their personal physician – had 33% lower cost of care – were 19% less likely to die (after controlling for age, gender, income, insurance, smoking, perceived health (SF-36) and 11 major health conditions) Source: Franks & Fiscella, J Fam Pract 1998; 47: 105 -9. Starfield 05/99 Starfield 1999 WC 1504 99 -096

Primary care physician supply is consistently associated with improved health outcomes (all-cause, cancer, heart Primary care physician supply is consistently associated with improved health outcomes (all-cause, cancer, heart disease, stroke, infant mortality, low birth weight, life expectancy, self-rated health). A 12% increase in such physicians (1 per 10, 000) improves outcomes an average of 4% (range 1. 3 -10. 8% depending on particular outcome and geographic unit of analysis). Source: Macinko et al, mss 2005 Starfield 06/05 WC 3217

In both England the US, each additional primary care physician per 10, 000 population In both England the US, each additional primary care physician per 10, 000 population (a 12 -20% increase) is associated with a decrease in mortality of 3 -10%, depending on the cause of death. This is true even after adjusting for sociodemographic and socioeconomic characteristics. Source: Gulliford, J Public Health Med 2002; 24: 252 -4, and personal communication 9/04. Starfield 03/05 WC 3102

Low Birth Weight among US Rural, Urban, and Primary Care Health Center Infants 8. Low Birth Weight among US Rural, Urban, and Primary Care Health Center Infants 8. 8 Urban health center infants Geographic area US urban infants 7. 5 US rural infants 6. 8 6. 0 African American urban infants 13. 6 African American urban health center infants 10. 4 African American rural infants 13. 0 African American rural health center infants 0. 0 7. 4 2. 0 Source: Politzer et al, Med Care Res Rev 2001; 58: 234 -48. 4. 0 6. 0 8. 0 10. 0 12. 0 Racial composition Rural health center infants 14. 0 Starfield 10/03 WC 2637 03 -257

Reductions* in Inequality in Health by Primary Care: Postneonatal Mortality, 50 US States, 1990 Reductions* in Inequality in Health by Primary Care: Postneonatal Mortality, 50 US States, 1990 Areas with low income inequality (mostly homogeneous high income areas) High primary care resources Low primary care resources 0. 8% decrease in mortality 1. 9% increase in mortality Areas with high income inequality High primary care resources Low primary care resources 17. 1% decrease in mortality 6. 9% increase in mortality *compared with population mean Based on data in Shi et al, J Fam Pract 1999; 48: 275 -84. Starfield 05/05 EQ 3215

Reductions* in Inequality in Health by Primary Care: Stroke Mortality, 50 US States, 1990 Reductions* in Inequality in Health by Primary Care: Stroke Mortality, 50 US States, 1990 Areas with low income inequality (mostly homogeneous high income areas) High primary care resources Low primary care resources 1. 3% decrease in mortality 2. 3% increase in mortality Areas with high income inequality High primary care resources Low primary care resources 2. 3% decrease in mortality 1. 1% increase in mortality *compared with population mean Based on data in Shi et al, J Fam Pract 1999; 48: 275 -84. Starfield 05/05 EQ 3213

Reductions in Inequality in Health by Primary Care: Self-Reported Health, 60 US Communities, 1996 Reductions in Inequality in Health by Primary Care: Self-Reported Health, 60 US Communities, 1996 Percent reporting fair or poor health • Areas with low income inequality (mostly homogeneous high income areas) – No effect of primary care resources* • Areas with moderate income inequality – 16% increase in areas with low primary care resources* • Areas with high income inequality – 33% increase in areas with low primary care resources* *compared with median # of primary care physicians to population ratios Based on data in Shi & Starfield, Int J Health Serv 2000; 30: 541 -55. Starfield 08/02 EQ 2181 02 -156

In the United States, an increase of 1 primary care doctor is associated with 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. Source: Shi et al, Soc Sci Med 2005; 61(1): 65 -75. Starfield 06/05 WC 3216

25% of US physicians are trained outside the US. Most notably, those countries that 25% of US physicians are trained outside the US. Most notably, those countries that contribute to maintaining the PRIMARY CARE (but not specialist) physician supply in the US are those countries that rate particularly poor in health and are particularly deprived of health professionals. Source: Starfield B, Fryer GE Jr. , 2006 Starfield 03/06 WF 3385

Primary Care and Specialty Care Starfield 08/05 GS 3290 Primary Care and Specialty Care Starfield 08/05 GS 3290

The Regional Primary Care and Specialty Physician Supply and Odds of Late-stage Diagnosis of The Regional Primary Care and Specialty Physician Supply and Odds of Late-stage Diagnosis of Colorectal Cancer 1. 6 1. 4 1 0. 8 0. 6 Odds Ratios 1. 2 0. 4 0. 2 0 10 20 30 40 50 60 70 80 90 100 Percentiles Primary Care Source: Roetzheim et al, J Fam Pract 1999; 48: 850 -8. Specialists Starfield 08/02 WC 2179 02 -154

Early detection of breast cancer is greater when the supply of primary care physicians Early detection of breast cancer is greater when the supply of primary care physicians is higher. Each tenth percentile increase in primary care physician supply is associated with a statistically significant 4% increase in the likelihood of EARLY (rather than late) stage diagnosis. Source: Ferrante et al, J Am Board Fam Pract 2000; 13: 408 -14. Starfield 09/04 WC 2960 04 -139

For cervical cancer, rates of incidence of advanced stage presentation are lower in areas For cervical cancer, rates of incidence of advanced stage presentation are lower in areas that are well-supplied with family physicians, but there is no advantage of having a greater supply of specialist physicians, either in total or for obstetrician/gynecologists. Source: Campbell et al, Fam Med 2003; 35: 60 -4. Starfield 09/04 WC 2961 04 -140

Melanoma is identified at an earlier stage in areas where the supply of family Melanoma is identified at an earlier stage in areas where the supply of family physicians is high, both in urban areas and non-urban areas. The same is the case for dermatologists, but the relationship is not statistically significant, and there is no relationship of early detection with the supply of other specialists. Source: Roetzheim et al, J Am Acad Dermatol 2000; 43: 211 -8. Starfield 10/04 09/04 WC 2962 04 -249

The variation in numbers (per population) of neonatologists does not vary with measures of The variation in numbers (per population) of neonatologists does not vary with measures of need (very low birth weight ratios); there is no relationship between the supply of neonatal resources and infant mortality, and increases in the supply of neonatologists beyond a moderate level confer no additional benefit. Source: Goodman et al, N Engl J Med 2002; 346: 1538 -44. Starfield 10/04 09/04 SP 2959 04 -194

There are large variations in both costs of care and in frequency of interventions. 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; W 4: 184 -97. Wennberg et al, Health Aff 2005; W 5: 526 -43. Starfield 12/05 SP 3343

Above a certain level of specialist supply, the more specialists per population, the worse Above a certain level of specialist supply, the more specialists per population, the worse the outcomes. In 35 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 08/05 SP 3256

What is the right number of specialists? What do specialists do? Starfield 01/06 SP What is the right number of specialists? What do specialists do? Starfield 01/06 SP 3354

Percentage of Patients* Referred in a Year United States Mid-Atlantic HMO Midwestern POS Northeastern Percentage of Patients* Referred in a Year United States Mid-Atlantic HMO Midwestern POS Northeastern POS Lower mid-Atlantic POS % 30. 0 35. 7 34. 9 32. 6 36. 8 United Kingdom GP Research Database 13. 9 *Case-mix adjusted Source: Forrest et al, BMJ 2002; 325: 370 -1. Starfield 02/03 GS 2422 03 -038

Percentage of Patients, from Birth to Age 17, Referred in a Year United States Percentage of Patients, from Birth to Age 17, Referred in a Year United States Mid-Atlantic HMO Midwestern POS Northeastern POS Lower mid-Atlantic POS % 18. 6 28. 8 25. 7 21. 1 22. 9 United Kingdom GP Research Database 8. 7 Source: Forrest et al, Arch Pediatr Adolesc Med 2003; 157: 279 -85. Starfield 03/05 GS 3113

What Is the Appropriate Role for Primary Care and Specialist Physicians? Primary care: person-focused What Is the Appropriate Role for Primary Care and Specialist Physicians? Primary care: person-focused care over time, firstcontact access, ongoing care of all but uncommon problems, coordination of care Specialist care: • Short-term consultation for diagnosis or initiation of management • Recurrent consultation for advice on continuing management • Long-term referral for management of unusual conditions Starfield 12/04 GS 3079

About half of all referrals are for short-term consultation. For the remaining half, the About half of all referrals are for short-term consultation. For the remaining half, the overwhelming expectation is for shared care rather than transferred care. Source: Starfield et al, J Am Board Fam Pract 2002; 15: 473 -80. Starfield 07/03 GS 2518 03 -135

Percent of Visits Made by Patients Who Were Referred*: US, 1994 All ages Children Percent of Visits Made by Patients Who Were Referred*: US, 1994 All ages Children under age 15 14 7 Family practice 3 2 Internal medicine 8 25 Pediatrics 3 2 24 35 All physicians Other specialties *for this visit Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 10/00 Starfield 2000 GS 1751 00 -123

Could it be that 65 -75% of visits to specialists are for routine follow-up? Could it be that 65 -75% of visits to specialists are for routine follow-up? Does this seem like a rational use of expensive and potentially dangerous use of resources? Starfield 01/06 SP 3355

Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two Percent of Patients Reporting Any Error by Number of Doctors Seen in Past Two Years Country One doctor 4 or more doctors Australia 12 37 Canada 15 40 Germany 14 31 New Zealand 14 35 UK 12 28 US 22 49 Source: Schoen et al, Health Affairs 2005; W 5: 509 -525. Starfield 01/06 IC 3352

Association of Regional Quality of Care for Acute Myocardial Infarction (AMI) and Average Number Association of Regional Quality of Care for Acute Myocardial Infarction (AMI) and Average Number of Physicians per AMI Patient (Quartiles) with Changes in Survival and Spending, 1968 -2002 Source: Skinner et al, Health Aff 2006; W 6: W 23 -W 47. Starfield 03/06 QC 3391

Monthly Prevalence Estimates of Illness in the Community and the Roles of Physicians, Hospitals, Monthly Prevalence Estimates of Illness in the Community and the Roles of Physicians, Hospitals, and University Medical Centers in the Provision of Medical Care 1000 Adult population at risk 750 Adults reporting one or more illnesses or injuries per month Adults consulting a physician one or more times per month 250 9 adult patients admitted to a hospital per month 5 adult patients referred to another physician per month 1 adult patient referred to a university medical center per month Source: White et al, N Engl J Med 1961; 265: 885 -92. Starfield 10/05 GS 3321

Results of a Reanalysis of the Monthly Prevalence of Illness in the Community and Results of a Reanalysis of the Monthly Prevalence of Illness in the Community and the Roles of Various Sources of Health Care 1000 persons 800 report symptoms 327 consider seeking medical care 217 visit a physician’s office (113 visit a primary care physician’s office) 65 visit a complementary or alternative medical care provider 21 visit a hospital outpatient clinic 14 receive home health care 13 visit an emergency department 8 are hospitalized <1 is hospitalized in an academic medical center Source: Green et al, N Engl J Med 2001; 344: 2021 -5. Starfield 12/05 GS 3345

Participation in Medical and Dental Care in a Typical Month for 1000 Children and Participation in Medical and Dental Care in a Typical Month for 1000 Children and Adolescents Aged 0 to 17 years (A), and 1000 adults >=18 years (B) A. Children aged 0 -17 years 167 visit a physician’s office 82 visit a dentist’s office 13 visit an emergency department 8 visit a hospital outpatient clinic 3 are hospitalized 2 receive home health care Source: Dovey et al, Pediatrics 2003; 111: 1024 -9. B. Adults >= 18 years 235 visit a physician’s office 73 visit a dentist’s office 13 visit an emergency department 26 visit a hospital outpatient clinic 10 are hospitalized 18 receive home health care Starfield 02/01 GS 3370

The positive predictive value of rectal bleeding for colorectal cancer is less than 1 The positive predictive value of rectal bleeding for colorectal cancer is less than 1 in 1000 in the community, 1 in 50 in general practice, and 1 in 3 of those referred to hospital by GPs. Source: Fijten et al, Br J Gen Pract 1994; 44(384): 320 -5. Starfield 10/05 D 3322

What We Need to Know • What specialists contribute to population health • The What We Need to Know • What specialists contribute to population health • The optimum ratio of specialists to population • The functions of specialty care and the appropriate balance among the functions • The appropriate division of effort between primary care and specialty care • The point at which an increasing supply of specialists becomes dysfunctional Starfield 11/05 SP 3328

PC 3395 1. Challenges and opportunities – Contributing to improving health systems through • PC 3395 1. Challenges and opportunities – Contributing to improving health systems through • Strengthening of primary care • Strengthening the relationship between primary care, secondary care (diagnostic and management support), and tertiary care (unusual or unusually complex health problems) – Contributing to knowledge in the areas of • The impact of multi-morbidity on assessment of the quality of health services • Reductions in adverse effects of health services through better integration of services 2. Imperatives – Residency training in the community, not in the hospital – Advocacy for primary care at the national and international levels, based on a unified strategy combining the forces of all primary care specialties Starfield 03/06 PC 3395




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